Food Impaction

Esophageal Food ImpactionThanksgiving is a wonderful time of the year in the USA. We take time out of our busy schedules to stop and express our true gratitude for what is more important in our lives. Oh, yes… and we overindulge and binge on food and beverage with the zeal of a new puppy tearing apart a pair of brand new leather shoes. Hmm… delicious indulgence (some may even say that is what many are truly thankful for)! Of course, all actions have risks and benefits. One hazard of such behavior is getting a bolus of food lodged in the ol’ food pipe. Of course, that is mostly an adult problem and not one we need to mention in the PedEMMorsels… right? Well, let’s take a minute to review: Food Impaction in Children!

 

Esophageal Foreign Bodies

  • Foreign Bodies (FB) get stuck in the esophagus commonly.
  • Typically, we worry most about the possible aspiration of a FB.
  • But, esophageal FBs can also lead to significant problems (ex, Button Batteries).
    • Young children most often have non-food items stuck (ex, coins).
    • Older children are more likely to have food impaction!

 

Food Impaction in Children

  • Food impaction accounts for ~13% of all esophageal FBs. [Kriem, 2017]
  • Presents with:
    • Dysphagia
    • Refusal to eat/drink
    • FB sensation
    • Drooling
    • Vomiting
  • Cause of:
    • Be leery of ascribed food impaction to eating too quickly or inadequate mastication.
    • Food impaction in children is often related to underlying esophageal pathology. [Hudson, 2013; Hurtado, 2011]
    • Some associated esophageal pathology that would warrant additional therapy:
      • Eosinophilic Esophagitis [Hudson, 2013]
        • History of Gastroesophageal Reflux has also been associated with food impaction cases.
      • Esophageal Strictures and Inflammation [Hurtado, 2011]
      • Motility disorders
      • Prior Nissen fundoplication

 

Food Impaction Management

  • Most will not resolve spontaneously. [Hurtado, 2011]
    • Relief of the impaction is important not just for symptom improvement.
    • Food impaction can lead:
      • Complete esophageal obstruction
      • Massive bleeding
      • Esophageal perforation
      • Pneumomediastinum
      • Aspiration.
  • Imaging:
    • Plain X-rays may not be helpful (unless it is a large bolus leading to a visible mass).
    • Swallowing study with contrast is useful
      • May be challenging if the patient won’t swallow.
      • Can show other underlying anatomic abnormalities
    • Ultrasound has been used to visualize food impaction positioned at the thoracic inlet. [Tessaro, 2016]
  • Therapy:
    • “Medical therapies”
      • Carbonated beverages
        • Thought to increase the pressure within the esophagus, perhaps moving the bolus distally.
        • Tough to use if patient won’t swallow.
      • Glucagon
        • Can reduce the lower esophageal sphincter tone.
        • Won’t work for anatomic obstruction.
        • Also leads to nausea and vomiting… something potentially harmful if there is esophageal obstruction. (see RebelEM)
    • Endoscopic disimpaction is preferred management.
      • It is safe and effective. [Kriem, 2017; Hurtado, 2011]
      • It is required in ~75% of cases. [Hurtado, 2011]
      • Endoscopy can be used to extract (pull) the material out, or push it into the stomach. [Kriem, 2017]
      • With the potential for eosinophilic esophagitis, biopsy specimens should be obtained during endoscopic procedure.
  • Ensure appropriate follow-up!
    • Follow-up is noted to be infrequent when food impaction is successfully treated from the ED. [Hurtado, 2011]
    • Due to risk of possible underlying pathology, outpatient follow-up may still be warranted even if food impaction is resolved in the ED.

 

Moral of the Morsel

  • Be thankful every day… not just one day a year.
  • Enjoy your food and beverage… but, perhaps with some moderation (or at least fully chew it people!!).
  • Kids get food impactions too.
  • If you successfully treat an esophageal food impaction in a child, they still need follow-up with GI as they may have an underlying pathologic condition!

 

References

Kriem J1, Rahhal R. Safety and Efficacy of the Push Endoscopic Technique in the Management of Esophageal Food Bolus Impactions in Children. J Pediatr Gastroenterol Nutr. 2017 Jun 9. PMID: 28604510. [PubMed] [Read by QxMD]

Simone LA1, Orsborn J2, Berant R3, Tessaro MO4. Point-of-care ultrasonography in the detection of pediatric esophageal food impaction. Am J Emerg Med. 2016 Apr;34(4):763. PMID: 26349776. [PubMed] [Read by QxMD]
Diniz LO1, Towbin AJ. Causes of esophageal food bolus impaction in the pediatric population. Dig Dis Sci. 2012 Mar;57(3):690-3. PMID: 21948341. [PubMed] [Read by QxMD]

Hurtado CW1, Furuta GT, Kramer RE. Etiology of esophageal food impactions in children. J Pediatr Gastroenterol Nutr. 2011 Jan;52(1):43-6. PMID: 20975581. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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