Section: UGI Sub-section: Oesophagus Curriculum: Curriculum, page 95

Incidence

Oesophagus most common site for impaction of ingested foreign bodies (75% of all)
Majority in children under 10yrs
Most commonly cervical oesophagus
Can occur at any of the narrowings
- Cricopharyngeus
- Aortic arch
- Left main bronchus
- GOJ

Aetiology

90% have clear history of ingestion followed by dysphagia
May be more difficult in young children or uncooperative adults
- May also get
  - Refusal of feeds
  - Gagging or chocking
- May be undiscovered for months and get chronic aspiration or reflux
Respiratory symptoms in 15%, especially children and cervical impaction
- Cough, wheeze, stridor, dyspnoea
Cervical impaction can also cause associated tracheal obstruction
- “Café coronary” or steakhouse syndrome”
Sharp object ingestion can mimic symptoms even if passes easily
Impaction obstruction can lead to drooling
Can be complicated by perforation

Plain CXR (AP and Lateral)
- Can localise radio-opaque objects
- Useful if perforation suspected
- Use in children to confirm diagnosis, even if asymptomatic
Consider CT if
- Sharp objects, ? Perforation, ? Narcotic packets
Endoscopy investigation of choice
- Allows for therapeutic intervention

Observation of objects for up to 24hrs can be considered is asymptomatic smooth objects
Proteolytic agents (Papain)
- Dissolve food bolus
- Cause oesophageal trauma, and dangerous if aspirated
  - Not Recommended!
Effervescents and smooth muscle relaxants
- E.g. Carbonated drinks, Glucagon, Buscopan
- ? May help by dis-impacting food
- No good evidence to support use

Indications for urgent intervention
- Airway compromise
- Absolute dysphagia (aspiration risk)
- Oesophageal impaction of sharp objects, magnets or button battery
- Oesophageal impaction of > 24hrs
- Objects over 5cm long or 2cm in diameter will need endoscopic removal as will likely not pass through pylorus/duodenal curves
- Sharp objects should be removed if can be done safely
  - 35% risk of perforation if left
General anaesthesia may be required, especially in young children
Success rate > 95%
- Failure generally linked to size of objects (e.g. dentures!)
- Smooth objects may be harder to retrieve
- Can use graspers, snares or magnet baskets etc
- Remove sharp objects blunt end first
Remove coins on their sides to pass through cricopharyngeus
Never attempt to push into stomach unless have passed scope into stomach first

Should always be removed if oesophageal impaction
- Can have electrical discharge or release of alkali contents
- Can cause local damage, necrosis, perforation
But if passed into stomach and duodenum
- 80-90% will pass without complication
- Observe with serial radiography
  - Intervene (endoscopic or surgical) if
    - Fails to progress from stomach in 48hrs
    - Symptoms of intestinal injury
    - Battery fragments and symptoms of mercury toxicity

May be necessary if endoscopy fails
- Large objects
- Objects embedded into the oesophageal wall
- Associated iatrogenic perforation
Approach depends on
- Site and severity of perforation
- Amount of inflammation
- Underlying pathology