Complete Gastroesophageal Obstruction by Food Bolus

Case Summary

A 54-year-old male with history of esophageal varices, alcoholic cirrhosis and alcohol abuse presented with inability to swallow that started on the day of presentation to the emergency room. The patient woke up at 3 a.m. and ate steak, then went back to sleep. Shortly there after, he woke up to drink water but was unable to swallow the water and had not been able to swallow since then. The patient was coughing up yellow phlegm frequently. He had his last drink of alcohol before eating the steak and about 12 hours prior to presentation to the emergency room. His serum alcohol toxicology screen was 120 mg/dl. The patient was tremulous at presentation to the emergency room. The patient reported no blood in sputum but reported bright red blood per rectum with history of hemorrhoids and blood in urine one month ago, which had turned dark ever since.

Table 1. Results of various studies
Study	Population	Sample size	Most common impaction	Other impactions	Gastrointestinal comorbidity	Flexible esophagoscopy success rate (%)	Flexible esophagoscopy complication rate (%) and types
Webb¹	USA	242	Meat (59.9%)			98.8%	0%
Li et al²	China	1088	Food boluses		Esophageal carcinoma, stricture, diverticulum, post gastrectomy, hiatal hernia, achalasia	94.1%	2.8%; mucosal laceration, bleeding, pyrexia, perforation
Vicente et al³	Spain	8	Meat (100%)		Gastroesophageal reflux like vomiting, heartburn, respiratory tract disease (75%). No stenosis. Hiatal hernia (38%), esophagitis (75%), Schiatzki's ring (13%)
Carr & Drennan⁴	USA	64	Meat (92%)	Orange (1.5%), vegetables (1.5%), pills (3%), bagel (1.5)	Reflux strictures (66%), neuromuscular disease or dysmotility (3%), esophageal cancer (2%), no underlying pathology (29%)		4%; retained meat, esophageal tear & subsequent death, mucosal tear, barium aspiration & infection
Sperry et al⁵	USA	548	Meat (25%)	Food (31%), coin (21%), beans, fruit, vegetable (18%), unknown (5%)	Eosinophilic esophagitis (9%), Gastroesophageal reflux disease/erosive esophagitis (15%), esophageal stricture (12%), hiatal hernia (11%), Schiatzki's ring (7%), cancer (2%), others (ulcer, Barrett's esophagus, prior surgery (20%)
Crockett et al⁶	USA	548	Meat (35%)	Beans, fruit, vegetable (19%), coin (27%), bone (6%), pill (3%), battery (1%), toy (Legos, Lite Brite pieces) (1%), others (bottle cap, toothpick, blister pack of pills, pebble) (6%), unknown (3%)	Schiatzki's ring (43%), peptic ulcer stricture (35%), hiatal hernia only (4%), miscellaneous (other strictures, webs, esophagitis, cancer, dysmotility) (7%), no abnormality (12%)
Longstreth et al⁷	USA	194 patients, 223 episodes	Meat (85%) vegetable (3%), nuts, rice, egg sandwich, pastry (3%), fruit (2%), unspecified (8%)			98%
Gretarsdottir et al⁸	Iceland	308	Meat (68%)	Fish (12%), vegetable (4%), other (16%)	Hiatal hernia (22%), reflux esophagitis (23%), stricture (45%), eosinophilic esophagitis (16%), malignancy (2%), Schiatzki's ring (12%), ring (7%), furrows (3%), normal esophagus (33%)	98%	Apart from minor bleeding, 1.9%: 1.3% patients aspiration, 0.3% esophageal perforation, 0.3% Boerhaave syndrome

Table 1. Results of various studies

Study

Population

Sample size

Most common impaction

Other impactions

Gastrointestinal comorbidity

Flexible esophagoscopy success rate (%)

Flexible esophagoscopy complication rate (%) and types

Webb¹

USA

242

Meat (59.9%)

98.8%

Li et al²

China

1088

Food boluses

Esophageal carcinoma, stricture, diverticulum, post gastrectomy, hiatal hernia, achalasia

94.1%

2.8%; mucosal laceration, bleeding, pyrexia, perforation

Vicente et al³

Spain

Meat (100%)

Gastroesophageal reflux like vomiting, heartburn, respiratory tract disease (75%). No stenosis. Hiatal hernia (38%), esophagitis (75%), Schiatzki's ring (13%)

Carr & Drennan⁴

USA

Meat (92%)

Orange (1.5%), vegetables (1.5%), pills (3%), bagel (1.5)

Reflux strictures (66%), neuromuscular disease or dysmotility (3%), esophageal cancer (2%), no underlying pathology (29%)

4%; retained meat, esophageal tear & subsequent death, mucosal tear, barium aspiration & infection

Sperry et al⁵

USA

548

Meat (25%)

Food (31%), coin (21%), beans, fruit, vegetable (18%), unknown (5%)

Eosinophilic esophagitis (9%), Gastroesophageal reflux disease/erosive esophagitis (15%), esophageal stricture (12%), hiatal hernia (11%), Schiatzki's ring (7%), cancer (2%), others (ulcer, Barrett's esophagus, prior surgery (20%)

Crockett et al⁶

USA

548

Meat (35%)

Beans, fruit, vegetable (19%), coin (27%), bone (6%), pill (3%), battery (1%), toy (Legos, Lite Brite pieces) (1%), others (bottle cap, toothpick, blister pack of pills, pebble) (6%), unknown (3%)

Schiatzki's ring (43%), peptic ulcer stricture (35%), hiatal hernia only (4%), miscellaneous (other strictures, webs, esophagitis, cancer, dysmotility) (7%), no abnormality (12%)

Longstreth et al⁷

USA

194 patients, 223 episodes

Meat (85%) vegetable (3%), nuts, rice, egg sandwich, pastry (3%), fruit (2%), unspecified (8%)

98%

Gretarsdottir et al⁸

Iceland

308

Meat (68%)

Fish (12%), vegetable (4%), other (16%)

Hiatal hernia (22%), reflux esophagitis (23%), stricture (45%), eosinophilic esophagitis (16%), malignancy (2%), Schiatzki's ring (12%), ring (7%), furrows (3%), normal esophagus (33%)

98%

Apart from minor bleeding, 1.9%: 1.3% patients aspiration, 0.3% esophageal perforation, 0.3% Boerhaave syndrome