Esophageal food bolus obstruction
Encyclopedia
An esophageal food bolus
obstruction (or steakhouse syndrome) is a medical emergency caused by the obstruction of the esophagus
by an ingested foreign body
. It is usually associated with diseases that narrow the lumen
of the esophagus, such as eosinophilic esophagitis
, Schatzki ring
s, peptic stricture
s, webs, or cancers
of the esophagus; rarely it can be seen in disorders of the movement of the esophagus, such as nutcracker esophagus
. While some esophageal food boluses can pass by themselves or with the assistance of medications, some require the use of endoscopy
to push the obstructing food into the stomach, or remove it from the esophagus.
, but the most common are meats such as steak
, poultry
, or pork
leading to the colourful description of the phenomenon as steakhouse syndrome. People with food bolus obstruction typically display acute dysphagia
(difficulty swallowing), often to the point that they cannot even swallow their saliva
, leading to drooling. They may also suffer from chest pain, neck pain, regurgitation of food, or painful swallowing (odynophagia
).
Patients with esophageal food bolus
es are also at risk of complications, such as perforation of the esophagus, and aspiration into the lungs
. As a result, urgent treatment of patients with high-risk features, or a lengthy duration of symptoms, is recommended.
s, which are mucosal rings of unknown cause in the lower esophagus. Foodstuff jams into the esophagus due to the narrowing caused by the ring. An increasingly commonly recognized cause for esophageal food bolus obstruction is eosinophilic esophagitis
, which is an inflammatory disorder of the mucosa of the esophagus, of unknown cause. Many alterations caused by eosinophilic esophagitis can predispose to food boluses; these include the presence of multiple rings and narrowing of the lumen. When considering esophageal dilation to treat a patient with food bolus obstruction, care must be made to look for features of eosinophilic esophagitis, as these patients are at a higher risk of dilation-associated complications.
Other conditions that predispose to food bolus obstructions are esophageal web
s and peptic stricture
s. Food boluses are common in the course of illness in patients with esophageal cancer
but are more difficult to treat as endoscopy to push the bolus is less safe. Patients with esophageal self-expandable metallic stent
s may present with food boluses lodged within the stent lumen. Rarely disorders of movement of the esophagus, such as nutcracker esophagus
, can predispose to food bolus obstruction.
or fibre-optic cameras inserted by mouth into the esophagus. Endoscopes can be used to diagnose the cause of the food bolus obstruction, as well as to remove the obstruction. Traditional endoscopic techniques involved the use of an overtube, a plastic tube inserted into the esophagus prior to the removal of the food bolus, in order to reduce the risk of aspiration into the lung
s at the time of endoscopy. However, the push technique, which involves insufflating air into the esophagus, and gently pushing the bolus toward the stomach instead, has emerged as a common and safe way of removing the obstruction.
Other tools may be used to remove food boluses. The Roth net is a mesh net that can be inserted through the endoscope, and opened and closed from the outside; it can be used to retrieve pieces of obstructed food. Snares, which are normally used to remove polyps
can be used to macerate the food causing the obstruction. Dormia baskets, which are metal baskets used to remove stones from the common bile duct
in a procedure known as endoscopic retrograde cholangiopancreatography
, can be opened and closed from the outside in a similar manner to macerate food and facilitate removal. Forceps
used for biopsies
can also be employed in a similar manner.
Historical treatment of food bolus obstruction included administration of proteolytic enzymes (such as meat tenderizer
s), or even acidic substances, such as Coca-Cola
with the purpose of degrading the meat that was blocked; however, this was often complicated by perforation of the esophagus. Other modalities rarely used now include administration of anti-spasmodic medications, such as hyoscine butylbromide, removal of boluses using catheter
s, and the use of large-bore tubes inserted into the esophagus to forcefully lavage it.
Recently a combination therapy that uses intravenous glucagon
, an effervescent agent and water has been used as a less invasive method to relieve esophageal food bolus obstruction. This procedure is performed by a radiologist or other qualifying physician using fluoroscopy
to identify the location of the obstruction before the procedure and confirm successful clearance of food bolus after the procedure. Glucagon relaxes the lower esophageal muscles, the effervescent agent distends the esophagus and hydrostatic pressure caused by the water and the use of gravity push the food bolus into the stomach. There are however limitations to this technique and situations which would predispose the esophagus to rupture or the procedure to fail should be avoided. Patients who don't qualify for the procedure or those who fail initial attempts should be treated with the standard endoscopic methods. Appropriate patient selection is crucial for the procedure to succeed and to minimize complications.
Bolus (digestion)
In digestion, a bolus is a mass of food that has been chewed at the point of swallowing. Once a bolus reaches the stomach, digestion begins....
obstruction (or steakhouse syndrome) is a medical emergency caused by the obstruction of the esophagus
Esophagus
The esophagus is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach...
by an ingested foreign body
Foreign body
A foreign body is any object originating outside the body. In machinery, it can mean any unwanted intruding object.Most references to foreign bodies involve propulsion through natural orifices into hollow organs....
. It is usually associated with diseases that narrow the lumen
Lumen (anatomy)
A lumen in biology is the inside space of a tubular structure, such as an artery or intestine...
of the esophagus, such as eosinophilic esophagitis
Eosinophilic esophagitis
Eosinophilic esophagitis is an allergic inflammatory condition of the esophagus. Symptoms are swallowing difficulty, food impaction, and heartburn. The disease was first described in children but occurs in adults as well...
, Schatzki ring
Schatzki ring
A Schatzki ring or Schatzki-Gary ring is a narrowing of the lower part of the esophagus that can cause difficulty swallowing. The narrowing is caused by a ring of mucosal tissue or muscular tissue. Patients with Schatzki rings can develop intermittent dysphagia , or, more seriously, a completely...
s, peptic stricture
Stenosis
A stenosis is an abnormal narrowing in a blood vessel or other tubular organ or structure.It is also sometimes called a stricture ....
s, webs, or cancers
Esophageal cancer
Esophageal cancer is malignancy of the esophagus. There are various subtypes, primarily squamous cell cancer and adenocarcinoma . Squamous cell cancer arises from the cells that line the upper part of the esophagus...
of the esophagus; rarely it can be seen in disorders of the movement of the esophagus, such as nutcracker esophagus
Nutcracker esophagus
Nutcracker esophagus is a disorder of the movement of the esophagus, and is one of many motility disorders of the esophagus, including achalasia and diffuse esophageal spasm. It causes difficulty swallowing, or dysphagia, to both solid and liquid foods, and can cause chest pain; it may also be...
. While some esophageal food boluses can pass by themselves or with the assistance of medications, some require the use of endoscopy
Endoscopy
Endoscopy means looking inside and typically refers to looking inside the body for medical reasons using an endoscope , an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices, endoscopes are inserted directly into the organ...
to push the obstructing food into the stomach, or remove it from the esophagus.
Clinical presentation
Many foods can lodge themselves in the esophagusEsophagus
The esophagus is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach...
, but the most common are meats such as steak
Steak
A steak is a cut of meat . Most are cut perpendicular to the muscle fibers, improving the perceived tenderness of the meat. In North America, steaks are typically served grilled, pan-fried, or broiled. The more tender cuts from the loin and rib are cooked quickly, using dry heat, and served whole...
, poultry
Poultry
Poultry are domesticated birds kept by humans for the purpose of producing eggs, meat, and/or feathers. These most typically are members of the superorder Galloanserae , especially the order Galliformes and the family Anatidae , commonly known as "waterfowl"...
, or pork
Pork
Pork is the culinary name for meat from the domestic pig , which is eaten in many countries. It is one of the most commonly consumed meats worldwide, with evidence of pig husbandry dating back to 5000 BC....
leading to the colourful description of the phenomenon as steakhouse syndrome. People with food bolus obstruction typically display acute dysphagia
Dysphagia
Dysphagia is the medical term for the symptom of difficulty in swallowing. Although classified under "symptoms and signs" in ICD-10, the term is sometimes used as a condition in its own right. Sufferers are sometimes unaware of their dysphagia....
(difficulty swallowing), often to the point that they cannot even swallow their saliva
Saliva
Saliva , referred to in various contexts as spit, spittle, drivel, drool, or slobber, is the watery substance produced in the mouths of humans and most other animals. Saliva is a component of oral fluid. In mammals, saliva is produced in and secreted from the three pairs of major salivary glands,...
, leading to drooling. They may also suffer from chest pain, neck pain, regurgitation of food, or painful swallowing (odynophagia
Odynophagia
Odynophagia is painful swallowing, in the mouth or esophagus. It can occur with or without dysphagia, or difficult swallowing....
).
Patients with esophageal food bolus
Bolus
-Medicine:* Bolus , the administration of a drug, medication or other substance in the form of a single, large dose* Bolus , a tissue equivalent substance used in radiation therapy...
es are also at risk of complications, such as perforation of the esophagus, and aspiration into the lungs
Aspiration pneumonia
Aspiration pneumonia is bronchopneumonia that develops due to the entrance of foreign materials into the bronchial tree, usually oral or gastric contents...
. As a result, urgent treatment of patients with high-risk features, or a lengthy duration of symptoms, is recommended.
Predisposing conditions
Food bolus obstruction is most commonly caused by Schatzki ringSchatzki ring
A Schatzki ring or Schatzki-Gary ring is a narrowing of the lower part of the esophagus that can cause difficulty swallowing. The narrowing is caused by a ring of mucosal tissue or muscular tissue. Patients with Schatzki rings can develop intermittent dysphagia , or, more seriously, a completely...
s, which are mucosal rings of unknown cause in the lower esophagus. Foodstuff jams into the esophagus due to the narrowing caused by the ring. An increasingly commonly recognized cause for esophageal food bolus obstruction is eosinophilic esophagitis
Eosinophilic esophagitis
Eosinophilic esophagitis is an allergic inflammatory condition of the esophagus. Symptoms are swallowing difficulty, food impaction, and heartburn. The disease was first described in children but occurs in adults as well...
, which is an inflammatory disorder of the mucosa of the esophagus, of unknown cause. Many alterations caused by eosinophilic esophagitis can predispose to food boluses; these include the presence of multiple rings and narrowing of the lumen. When considering esophageal dilation to treat a patient with food bolus obstruction, care must be made to look for features of eosinophilic esophagitis, as these patients are at a higher risk of dilation-associated complications.
Other conditions that predispose to food bolus obstructions are esophageal web
Esophageal web
-Presentation:Its main symptoms are pain and difficulty in swallowing .Esophageal webs are thin membranes of normal esophageal tissue consisting of mucosa and submucosa. They can be congenital or acquired. Congenital webs commonly appear in the middle and inferior third of the esophagus, and they...
s and peptic stricture
Stenosis
A stenosis is an abnormal narrowing in a blood vessel or other tubular organ or structure.It is also sometimes called a stricture ....
s. Food boluses are common in the course of illness in patients with esophageal cancer
Esophageal cancer
Esophageal cancer is malignancy of the esophagus. There are various subtypes, primarily squamous cell cancer and adenocarcinoma . Squamous cell cancer arises from the cells that line the upper part of the esophagus...
but are more difficult to treat as endoscopy to push the bolus is less safe. Patients with esophageal self-expandable metallic stent
Self-expandable metallic stent
A self-expandable metallic stent is a metallic tube, or stent, used in order to hold open a structure in the gastrointestinal tract in order to allow the passage of food, chyme, stool, or other secretions required for digestion...
s may present with food boluses lodged within the stent lumen. Rarely disorders of movement of the esophagus, such as nutcracker esophagus
Nutcracker esophagus
Nutcracker esophagus is a disorder of the movement of the esophagus, and is one of many motility disorders of the esophagus, including achalasia and diffuse esophageal spasm. It causes difficulty swallowing, or dysphagia, to both solid and liquid foods, and can cause chest pain; it may also be...
, can predispose to food bolus obstruction.
Treatment
The standard treatment of food bolus obstruction is the use of endoscopyEndoscopy
Endoscopy means looking inside and typically refers to looking inside the body for medical reasons using an endoscope , an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices, endoscopes are inserted directly into the organ...
or fibre-optic cameras inserted by mouth into the esophagus. Endoscopes can be used to diagnose the cause of the food bolus obstruction, as well as to remove the obstruction. Traditional endoscopic techniques involved the use of an overtube, a plastic tube inserted into the esophagus prior to the removal of the food bolus, in order to reduce the risk of aspiration into the lung
Lung
The lung is the essential respiration organ in many air-breathing animals, including most tetrapods, a few fish and a few snails. In mammals and the more complex life forms, the two lungs are located near the backbone on either side of the heart...
s at the time of endoscopy. However, the push technique, which involves insufflating air into the esophagus, and gently pushing the bolus toward the stomach instead, has emerged as a common and safe way of removing the obstruction.
Other tools may be used to remove food boluses. The Roth net is a mesh net that can be inserted through the endoscope, and opened and closed from the outside; it can be used to retrieve pieces of obstructed food. Snares, which are normally used to remove polyps
Polyp (medicine)
A polyp is an abnormal growth of tissue projecting from a mucous membrane. If it is attached to the surface by a narrow elongated stalk, it is said to be pedunculated. If no stalk is present, it is said to be sessile. Polyps are commonly found in the colon, stomach, nose, sinus, urinary bladder...
can be used to macerate the food causing the obstruction. Dormia baskets, which are metal baskets used to remove stones from the common bile duct
Common bile duct
The common bile duct is a tube-like anatomic structure in the human gastrointestinal tract. It is formed by the union of the common hepatic duct and the cystic duct . It is later joined by the pancreatic duct to form the ampulla of Vater...
in a procedure known as endoscopic retrograde cholangiopancreatography
Endoscopic retrograde cholangiopancreatography
Endoscopic retrograde cholangiopancreatography is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems...
, can be opened and closed from the outside in a similar manner to macerate food and facilitate removal. Forceps
Forceps
Forceps or forcipes are a handheld, hinged instrument used for grasping and holding objects. Forceps are used when fingers are too large to grasp small objects or when many objects need to be held at one time while the hands are used to perform a task. The term 'forceps' is used almost exclusively...
used for biopsies
Biopsy
A biopsy is a medical test involving sampling of cells or tissues for examination. It is the medical removal of tissue from a living subject to determine the presence or extent of a disease. The tissue is generally examined under a microscope by a pathologist, and can also be analyzed chemically...
can also be employed in a similar manner.
Historical treatment of food bolus obstruction included administration of proteolytic enzymes (such as meat tenderizer
Meat tenderizer
A meat tenderizer is hand-powered tool used to tenderize slabs of meat in preparation for cooking the meat. Although a meat tenderizer can be made out of virtually any object there are three types that manufactured specifically for tenderizing meat. The first, most common, is a tool that resembles...
s), or even acidic substances, such as Coca-Cola
Coca-Cola
Coca-Cola is a carbonated soft drink sold in stores, restaurants, and vending machines in more than 200 countries. It is produced by The Coca-Cola Company of Atlanta, Georgia, and is often referred to simply as Coke...
with the purpose of degrading the meat that was blocked; however, this was often complicated by perforation of the esophagus. Other modalities rarely used now include administration of anti-spasmodic medications, such as hyoscine butylbromide, removal of boluses using catheter
Catheter
In medicine, a catheter is a tube that can be inserted into a body cavity, duct, or vessel. Catheters thereby allow drainage, administration of fluids or gases, or access by surgical instruments. The process of inserting a catheter is catheterization...
s, and the use of large-bore tubes inserted into the esophagus to forcefully lavage it.
Recently a combination therapy that uses intravenous glucagon
Glucagon
Glucagon, a hormone secreted by the pancreas, raises blood glucose levels. Its effect is opposite that of insulin, which lowers blood glucose levels. The pancreas releases glucagon when blood sugar levels fall too low. Glucagon causes the liver to convert stored glycogen into glucose, which is...
, an effervescent agent and water has been used as a less invasive method to relieve esophageal food bolus obstruction. This procedure is performed by a radiologist or other qualifying physician using fluoroscopy
Fluoroscopy
Fluoroscopy is an imaging technique commonly used by physicians to obtain real-time moving images of the internal structures of a patient through the use of a fluoroscope. In its simplest form, a fluoroscope consists of an X-ray source and fluorescent screen between which a patient is placed...
to identify the location of the obstruction before the procedure and confirm successful clearance of food bolus after the procedure. Glucagon relaxes the lower esophageal muscles, the effervescent agent distends the esophagus and hydrostatic pressure caused by the water and the use of gravity push the food bolus into the stomach. There are however limitations to this technique and situations which would predispose the esophagus to rupture or the procedure to fail should be avoided. Patients who don't qualify for the procedure or those who fail initial attempts should be treated with the standard endoscopic methods. Appropriate patient selection is crucial for the procedure to succeed and to minimize complications.