A food bolus impaction can be a distressing experience. This article will explore what a food bolus is, what happens when it becomes impacted, the potential causes, and how it’s treated.
When we eat, food is chewed and mixed with saliva, forming a soft, round mass called a bolus. This bolus is then swallowed and travels down the esophagus to the stomach. Usually, this process happens smoothly and without any issues. However, sometimes the food bolus can get stuck in the esophagus, leading to what’s known as a food bolus impaction.
Understanding Food Bolus Impaction
Symptoms of Food Bolus Impaction
Food bolus impactions are typically acute events, meaning they happen suddenly. In most cases, the impaction resolves on its own, either by passing into the stomach or by the patient regurgitating the contents. However, when the obstruction persists, and particularly when accompanied by substantial chest discomfort, medical attention is usually required.
Patients often describe a sensation of squeezing in the chest, which can be alarming as it can mimic the pain of a heart attack. Excessive salivation, known as sialorrhea, often accompanies esophageal obstruction. The inability to eat or drink further is another key symptom.
It is crucial to differentiate food bolus impaction from choking. Patients with a food bolus impaction can still breathe, talk, and cough. In contrast, someone who is truly choking is unable to perform these actions.
Primary Causes of Food Bolus Impaction
Food bolus impactions often occur when there is an underlying issue, either mechanical or functional, affecting the esophagus.
- Mechanical Causes: These involve physical narrowing of the esophagus. Common causes include:
- Schatzki ring: A ring of tissue that narrows the esophagus.
- Peptic stricture: Scarring and narrowing of the esophagus caused by acid reflux.
- Eosinophilic esophagitis: An inflammatory condition where eosinophils (a type of white blood cell) accumulate in the esophagus, leading to narrowing.
- Functional Causes: These involve problems with the esophagus’s ability to contract and move food along. Examples include:
- Diffuse esophageal spasm: Uncoordinated contractions of the esophageal muscles.
- Esophageal motility disorders: Various conditions that impair the normal movement of the esophagus. In these cases, the impaction usually resolves after a period of relaxation, allowing the bolus to pass.
The “steakhouse syndrome” or “backyard barbeque syndrome” are classic examples of food bolus impaction scenarios. These impactions often happen when eating meat, especially when the food is not chewed thoroughly. Factors contributing to this include poor dentition, ill-fitting dentures, alcohol consumption, and eating too quickly. Commonly implicated foods are beef, chicken, pork, and al dente-cooked vegetables.
Food Bolus vs. Foreign Object
It is essential to distinguish a food bolus impaction from the ingestion of a true foreign object. This is primarily achieved through a detailed and accurate patient history. While food boluses are organic matter, ingested foreign objects are often radiopaque, meaning they can be seen on X-rays. Therefore, imaging is crucial for differentiation. Furthermore, even within a food bolus, the possibility of unrecognized bones, particularly in meat impactions, should be considered. X-rays of the chest and neck can help identify such bones.
Treatment Options for Food Bolus Impaction
When a food bolus impaction persists and the patient seeks emergency care, a chest X-ray is typically performed to rule out esophageal perforation or the presence of a radiopaque foreign object. Once those are ruled out, endoscopy is often the next step.
The timing of the endoscopy depends on the patient’s condition. Factors to consider include:
- Airway and Ventilation Status: Ensuring the patient can breathe and handle their secretions is paramount. Excessive salivation that the patient can’t manage warrants urgent endoscopy.
- Duration of Impaction: Impactions lasting longer than 12-24 hours increase the risk of serious complications, including esophageal perforation.
Small doses of intravenous glucagon may be administered to relax the esophagus and potentially allow the bolus to pass spontaneously. However, this should not delay definitive endoscopic management. Other historical approaches, such as sodium bicarbonate tablets or carbonated beverages to increase pressure, or blind passage of a nasogastric tube, are generally discouraged.
Sedation during endoscopy is individualized based on the patient’s airway risk. Endoscopic inspection helps identify the location and characteristics of the bolus and any accumulated fluids. An esophageal overtube or endotracheal intubation may be considered to minimize the risk of aspiration, especially when copious esophageal contents are present. Overtubes can also facilitate repeated endoscope insertions and withdrawals.
Gentle forward pressure with the endoscope can sometimes help the bolus pass spontaneously, especially with sedation. If this fails, the endoscopist may attempt to navigate the endoscope around the bolus. However, forceful pushing or blind advancement alongside the bolus should be avoided.
If these techniques are unsuccessful, grasping forceps or other devices can be used to dislodge and debulk the bolus. This often allows it to clear in an antegrade (forward) fashion. If this is not possible, piecemeal removal of the bolus contents retrograde (backward), through an esophageal overtube, may be necessary.
Recurrent Food Bolus Impactions
Patients who experience a food bolus impaction often have a history of previous, spontaneously resolved episodes. When the underlying cause is related to gastroesophageal reflux disease (GERD), recurrent episodes are likely unless effective acid suppression therapy is implemented. Esophageal dilation for strictures identified during acute impaction management is usually deferred to a separate endoscopy session 2-8 weeks later to allow mucosal healing.
Conclusion
Food bolus impaction can be a frightening experience, but understanding the causes, symptoms, and treatment options can help patients and medical professionals address the issue effectively. While most impactions resolve spontaneously, persistent or severe cases require prompt medical attention to prevent complications. Addressing underlying esophageal conditions is crucial to prevent recurrent episodes.
