今日の臨床サポート

食塊による食道閉塞

概要・推奨   

  1. Food bolus impactionは食道異常の症状と考え、精査していくことが勧められる(推奨度1)
  1. Food bolus impactionは食塊内に鋭利なものがなく、食道完全閉塞状態でなければ24時間までは自然経過観察をしても許容される(推奨度2)
  1. 小児におけるfood bolus impactionでは、喘鳴(stridor)や呼吸状態などを観察することが勧められる(推奨度1)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
西川佳友 : 特に申告事項無し[2022年]
監修:林寛之 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 定期レビューを行い、ガイドラインに追加された事項について記載した。
  1. 完全閉塞を来している食塊による食道閉塞においては、可能であれば2時間以内での解除が推奨されていることを強調したい。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 食塊による食道閉塞(food bolus impaction)では7~8割近くに食道疾患(食道アカラシア好酸球性食道炎、狭窄、憩室、強皮症食道癌など)を有する。food bolus impactionは食道異常の症状とみなす。
 
Food bolus impactionの内視鏡像

食道に食塊が詰まった内視鏡像。食道粘膜に気管様多発輪状狭窄を認め、基礎疾患として好酸球性食道炎の存在が疑われる。

 
  1. ゴールドスタンダードは内視鏡による解除および食道病変検索である。
  1. 唾液を飲み込めないなど完全閉塞を疑うときは緊急内視鏡による解除が必須となり、可能であれば2時間以内、少なくとも6時間以内の解除が推奨されている[1][2]
  1. 蛋白質分解酵素パパインには食道粘膜損傷や食道穿孔のリスク、造影剤ガストログラフィンには誤嚥による肺臓炎のリスクがあり使用を控える。
  1. グルカゴン、炭酸水、ニトロ製剤などLES(lower esophageal sphincter)圧低下による解除方法も存在するが、エビデンスに乏しい。
  1. 内視鏡による解除は、胃内へと押し込むpush法、体外へ取り出すextraction法に大別される。どちらも有効であるが、大きな食塊、食塊内に骨など鋭利なものが内在している場合や、遠位食道に狭窄病変が既知の場合は体外へ取り出すextraction法を選択する。
  1. 食塊内に骨など鋭利なものが存在する場合、オーバーチューブを使用するなど食道粘膜保護にも注意を払う。
 
オーバーチューブの概観

(食塊内に骨など鋭利なものが存在する場合に、)オーバーチューブを用いて、食道粘膜の保護を図る。

 
  1. Food bolus impactionは食道異常の症状と考え、精査していくことが勧められる[3](推奨度 1MG)
  1. Food bolus impactionを起こした患者では8割近く[1]に食道疾患(狭窄、憩室、食道癌強皮症、びまん性食道攣縮、食道アカラシア好酸球性食道炎、消化管手術既往、奇形など)を認めた[3][4][5][6]
  1. 食道癌は進行するとfood bolus impactionを起こすが、早期癌では意外にもfood bolus impactionを起こさない[3]。食道病変を有する人が、あまり咀嚼しないで食べると起こりやすい[7]
 
  1. Food bolus impactionは食塊内に鋭利なものがなく、食道完全閉塞状態でなければ24時間までは自然経過観察をしても許容される[8][6](推奨度 2MG)
  1. Food bolus impactionの54%は自然に解除される[8]
  1. 食塊の大きさ、形、種類、中身、詰まった場所、時間経過、患者の状態、患者年齢、基礎疾患、合併症の有無などによって治療戦略が異なる[6][9][10]。涎が出る、唾液を飲み込むことができないなどの症状は食道完全閉塞状態を示唆しており、内視鏡による緊急解除を要する[6][9][10][5]
  1. 合併症は食道粘膜びらん、出血、潰瘍形成、裂傷、穿孔、食道‐大動脈瘻、食道‐気管瘻などが挙げられる[6][9]。食塊による長期間の食道粘膜圧迫や骨など鋭利なものの存在は、穿孔リスクが上昇する[6]。肉塊は他の食べものより自然解除が期待できず、内視鏡での解除が必要とされる[7]。発症6~12時間までであれば、食道粘膜の圧迫や食塊の軟化も高度でなく、一塊で取り出すことができる[5][4]
  1. Zhao-Shenらによると、中国でのfood bolus impactionは魚骨や鶏骨を含むことが多いためか自覚症状が強く、合併症も多いため内視鏡による早期の解除を勧めている[11]
 
  1. 薬剤による食塊解除方法も存在するが、エビデンスに乏しくあまり推奨しない。(推奨度 3MG)
  1. グルカゴン、炭酸水、ニトロ製剤などLES(lower esophageal sphincter)圧低下による解除方法も存在するが、プラセボより優れた効果は見いだせていない[6][12][9][13]。比較的安全な薬剤でもあり試す価値はあるかもしれないが、内視鏡での除去を遅らせるものではない[6]
  1. 蛋白質分解酵素パパインは食道粘膜損傷や食道穿孔の恐れがあり、使用してはならない[6][14]
  1. ガストログラフィンなどの造影剤は誤嚥および肺臓炎のリスクがあるため、使用してはならない[6][10][5]
 
問診・診察のポイント  
  1. 何を飲み込んだか、どこに詰まった感じがするか、飲み込んでから何時間経過しているか、今までにも同じエピソードがあったかなどの質問は治療方針にも影響するため、可能な限り聴取する。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

Michael Birk, Peter Bauerfeind, Pierre H Deprez, Michael Häfner, Dirk Hartmann, Cesare Hassan, Tomas Hucl, Gilles Lesur, Lars Aabakken, Alexander Meining
Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline.
Endoscopy. 2016 May;48(5):489-96. doi: 10.1055/s-0042-100456. Epub 2016 Feb 10.
Abstract/Text This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the removal of foreign bodies in the upper gastrointestinal tract in adults. Recommendations Nonendoscopic measures 1 ESGE recommends diagnostic evaluation based on the patient's history and symptoms. ESGE recommends a physical examination focused on the patient's general condition and to assess signs of any complications (strong recommendation, low quality evidence). 2 ESGE does not recommend radiological evaluation for patients with nonbony food bolus impaction without complications. We recommend plain radiography to assess the presence, location, size, configuration, and number of ingested foreign bodies if ingestion of radiopaque objects is suspected or type of object is unknown (strong recommendation, low quality evidence). 3 ESGE recommends computed tomography (CT) scan in all patients with suspected perforation or other complication that may require surgery (strong recommendation, low quality evidence). 4 ESGE does not recommend barium swallow, because of the risk of aspiration and worsening of the endoscopic visualization (strong recommendation, low quality evidence). 5 ESGE recommends clinical observation without the need for endoscopic removal for management of asymptomatic patients with ingestion of blunt and small objects (except batteries and magnets). If feasible, outpatient management is appropriate (strong recommendation, low quality evidence). 6 ESGE recommends close observation in asymptomatic individuals who have concealed packets of drugs by swallowing ("body packing"). We recommend against endoscopic retrieval. We recommend surgical referral in cases of suspected packet rupture, failure of packets to progress, or intestinal obstruction (strong recommendation, low quality evidence). Endoscopic measures 7 ESGE recommends emergent (preferably within 2 hours, but at the latest within 6 hours) therapeutic esophagogastroduodenoscopy for foreign bodies inducing complete esophageal obstruction, and for sharp-pointed objects or batteries in the esophagus. We recommend urgent (within 24 hours) therapeutic esophagogastroduodenoscopy for other esophageal foreign bodies without complete obstruction (strong recommendation, low quality evidence). 8 ESGE suggests treatment of food bolus impaction in the esophagus by gently pushing the bolus into the stomach. If this procedure is not successful, retrieval should be considered (weak recommendation, low quality evidence). The effectiveness of medical treatment of esophageal food bolus impaction is debated. It is therefore recommended, that medical treatment should not delay endoscopy (strong recommendation, low quality evidence). 9 In cases of food bolus impaction, ESGE recommends a diagnostic work-up for potential underlying disease, including histological evaluation, in addition to therapeutic endoscopy (strong recommendation, low quality evidence). 10 ESGE recommends urgent (within 24 hours) therapeutic esophagogastroduodenoscopy for foreign bodies in the stomach such as sharp-pointed objects, magnets, batteries and large/long objects. We suggest nonurgent (within 72 hours) therapeutic esophagogastroduodenoscopy for medium-sized blunt foreign bodies in the stomach (strong recommendation, low quality evidence). 11 ESGE recommends the use of a protective device in order to avoid esophagogastric/pharyngeal damage and aspiration during endoscopic extraction of sharp-pointed foreign bodies. Endotracheal intubation should be considered in the case of high risk of aspiration (strong recommendation, low quality evidence). 12 ESGE suggests the use of suitable extraction devices according to the type and location of the ingested foreign body (weak recommendation, low quality evidence). 13 After successful and uncomplicated endoscopic removal of ingested foreign bodies, ESGE suggests that the patient may be discharged. If foreign bodies are not or cannot be removed, a case-by-case approach depending on the size and type of the foreign body is suggested (weak recommendation, low quality evidence).

© Georg Thieme Verlag KG Stuttgart · New York.
PMID 26862844
Mircea Chirica, Michael D Kelly, Stefano Siboni, Alberto Aiolfi, Carlo Galdino Riva, Emanuele Asti, Davide Ferrari, Ari Leppäniemi, Richard P G Ten Broek, Pierre Yves Brichon, Yoram Kluger, Gustavo Pereira Fraga, Gil Frey, Nelson Adami Andreollo, Federico Coccolini, Cristina Frattini, Ernest E Moore, Osvaldo Chiara, Salomone Di Saverio, Massimo Sartelli, Dieter Weber, Luca Ansaloni, Walter Biffl, Helene Corte, Imtaz Wani, Gianluca Baiocchi, Pierre Cattan, Fausto Catena, Luigi Bonavina
Esophageal emergencies: WSES guidelines.
World J Emerg Surg. 2019;14:26. doi: 10.1186/s13017-019-0245-2. Epub 2019 May 31.
Abstract/Text The esophagus traverses three body compartments (neck, thorax, and abdomen) and is surrounded at each level by vital organs. Injuries to the esophagus may be classified as foreign body ingestion, caustic ingestion, esophageal perforation, and esophageal trauma. These lesions can be life-threatening either by digestive contamination of surrounding structures in case of esophageal wall breach or concomitant damage of surrounding organs. Early diagnosis and timely therapeutic intervention are the keys of successful management.

PMID 31164915
J Stadler, A H Hölscher, H Feussner, J Dittler, J R Siewert
The "steakhouse syndrome". Primary and definitive diagnosis and therapy.
Surg Endosc. 1989;3(4):195-8.
Abstract/Text Over a period of 5 years, 28 instances of acute food impaction of the esophagus were documented in 26 patients at our institution. In all patients the impacted bolus was successfully removed without complication using a flexible endoscope. Underlying diseases were identified during primary endoscopy in 31% of the cases. Further diagnostic workup was performed in all but 5 of the patients. After adequate evaluation pathologic findings were demonstrated in 90% of the cases (38% malignant and 52% benign diseases). Long-term therapy was deemed necessary in 17 of these 21 patients. Operative intervention was indicated in 4 cases, 2 of which were for malignant tumors. Acute food impaction should always be regarded as a symptom of esophageal disorders. In patients with esophageal cancer or other mediastinal tumors bolus impaction generally indicates an advanced tumor stage.

PMID 2623551
Milton T Smith, Roy K H Wong
Foreign bodies.
Gastrointest Endosc Clin N Am. 2007 Apr;17(2):361-82, vii. doi: 10.1016/j.giec.2007.03.002.
Abstract/Text The spectrum of gastrointestinal (GI) foreign bodies includes food bolus impaction in the esophagus, nonfood objects that are swallowed, and various objects that may be inserted into the rectum. The risk depends upon the type of object and its location. Fortunately, 80% to 90% of ingested foreign bodies will pass without intervention. Objects with sharp edges or pointed tips have the highest risk of complications, up to 35%. All objects impacted in the esophagus require urgent or emergent treatment. Rectal foreign bodies are usually removable transanally, although general anesthesia and operative intervention sometimes are required.

PMID 17556153
Hin Hin Ko, Robert Enns
Review of food bolus management.
Can J Gastroenterol. 2008 Oct;22(10):805-8. doi: 10.1155/2008/682082.
Abstract/Text
PMID 18925301
ASGE Standards of Practice Committee, Steven O Ikenberry, Terry L Jue, Michelle A Anderson, Vasundhara Appalaneni, Subhas Banerjee, Tamir Ben-Menachem, G Anton Decker, Robert D Fanelli, Laurel R Fisher, Norio Fukami, M Edwyn Harrison, Rajeev Jain, Khalid M Khan, Mary Lee Krinsky, John T Maple, Ravi Sharaf, Laura Strohmeyer, Jason A Dominitz
Management of ingested foreign bodies and food impactions.
Gastrointest Endosc. 2011 Jun;73(6):1085-91. doi: 10.1016/j.gie.2010.11.010.
Abstract/Text
PMID 21628009
Thomas C Sodeman, Gavin C Harewood, Todd H Baron
Assessment of the predictors of response to glucagon in the setting of acute esophageal food bolus impaction.
Dysphagia. 2004 Winter;19(1):18-21. doi: 10.1007/s00455-003-0019-5.
Abstract/Text Esophageal food impactions are frequently seen in endoscopic practice. Glucagon is known to relax the lower esophageal sphincter and has been used with variable success to treat food impactions. We retrieved clinical information of all patients with acute food impactions who attended the emergency room from 1975 to 2000 from the Mayo diagnostic database. Data were abstracted on age, sex, body mass index, relevant prior medical history, food type ingested (meat, bread, vegetable, or other), duration of symptoms at presentation, dosage (in mg) of glucagon, outcome including success of glucagon or spontaneous passage, and endoscopic findings. A total of 222 cases of food impaction were identified, of whom 106 patients (48%) received glucagon, average 1 mg. In glucagon responders, meat was less likely to be the offending food type, accounting for 70% (glucagon responders) vs. 90% (in nonresponders) ( p = 0.03), while responders were less likely to have esophageal rings/strictures detected on subsequent EGD compared with nonresponders, 0% (glucagon responders) vs. 31% (nonresponders) ( p = 0.05). In the patients that did not receive glucagon, spontaneous resolvers had a shorter duration of symptoms at presentation, 3.3 h vs. 12.4 h ( p = 0.07) and were less likely to have an organic esophageal obstruction detected on EGD, 0% vs. 21%. There were no significant differences between the resolvers and nonresolvers in terms of age, gender, BMI, and prior medical history. Conservative management of acute food bolus obstruction, either with or without glucagon, is most successful in the absence of a fixed esophageal obstruction. An impacted meat bolus is more likely to require intervention for removal than other food types. These clinical predictors should be considered before administration of glucagon.

PMID 14745641
A Tsikoudas, X Kochillas, R J Kelleher, R Mills
The management of acute oesophageal obstruction from a food bolus. Can we be more conservative?
Eur Arch Otorhinolaryngol. 2005 Jul;262(7):528-30. doi: 10.1007/s00405-004-0853-6. Epub 2004 Dec 9.
Abstract/Text The objective was to assess the number of patients with acute oesophageal bolus obstruction that resolves spontaneously and to aid the identification of the best practice. This prospective and retrospective case series study at a teaching hospital and a district general hospital in Scotland, UK, involved 37 patients with acute oesophageal obstruction from a food bolus who were observed for 24 h from the beginning of symptoms. The bolus passed spontaneously in 54% of the patients during the observational period. A short observational period following the admission of patients with acute food bolus obstruction is reasonable as it may reduce exposure to surgical morbidity and decrease inpatient stay.

PMID 15592861
G Paul Digoy
Diagnosis and management of upper aerodigestive tract foreign bodies.
Otolaryngol Clin North Am. 2008 Jun;41(3):485-96, vii-viii. doi: 10.1016/j.otc.2008.01.013.
Abstract/Text Although often listed together in review articles and case series, tracheobronchial and esophageal foreign bodies can be dissimilar. Airway foreign bodies can range widely in the severity of presentation. When to proceed with a diagnostic bronchoscopy is not always obvious and is based on three diagnostic tools: clinical history, physical examination, and radiography. Radiography plays a more central role in the diagnosis of an esophageal foreign body. In either condition, a delay in diagnosis leads to a greater complication rate. This article provides diagnostic and treatment guidelines in the management of aerodigestive foreign bodies.

PMID 18435994
Zhao-Shen Li, Zhen-Xing Sun, Duo-Wu Zou, Guo-Ming Xu, Ren-Pei Wu, Zhuan Liao
Endoscopic management of foreign bodies in the upper-GI tract: experience with 1088 cases in China.
Gastrointest Endosc. 2006 Oct;64(4):485-92. doi: 10.1016/j.gie.2006.01.059. Epub 2006 Aug 22.
Abstract/Text BACKGROUND: Reports on endoscopic management of ingested foreign bodies of the upper-GI tract in China are scarce.
OBJECTIVE: To report our experience and outcome in the management of ingestion of foreign bodies in Chinese patients.
SETTING AND PATIENTS: Between January 1980 and January 2005, a total of 1088 patients (685 men and 403 women; age range, 1 day to 96 years old) with suspected foreign bodies were admitted to our endoscopy center.
INTERVENTIONS: All patients underwent endoscopic procedure after admission.
MAIN OUTCOME MEASUREMENTS: Demographic and endoscopic data, including age, sex, and referral sources of patients, types, number and location of foreign bodies, associated upper-GI diseases, endoscopic methods, and accessory devices for removal of foreign bodies were collected and analyzed.
RESULTS: A total of 1090 foreign bodies were found in 988 (90.8%) patients. The types of foreign bodies varied greatly: mainly food boluses, coins, fish bones, dental prostheses, or chicken bones. The foreign bodies were located in the pharynx (n = 12), the esophagus (n = 577), the stomach (n = 441), the duodenum (n = 50), and the surgical anastomosis (n = 10). The associated GI diseases (n = 88) included esophageal carcinoma (33.0%), stricture (23.9%), diverticulum (15.9%), postgastrectomy (11.4%), hiatal hernia (10.2%), and achalasia (5.7%). A rat-tooth forceps and a snare were the most frequently used accessory devices. The success rate for foreign-body removal was 94.1% (930/988).
CONCLUSIONS: Ingestion of foreign bodies is a common clinic problem in China. Endoscopy procedures are frequently performed, and a high proportion of patients with foreign bodies require endoscopic intervention.

PMID 16996336
D Leopard, S Fishpool, S Winter
The management of oesophageal soft food bolus obstruction: a systematic review.
Ann R Coll Surg Engl. 2011 Sep;93(6):441-4. doi: 10.1308/003588411X588090.
Abstract/Text INTRODUCTION: Oesophageal soft food bolus obstruction (OSFBO) is a surgical emergency. However, no national guidelines exist regarding its management. This paper systematically reviews the literature with respect to the management of OSFBO.
METHODS: Relevant studies included were identified from the the Cochrane Library, the National Center for Biotechnology Information and the US National Library of Medicine resources. A systematic review was performed on 8 November 2010.
RESULTS: This systematic review of the management of OSFBO shows no evidence that any medical intervention is more effective than a 'watch and wait' policy in enabling spontaneous disimpaction. Furthermore, the use of hyoscine butylbromide for OSFBO probably stems from a misquoted textbook. Surgical removal of an OSFBO is effective but not without potential risk. There is some evidence to support surgical intervention within 24 hours to prevent complications deriving from the initial obstruction.
CONCLUSIONS: There is a need for large double-blind, randomised, placebo controlled trials of drugs used in the medical management of OSFBO. Until the results from such trials are available, the treatment of OSFBO will remain based on inconsistent clinical judgement.

PMID 21929913
Marten Duncan, Roy K Wong
Esophageal emergencies: things that will wake you from a sound sleep.
Gastroenterol Clin North Am. 2003 Dec;32(4):1035-52.
Abstract/Text Esophageal emergencies are a common problem facing practicing gastroenterologists and it is important to know what therapies are indicated for different situations. Patients ingesting caustic agents should be monitored intensively for signs of perforation and ultimately for signs of stricture development. Foreign bodies impacted in the esophagus should be removed promptly to prevent perforation. Although esophageal perforations are generally managed surgically, conservative management of localized perforations has become more common especially with improved antibiotics and the use of nonsurgical interventional drainage techniques. In either elected course the gastroenterologist should work closely with the surgical team.

PMID 14696296
Amanda Muir, Gary W Falk
Eosinophilic Esophagitis: A Review.
JAMA. 2021 Oct 5;326(13):1310-1318. doi: 10.1001/jama.2021.14920.
Abstract/Text Importance: Eosinophilic esophagitis (EoE) is a chronic immune-mediated inflammatory disease of the esophagus that affects an estimated 34.4/100 000 people in Europe and North America. EoE affects both children and adults, and causes dysphagia, food impaction of the esophagus, and esophageal strictures.
Observations: EoE is defined by symptoms of esophageal dysfunction, such as vomiting, dysphagia, or feeding difficulties, in a patient with an esophageal biopsy demonstrating at least 15 eosinophils per high-power field in the absence of other conditions associated with esophageal eosinophilia such as gastroesophageal reflux disease or achalasia. Genetic factors and environmental factors, such as exposure to antibiotics early in life, are associated with EoE. Current therapies include proton pump inhibitors; topical steroid preparations, such as fluticasone and budesonide; dietary therapy with amino acid formula or empirical food elimination; and endoscopic dilation. In a systematic review of observational studies that included 1051 patients with EoE, proton pump inhibitor therapy was associated with a histologic response, defined as less than 15 eosinophils per high-power field on endoscopic biopsy, in 41.7% of patients, while placebo was associated with a 13.3% response rate. In a systematic review of 8 randomized trials of 437 patients with EoE, topical corticosteroid treatment was associated with histologic remission in 64.9% of patients compared with 13.3% for placebo. Patients with esophageal narrowing may require dilation. Objective assessment of therapeutic response typically requires endoscopy with biopsy.
Conclusions and Relevance: EoE has a prevalence of approximately 34.4/100 000 worldwide. Treatments consist of proton pump inhibitors, topical steroids, elemental diet, and empirical food elimination, with esophageal dilation reserved for patients with symptomatic esophageal narrowing.

PMID 34609446
Melanie A Ruffner, Linola Juste, Amanda B Muir
Medical Management of Eosinophilic Esophagitis in Pediatric Patients.
Pediatr Clin North Am. 2021 Dec;68(6):1191-1204. doi: 10.1016/j.pcl.2021.07.014.
Abstract/Text Eosinophilic esophagitis is an immune-mediated allergic disease of the esophagus that affects pediatric patients of all ages. The diagnosis is made by esophagogastroduodenoscopy demonstrating eosinophilic infiltrate of the esophagus. Approaches to treatment involve proton pump inhibitors (PPIs), swallowed topical steroid preparations, as well as dietary elimination. In this review we discuss the evidence and efficacy of each of these approaches.

Copyright © 2021 Elsevier Inc. All rights reserved.
PMID 34736584
Ikuo Hirano, Edmond S Chan, Matthew A Rank, Rajiv N Sharaf, Neil H Stollman, David R Stukus, Kenneth Wang, Matthew Greenhawt, Yngve T Falck-Ytter, AGA Institute Clinical Guidelines Committee, Joint Task Force on Allergy-Immunology Practice Parameters
AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters Clinical Guidelines for the Management of Eosinophilic Esophagitis.
Gastroenterology. 2020 May;158(6):1776-1786. doi: 10.1053/j.gastro.2020.02.038.
Abstract/Text
PMID 32359562
Tusar K Desai, Veslav Stecevic, Chung-Ho Chang, Neal S Goldstein, Kamran Badizadegan, Glenn T Furuta
Association of eosinophilic inflammation with esophageal food impaction in adults.
Gastrointest Endosc. 2005 Jun;61(7):795-801.
Abstract/Text INTRODUCTION: Esophageal food impaction is a common presentation of eosinophilic esophagitis. The prevalence of eosinophilic esophagitis among patients with food impaction is unknown. To address this, we evaluated clinicopathologic features of adults with food impaction.
METHODS: For a 3-year period, patients from a single, adult, community-based gastroenterology practice with esophageal food impaction were evaluated. Histories were assessed and esophageal biopsy specimens were evaluated by routine and immunohistochemical techniques.
RESULTS: Thirty-one patients with food impaction were evaluated. Seventeen of 31 patients had >20 eosinophils/high power field (HPF) without gender predilection. Thirteen of these 17 patients had been treated with proton pump inhibitors at the time biopsy specimens were obtained. Patients with >20 eosinophils/HPF were significantly younger (mean age 42 +/- 4 years) than patients with <20 eosinophils/HPF (mean age 70 + 3 years). Superficial white exudates and eosinophilic microabscesses in the squamous epithelium were features observed only in patients with >20 eosinophils/HPF. Immunopathologic analysis demonstrated increased CD8 lymphocytes and major basic protein deposition in their squamous epithelium.
CONCLUSIONS: More than half of patients with esophageal food impaction in a primary gastroenterology practice have >20 eosinophils/HPF. Based on clinicopathologic features, a significant number likely have eosinophilic esophagitis.

PMID 15933677
Jaishree Rajagopalan, George Triadafilopoulos
Ring(s)-related esophageal meat bolus impaction: biopsy first, dilate later.
Dis Esophagus. 2009;22(5):E14-6. doi: 10.1111/j.1442-2050.2008.00894.x. Epub 2008 Nov 12.
Abstract/Text Distal esophageal or Schatzki's rings are a common cause of intermittent solid food dysphagia requiring endoscopic dilation for relief. Similarly, eosinophilic esophagitis (EE) is a rapidly emerging disease in both children and young adults, and manifests as dysphagia to solids and/or episodic food bolus impaction. Endoscopic findings vary considerably among patients with EE, posing significant recognition and management challenges. Esophageal dilation in EE can be painful and risky. This case report describes a patient with acute food bolus impaction due to underlying Schatzki's ring and associated but clinically indolent EE, and highlights some safety aspects of esophageal dilation.

PMID 19018847
Paul Kerlin, Dianne Jones, Matthew Remedios, Catherine Campbell
Prevalence of eosinophilic esophagitis in adults with food bolus obstruction of the esophagus.
J Clin Gastroenterol. 2007 Apr;41(4):356-61. doi: 10.1097/01.mcg.0000225590.08825.77.
Abstract/Text BACKGROUND AND GOALS: Acute food bolus impaction is a common emergency in gastrointestinal practice. Management previously used the endoscope with an overtube to allow retrieval of the bolus per os. The push technique using air insufflation and gentle pressure on the bolus provides an alternative approach. Esophageal mucosal biopsy at the time of the initial endoscopy has not been a part of traditional practice. In view of the increasing recognition of eosinophilic esophagitis (EE) as a cause of dysphagia and food bolus obstruction in adults the etiology needs to be reassessed.
STUDY: Forty-three consecutive adults presenting with acute dysphagia secondary to food bolus obstruction of the esophagus were studied. The bolus was advanced into the stomach with the push technique or removed per os with a retrieval net. Protocol biopsies from the proximal and distal esophagus were obtained in 29 patients. Biopsies were contraindicated or not obtained in the remainder.
RESULTS: Forty-one patients were successfully treated at endoscopy. Two subjects with a food bolus impacted at the crico-pharyngeal region required general anesthesia with endotracheal intubation for safe removal. Of 29 patients biopsied, 15 had peptic esophageal stricture as the cause. Fourteen patients (all males, mean age 32 y, range 19 to 62 y) had EE identified histologically. This represents 50% of those biopsied. Patients with EE had typical endoscopic features of linear furrows, mucosal rings, or narrow bore esophagus. Most had prior episodes of food bolus obstruction.
CONCLUSIONS: Food bolus obstruction can be safely managed by the push technique. EE is an important cause of food bolus obstruction that can be suspected on history and endoscopic appearance and confirmed on histology.

PMID 17413601
Gabriele I Kirchner, Ina Zuber-Jerger, Esther Endlicher, Cornelia Gelbmann, Claudia Ott, Petra Ruemmele, Jürgen Schölmerich, Frank Klebl
Causes of bolus impaction in the esophagus.
Surg Endosc. 2011 Oct;25(10):3170-4. doi: 10.1007/s00464-011-1681-6. Epub 2011 Apr 13.
Abstract/Text BACKGROUND: Bolus impaction in the esophagus is a common indication for emergency endoscopy. The aim of this study was to determine the most common causes of esophageal bolus impaction.
METHODS: In this retrospective study, data of 54 patients (41 male, 13 female) with bolus impaction in the esophagus were analyzed. Type and localization of the bolus and the endoscopic extraction tool used were evaluated. In 48 of 54 patients (89%), biopsy samples were taken of the esophagus for histological examination.
RESULTS: Mean age of the patients was 53 ± 20 years. Fourteen of 54 patients (26%) had experienced bolus impaction previously. Meat bolus (n = 35, 65%) was the most common cause of esophageal obstruction. In most cases, boluses were found in either the distal (n = 31) or the proximal (n = 18) esophagus. In 22 patients (41%), the bolus was pushed into the stomach by the endoscope. In most other cases the bolus, including foreign bodies, could be removed with the 5-arm polyp grasper or alligator forceps. Main causes of bolus impaction were eosinophilic esophagitis (n = 10) or reflux disease with or without peptic stenosis (n = 10), respectively.
CONCLUSION: Bolus impaction is frequently correlated with eosinophilic esophagitis and reflux esophagitis; therefore, diagnostic workup should include esophageal biopsy sampling.

PMID 21487866
Jay A Lieberman, Mirna Chehade
Eosinophilic esophagitis: diagnosis and management.
Immunol Allergy Clin North Am. 2012 Feb;32(1):67-81. doi: 10.1016/j.iac.2011.11.006. Epub 2011 Dec 16.
Abstract/Text Eosinophilic esophagitis is a clinicopathologic disease that can present with a constellation of upper gastrointestinal symptoms and endoscopic findings in conjunction with significant infiltration of the esophageal tissue with eosinophils. Clinical and histologic resolution of the disease can be seen with dietary restriction therapies and systemic and topical corticosteroids. Because most patients have an atopic background and the disease seems to have an underlying T-helper type 2 pathogenesis, allergists and gastroenterologists need to be familiar with the diagnosis and management of this disease. In this review, clinical characteristics, endoscopic and histologic findings, and available therapy options are discussed.

Copyright © 2012 Elsevier Inc. All rights reserved.
PMID 22244233
Ganapathy A Prasad, Jagadeshwar G Reddy, Felicity T Boyd-Enders, Jeffrey A Schmoll, Jason T Lewis, Louis-Michel Wongkeesong
Predictors of recurrent esophageal food impaction: a case-control study.
J Clin Gastroenterol. 2008 Aug;42(7):771-5. doi: 10.1097/MCG.0b013e31815576d2.
Abstract/Text BACKGROUND: Esophageal food impaction (FI) is a distressing condition requiring urgent endoscopic intervention, with a reported recurrence rate between 10% and 20%. Knowledge of factors predisposing to recurrent FI may enable preventive measures to minimize the risk of recurrence.
OBJECTIVE: To identify risk factors associated with recurrent FI.
DESIGN: Retrospective case-control study.
SETTING: Tertiary referral center.
PATIENTS: A prospectively maintained database and medical records of all patients undergoing emergent endoscopy for FI from 1989 to 2000 were reviewed. Cases were defined as those presenting with more than 1 episode of FI, whereas controls were defined as those without recurrence within 5 years of the index episode. Several demographic, clinical, endoscopic, and follow-up variables were extracted. Statistical analysis included chi2 tests and t tests for univariate analysis, and stepwise logistic regression for multivariate analysis.
INTERVENTIONS: NA.
MAIN OUTCOME MEASUREMENTS: Predictors of recurrent FI.
RESULTS: A total of 52 cases and 124 controls were identified (recurrence rate 30%). Presence of a diaphragmatic hernia [odds ratio (OR) 2.65; confidence interval (CI) 1.19-5.89], disimpaction by piecemeal extraction (OR 2.32; CI 1.09-4.97), and acquisition of esophageal biopsies (OR 3.69; CI 1.42-9.66) increased odds for recurrent FI. Physician follow-up after FI decreased the odds for recurrent FI (OR 0.38; CI 0.18-0.80).
LIMITATIONS: Retrospective study.
CONCLUSIONS: The presence of a diaphragmatic hernia, complexity of endoscopic disimpaction technique, and lack of follow-up increased risk for recurrent FI. Collection of esophageal biopsies as a risk factor suggests a visibly more severe esophageal disorder as a potential cause for recurrent FI.

PMID 18580498

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