The evolution of treatment and complications of esophageal food impaction

Association between time from esophageal food impaction to endoscopy and adverse events

BACKGROUND AND AIMS

Guidelines recommend emergent or urgent EGD for esophageal food impaction (EFI), but data on how time to EGD impacts the risk of adverse events remain limited. We determined whether EFI-to-EGD time was associated with adverse events.

METHODS

In this retrospective cohort study of patients with endoscopically confirmed EFI, adverse events were classified as esophageal (mucosal tear, bleeding, perforation) or extraesophageal (aspiration, respiratory compromise, hypotension, arrhythmia). Esophageal perforation and extraesophageal adverse events requiring intensive care unit admission were classified as serious adverse events. Baseline characteristics, event details, and procedural details were compared between patients with and without adverse events. Multivariable logistic regression was performed to assess for an association between EFI-to-EGD time and adverse events.

RESULTS

Of 188 patients with EFI, 22 (12%) had any adverse event and 2 (1%) had a serious adverse event. Patients with adverse events were older and more likely to have an esophageal motility disorder, to tolerate secretions at presentation, and to have a higher American Society of Anesthesiologists score. EFI-to-EGD time was similar in those with and without adverse events. On multivariable analysis, EFI-to-EGD time was not associated with adverse events (odds ratio, 1.00 [95% confidence interval, .97-1.04] for 1-hour increments; odds ratio, 1.03 [95% confidence interval, .86-1.24] for 6-hour increments). Results were similar after stratifying by eosinophilic esophagitis status and after adjusting for possible confounders.

CONCLUSIONS

Because the time from EFI to EGD is not associated with adverse events, emergent EGD for EFI may be unnecessary, and other considerations may determine EGD timing.

Nomogram for Predicting the Risk of Complications after Endoscopic Foreign Body Removal from the Adult Upper Gastrointestinal Tract

BACKGROUND

Ingested foreign bodies may become impacted in the upper gastrointestinal tract, requiring endoscopic removal.

AIMS

To establish and validate a nomogram to determine the risk of complications following endoscopic foreign body removal.

METHODS

We retrospectively analyzed the data of 1510 adult patients who underwent endoscopic removal of ingested foreign bodies between January 2019 and December 2022. All participants were randomly allocated in a 7:3 ratio to the training (n = 1057) and validation (n = 453) cohorts. A nomogram for the development of major complications associated with endoscopic foreign body removal was established based on risk factors identified by logistic regression analysis.

RESULTS

Four independent risk factors for the development of major complications were identified by multivariate regression analysis: older age, impaction time > 24 h, type of foreign body (animal bones and jujube pits), and number of pressure points exerted on the digestive tract wall (one and ≥ two). The nomogram constructed using these factors showed favorable discriminatory values, with an area under the curve of 0.76 (95% confidence interval, 0.73-0.78) in the training cohort and 0.74 (95% confidence interval, 0.72-0.76) in the validation cohort.

CONCLUSIONS

Older patients who ingested bones or jujube pits with more pressure points exerted on the digestive tract wall more than 24 h earlier should be considered most at risk of major complications after endoscopic removal of foreign bodies. The nomogram established in this study can be conveniently used to assess patients and develop treatment plans for the management of foreign body ingestion.

A retrospective cohort study on oesophageal food bolus obstruction in the North Denmark region in 2021-two thirds were never diagnosed with a cause

BACKGROUND

Food bolus obstruction (FBO) leading to hospital treatment is often associated with eosinophilic oesophagitis (EoE), stenosis, or oesophageal cancer (1). Danish national guidelines recommend that patients with FBO undergo a diagnostic upper endoscopy within two weeks of presentation to exclude possible malignancy, and histological evaluation of eight biopsies (2, 3).

AIMS

The aims of this study were to (1) report the incidence and describe the causes and treatment of FBO in the North Denmark Region (NDR), (2) determine the proportion of patients who underwent upper endoscopy and biopsy according to regional and national guidelines, and (3) identify International Classification of Diseases 10th Revision (ICD-10) diagnosis and procedure codes applied to the hospital visits due to FBO in the NDR.

METHODS

Among all acute hospital visits in the NDR in 2021, all visits with ICD-10 codes possibly reflecting FBO, as well as a random sample of 14,400 visits with unspecific ICD-10 codes (R and Z codes), were screened manually for possible FBO. Diagnosis, follow-up, and treatment of all patients with FBO were recorded.

RESULTS

The median patient age was 66.0 (Q1-Q3: 49.8-81.0) years, and half of the patients had experienced FBO before. Two thirds of patients (66.0%) were never diagnosed with a cause of FBO, followed by 17.3% with EoE. 30% of patients did not undergo upper endoscopy within two weeks of the hospital visit, and 50.7% were never biopsied in the oesophagus. Of 1886 hospital visits with registry ICD-10 codes that possibly reflected FBO, 8.4% were due to FBO, while FBO was present in 0.028% of the random sample of unspecific ICD-10 codes.

CONCLUSIONS

Most hospitalized FBO patients in the NDR in 2021 were never diagnosed with a cause. In these patients there is a high risk of overlooked EoE or upper gastrointestinal cancers. The area needs immediate focus and changed routines to improve treatment and prevent new FBO.

Comparable Efficacy for Push Versus Pull Technique in Esophageal Food Impaction: Systematic Review with Meta-Analysis

BACKGROUND

Esophageal food impaction (EFI) is a common GI emergency. Push and pull methods are used currently for EFI retrieval. We aim to review current available literature to compare success rates and evaluate adverse event rates of the two techniques.

METHODS

A comprehensive literature search was performed using MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science Core Collection, KCI-Korean Journal Index, SciELO and Global Index Medicus. Odds ratio (OR) with 95% confidence interval (CI) was calculated when comparing the dichotomous variables. We aimed to evaluate technical success and adverse events for EFI comparing push and pull technique on single arm and comparator analysis.

RESULTS

The search strategy yielded a total of 126 articles. 18 studies with 3528 participants were included. The technical success rate was 97.5% (CI 96.6-99.2%) in the push and 88.4% (CI 72.8-98.7%) in the pull technique with no statistical difference on comparator analysis. Overall rate of adverse events was 4.03% (CI 0.9-5.0%) in the push technique and 2.22% (CI 0-2.9%) in the pull technique with no statistical difference on comparator analysis (OR 95% CI 0.464-2.782, p = 0.78, I² = 31.54%). There was no statistical difference between rate of lacerations and perforations either between the two techniques.

CONCLUSION

Both techniques have acceptable clinical outcomes which appear within standard of care. Operator experience and individual clinical scenarios should guide decision-making regarding technique selection.

Diagnosis of Eosinophilic Esophagitis at the Time of Esophageal Food Impaction

BACKGROUND

Esophageal food impactions (EFI) often precede a diagnosis of eosinophilic esophagitis (EOE). Current guidelines suggest obtaining esophageal biopsies upon suspicion of EOE, treating with proton pump inhibitor (PPI), and repeating esophagogastroduodenoscopy (EGD). This study was conducted to determine provider practice patterns with these mentioned recommendations at the time of EFI.

METHODS

In this retrospective study, key outcomes were the proportion of patients who had EOE mucosal biopsies, EOE diagnosis, PPI initiation, and recommendations and completions of repeat EGD. Differences in outcomes among age, sex, race, off-hours time of procedure, and trainee involvement were examined. EOE diagnosis predictors were explored with logistic regression.

RESULTS

Twenty-nine percent of the patients had esophageal biopsies taken at the time of index EGD (iEGD). Sixteen patients were diagnosed with EOE at the time of index EFI, while fourteen patients were diagnosed on subsequent EGDs. Among those diagnosed with EOE at iEGD, 94% were placed on PPI. Of patients with confirmed EOE on index biopsy, 63% of patients were recommended repeat EGD, of which 50% completed it within 90 days. Older age was protective of EOE diagnosis while no GERD history and endoscopist suspicion of EOE predicted diagnosis of EOE.

CONCLUSIONS

Endoscopists uncommonly take biopsies at the time of EFI, which may delay diagnosis and treatment of EOE.

The Risk of Esophageal Food Impaction in Eosinophilic Esophagitis Patients: The Role of Clinical and Socioeconomic Factors

Background

Eosinophilic esophagitis (EoE) patients present with dysphagia and often suffer from esophageal food impaction (EFI). EFI can lead to life-threatening perforation, and requires emergent endoscopic intervention. The aim of this study is to evaluate the risk factors for EFI in EoE patients.

Methods

This is a retrospective study performed at a tertiary health-care system. Medical records and endoscopy images of EoE cases were reviewed. Clinical characteristics and outcomes including EFIs were documented. We used Zip-code median household income as a surrogate for patients' socioeconomic status.

Results

A total of 291 EoE cases were included, mean age was 42 years. Most patients (65%) had classic EoE endoscopic findings including linear furrows and/or concentric rings; however, a significant proportion (47%) had findings suggestive of gastroesophageal reflux disease (GERD), such as the presence of erosive-esophagitis, a hiatal hernia or Schatzki's ring. Forty-eight patients (16%) developed one or more esophageal food impaction (EFI). The risk of EFI was less likely in the absence of furrows and/or rings; odds ratio (OR) = 0.28, 95% CI (0.11, 0.72) [P = 0.008]. Females had less EFI risk; OR = 0.42, 95% CI (0.19, 0.95) [P = 0.04]. The type of medical insurance and socioeconomic status was not associated with EFI risk.

Conclusion

EFI risk is higher in EoE patients with esophageal furrows and/or rings and in men. Aggressive treatment might be required in this population. GERD and EoE can coexist in many patients. Further studies are required to examine the role of the socioeconomic status in EoE complications.

Total esophageal food impaction in the era of the COVID-19 pandemic: a delayed presentation in a patient with Parkinson's disease

Total esophageal food impaction is extremely rare. We report a patient with Parkinsonism who presented with total dysphagia to solids and liquids and with inability to swallow her saliva of 3 days duration. She did not present sooner as she was afraid of contracting COVID-19 during hospitalization. Chest CT scan revealed total esophageal food impaction. Awake fiberoptic endotracheal intubation followed by EGD and clearance of the impacted food were performed. This patient illustrates esophageal involvement in Parkinson’s disease, delayed presentation with an emergency in the COVID-19 era, and the multidisciplinary approach to minimize the risk of aspiration during endoscopy.

British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults

BACKGROUND

Eosinophilic oesophagitis (EoE) is an increasingly common cause of dysphagia in both children and adults, as well as one of the most prevalent oesophageal diseases with a significant impact on physical health and quality of life. We have provided a single comprehensive guideline for both paediatric and adult gastroenterologists on current best practice for the evaluation and management of EoE.

METHODS

The Oesophageal Section of the British Society of Gastroenterology was commissioned by the Clinical Standards Service Committee to develop these guidelines. The Guideline Development Group included adult and paediatric gastroenterologists, surgeons, dietitians, allergists, pathologists and patient representatives. The Population, Intervention, Comparator and Outcomes process was used to generate questions for a systematic review of the evidence. Published evidence was reviewed and updated to June 2021. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the evidence and make recommendations. Two rounds of voting were held to assess the level of agreement and the strength of recommendations, with 80% consensus required for acceptance.

RESULTS

Fifty-seven statements on EoE presentation, diagnosis, investigation, management and complications were produced with further statements created on areas for future research.

CONCLUSIONS

These comprehensive adult and paediatric guidelines of the British Society of Gastroenterology and British Society of Paediatric Gastroenterology, Hepatology and Nutrition are based on evidence and expert consensus from a multidisciplinary group of healthcare professionals, including patient advocates and patient support groups, to help clinicians with the management patients with EoE and its complications.

Endoscopic Image-guided treatment of Upper Gastrointestinal foreign body and nursing care of complications

Objective:

This study used phased array imaging algorithm to explore the epidemiological characteristics of endoscopic treatment of upper gastrointestinal foreign bodies to provide a basis for nursing intervention.

Methods:

We collected data on the age, sex, cause, type of foreign body, success rate of removal, retention location, time and complications of patients with foreign bodies in the upper gastrointestinal tract who were treated in the emergency department of the Digestive Endoscopy Center in our hospital. The study was conducted from January 2018 to December 2020 and we also performed statistical analysis.

Results:

The high incidence of foreign bodies in the upper digestive tract was in 45 years old to 74 years old patients. The foreign body types were mostly food balls and sharp foreign bodies, accounting for 37.0% and 44.2%, respectively. The cause was misuse and the most accounted for 52.1%, followed by oesophageal pathological stenosis which accounted for 45.5%. The oesophagus in the retention site accounted for up to 80.0%, and the success rate of foreign body extraction was 96.4%. The complications of patients with foreign body retention within twenty four our retention were mainly esophageal scratches and traumatic esophagitis, accounting for 48.5%. 39.6%.

Conclusion:

There are high risks in the treatment of foreign bodies in the upper digestive tract. Targeted, prospective, and streamlined nursing interventions can provide patients with fast and professional medical care services and minimize patient pain.

Is There a Role for Topical Swallowed Steroids upon Emergency Room Admission for Suspected Food Bolus Obstruction in Eosinophilic Esophagitis?

Since most pharmacological treatments in case of esophageal food impaction (EFI) are unsuccessful, an endoscopy is usually required to resolve EFI. We present the first results of a budesonide orodispersible tablet (BOT) as a medical treatment option before endoscopy. We evaluated all patients with a suspected EFI to receive BOT before emergent endoscopy at a tertiary hospital between March 2019 and June 2020. A total of eight patients received BOT before endoscopy. Mean age was 50.1 years and 87.5% were male. In 38% (3/8) of patients the EFI resolved without endoscopic intervention. No adverse events occurred. After endoscopy, a diagnosis of EoE was established in 75%. This case series demonstrate the potential of BOT as medical rescue therapy in case of EFI.

Esophageal perforation in eosinophilic esophagitis: A systematic review on clinical presentation, management and outcomes

There is evidence of an increased fragility in the inflamed esophagus of patients with eosinophilic esophagitis (EoE). We performed a systematic review on presentation, management and outcomes of and surgical interventions for esophageal perforation in these patients, by searching in the MEDLINE, Embase and Scopus databases. Of the 599 references identified, 41 full-papers and 9 abstract met the inclusion criteria. Overall, 76 esophageal perforation episodes in 70 individual patients aged between 9 and 65 years were reported. 51 patients had not been diagnosed with EoE at the time of perforation; 14 patients had an untreated disease and the remaining were non responsive to therapy. Acute or progressive pain after long-lasting dysphagia and food impaction was the most common symptom leading to diagnosis in 42 patients who presented with Boerhaave syndrome. Pushing impacted food into the stomach led to perforation in 5 cases. Eight episodes appeared after dilation. CT scans demonstrated perforation in 82.4% of patients. Conservative management (including esophageal stenting) was used in 67.1% patients. The 25 remaining patients underwent surgery. Recovery was uneventful in the vast majority of patients. No death was reported. Active inflammation due to undiagnosed or untreated EoE was present in most cases of esophageal perforation. Conservative treatment of perforation should always be considered in EoE.