Esophageal Obstruction

• • Ingestion of foreign object or bolus of meat

  • May be asymptomatic or accompanied by dysphagia, chest pain, or respiratory distress

  • Radiopaque objects can be detected on chest x-ray

  • Rings, webs, and bands usually detected by endoscopy or contrast radiographic study

  • Endoscopic treatment (extraction of foreign objects or dilation of ring, web or band) is usually successful

Epidemiology

• • Foreign objects

  • -90% pass into the stomach and pass without incident

    -Usually lodge just beyond the cricopharyngeus

    -Most cases occur in children; in adults esophageal meat impaction is most common and many affected patients have underlying esophageal disease

    -10% require endoscopic removal, and 1% require surgery

    -Cocaine smugglers may swallow small packets of cocaine which, if ruptured, can be fatal

  • Congenital bands or webs may develop at any level but are most frequent in the subcricoid region

  • Schatzki ring: Narrow mucosal ring at the squamocolumnar junction that occurs with gastroesophageal reflux

Symptoms and Signs

• • May be asymptomatic

  • Dysphagia

  • Chest pain

  • Respiratory distress

Imaging Findings

• • Anteroposterior and lateral chest film

  • -If ingested object is radiopaque, determine whether the object is in the esophagus or trachea

    -X-ray small children from the base of the skull to the anus in order to find any additional objects in the gut

  • Endoscopy will identify foreign objects suspected of causing esophageal obstruction

  • Endoscopy or contrast radiography may identify esophageal rings, bands, or webs that may be associated with esophagitis

Rule Out

• • Underlying esophageal disease precipitating obstruction, particularly with meat impaction

• • If radiopaque foreign object, chest film may be performed

  • Most foreign objects as well as webs, rings, or bands can be diagnosed endoscopically

When to Admit

• • Suspected esophageal perforation

  • Severe respiratory distress

  • Need for surgery

• • Foreign objects should be removed promptly

  • Most extracted endoscopically

  • Webs, bands, and rings are treated by endoscopic dilation

Surgery

Indications

• • Inability to treat endoscopically

  • All ingested packets containing cocaine

  • -Endoscopic extraction may cause rupture and death

Treatment Monitoring

• • Subsequent diagnostic endoscopy to exclude underlying esophageal disease

Complications

• • Esophagoaortic or esophagotracheal fistula

  • Tracheal obstruction and aspiration

  • Esophageal ulceration or perforation

Prognosis

• • 1500 deaths yearly from complications of ingested foreign bodies

  • Most webs, rings, and bands treated effectively by dilation

References