Management of Esophageal Foreign Bodies

Initial Assessment

For patients reporting a pill stuck in their throat or esophagus, urgent endoscopic intervention within 2-6 hours is recommended due to risks of aspiration, perforation, and development of pill-induced esophagitis 1
Obtain complete blood count, blood gas analysis, and other laboratory tests as part of the initial evaluation 1
Plain radiographs of the neck, chest, and abdomen can help assess for complications but have limited utility with high false-negative rates 1
CT scan should be performed if perforation or other complications are suspected, with a sensitivity of 90-100% compared to only 32% for plain X-rays 1
Contrast swallow studies are NOT recommended as they may increase aspiration risk and impair subsequent endoscopic visualization 1

For complete esophageal obstruction or significant symptoms, arrange emergent flexible endoscopy within 2-6 hours 1
For partial obstruction with mild symptoms, urgent flexible endoscopy within 24 hours is recommended 1
During endoscopy, first attempt gentle pushing of the pill into the stomach using air insufflation and instrumental pushing 1
If pushing fails, use retrieval techniques with baskets, snares, or grasping forceps 1, 2
Obtain diagnostic biopsies during the index endoscopy to assess for underlying conditions 1, 3
Rigid endoscopy should be considered as a second-line approach if flexible endoscopy fails, particularly for objects in the upper esophagus 1, 2

Patients with significant esophageal injury should be nursed upright and administered high-flow humidified oxygen 4
Keep the patient nil by mouth if there are concerns about laryngeal competence 4
Monitor for warning signs including stridor, obstructed breathing pattern, agitation, fever, and deep cervical or chest pain 4

An underlying esophageal disorder is found in up to 25% of patients with food or pill impaction 1, 2
Eosinophilic esophagitis is the most common cause, found in up to 46% of patients with food bolus obstruction 1, 3
Other common underlying conditions include esophageal stricture, hiatus hernia, esophageal web or Schatzki ring, achalasia, and tumors 1, 2

If adequate biopsies were not obtained during the initial endoscopy, arrange for elective repeat endoscopy 1, 3
For patients diagnosed with eosinophilic esophagitis, withhold PPI for at least 3 weeks before repeat endoscopy if symptoms persist 1, 3
Outpatient review should be arranged to confirm the cause of the impaction, educate the patient, and institute appropriate therapy for any underlying condition 1, 3

Identify and address any underlying esophageal disorders that may predispose to pill impaction 1, 2

Mediastinitis can occur after esophageal perforation, characterized by severe sore throat, deep cervical pain, chest pain, dysphagia, fever, and crepitus 4
Patients should be informed about the symptoms of mediastinitis and advised to seek immediate medical attention if they develop 4