Esophageal Foreign Body Management

Introduction to Esophageal Foreign Body

Patients taking anticoagulant medications should seek medical attention if they experience a foreign body sensation, as it may lead to serious complications, according to the American Heart Association guidelines 1

Patients with a foreign body sensation accompanied by difficulty breathing, stridor, inability to swallow saliva, progressive symptoms, or fever should seek immediate medical attention, as these symptoms may indicate a serious underlying condition, as recommended by the American College of Chest Physicians 2
Patients with a foreign body sensation should be evaluated for underlying esophageal disorders, such as eosinophilic esophagitis, esophageal stricture, or achalasia, and receive appropriate treatment, as recommended by the American College of Chest Physicians 3
Imaging modalities for esophageal foreign bodies have varying diagnostic yields, with plain radiographs having limited utility (up to 85% false-negative rate) and CT scans being highly recommended for accurate assessment of foreign body location and complications, as shown in the following table:

Imaging Modality	Diagnostic Yield
Plain Radiographs	Limited (up to 85% false-negative rate)
CT Scan	High (recommended for accurate assessment of foreign body location and complications)
CT Scan with Oral Contrast	High (recommended if persistent chest pain develops, or if perforation or other complications are suspected) [4, 5]

Patients with a foreign body sensation should drink water or other fluids to help wash away small food particles lodged in the epiglottis fold, and seek medical attention if the sensation persists, as recommended by the American Academy of Otolaryngology 1
Patients with a history of foreign body sensation should be advised to chew their food properly and eat slowly to prevent future incidents, as recommended by the American Gastroenterological Association 2
Endoscopic evaluation is recommended for patients with suspected eosinophilic esophagitis (EoE), with at least 6 esophageal biopsies from different anatomical sites obtained during the index endoscopy to confirm diagnosis, as recommended by the American Gastroenterological Association 6
Underlying esophageal disorders are found in up to 25% of patients with food bolus impaction, with common conditions including EoE, esophageal stricture, hiatus hernia, esophageal web or Schatzki ring, achalasia, and tumors, emphasizing the need for thorough diagnostic procedures 4, 6, 7

Endoscopic intervention is the recommended first-line treatment for acute food bolus impaction in EoE patients, with dilatation offered as first-line treatment in patients with acute symptoms such as food bolus obstruction (GRADE of evidence: moderate; strength of recommendation: strong), as recommended by the Gut journal 5
Flexible endoscopy is a recommended treatment with a success rate of up to 90%, and should be performed with adequate anesthetic support for airway management, considering both "push technique" and "extraction technique", as recommended by the European Society of Gastrointestinal Endoscopy 6
A combined approach using flexible and rigid endoscopy may be helpful for visualization and retrieval of foreign bodies, with fluoroscopic guidance enhancing safety during intervention for high-risk cases, as recommended by the European Society of Gastrointestinal Endoscopy 4, 5
Topical corticosteroids and dietary therapy have shown significant reduction in risk of recurrent food bolus obstruction, with the American Gastroenterological Association suggesting consideration of proton pump inhibitor therapy as adjunctive treatment, as recommended by the American Gastroenterological Association 6, 7

Close monitoring for at least 2 hours in recovery is recommended, with suspect perforation if patient develops pain, breathlessness, fever, or tachycardia, and clear written instructions should be provided with advice on fluids, diet, and medications, and contact information for the on-call team should symptoms develop, as recommended by the European Society of Gastrointestinal Endoscopy 5
Withhold proton pump inhibitors for at least 3 weeks prior to follow-up endoscopy if EoE is suspected but not confirmed, to ensure accurate diagnosis and treatment, and arrange elective endoscopy if food bolus obstruction spontaneously resolves or sufficient biopsies were not obtained, as recommended by the American Gastroenterological Association 6