History

Fact Explanation
Accidental swallowing of a foreign body Accidental swallowing of a foreign body is the third most common emergency involving the gastrointestinal tract. [1]
Impaction of a food bolus Food boluses, especially if not masticated properly, can get impacted in the esophagus, causing obstruction. Elderly patients are at especially at risk because they often have few teeth. [1]
Odynophagia Partial obstruction of the esophagus can cause odynophagia. [1]
Sialorrhea Sialorrhea refers to excessive accumulation of saliva, because patients cannot swallow it. [1,2]
Pain Patients experience diffuse retrosternal chest pain due to esophageal spasm and obstruction. Neck pain or throat pain can occur in patients with food impaction in the proximal esophagus. [2]
Choking and coughing Patients with esophageal and airway obstruction present acutely with choking, coughing, wheezing and in more severe obstruction stridor. [2]
Retching and or vomiting Patients with food or foreign body impaction can have retching and or vomiting. Some patients may induce vomiting to get rid of the obstruction. [2]
History of benign esophageal strictures Schatzki rings, acid strictures and esophageal webs (due to iron deficiency anemia) can cause external compression and esophageal obstruction. [1,2]
History of esophageal motility disorders Achalasia and other esophageal motility disorders can precipitate esophageal obstruction. [2]
References
  1. KHAYYAT YASIR MOHAMMED. Pharmacological Management of Esophageal Food Bolus Impaction. Emergency Medicine International [online] 2013 December, 2013:1-6 [viewed 08 August 2014] Available from: doi:10.1155/2013/924015
  2. KO HH, ENNS R. Review of food bolus management Can J Gastroenterol [online] 2008 Oct, 22(10):805-808 [viewed 08 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2661297

Examination

Fact Explanation
Drooling of saliva Patients often have drooling of saliva, especially the young children and elderly people. [1]
Stridor Patients can develop obstruction of the airway and in severe airway obstruction patients develop stridor. [2]
Tachycardia Patients can have tachycardia due to sympathetic overstimulation, anxiety and prolonged periods of coughing. [1]
Blood pressure Blood pressure can be elevated due to the similar mechanism mentioned above. [1]
Evidence of oropharyngeal obstruction Patients with more proximal obstruction can have erythema, tenderness and crepitus over the neck. [1]
Evidence of esophageal perforation Patients with esophageal obstruction can develop esophageal perforation. Fever, neck swelling, palpable subcutaneous crepitations can be detected in esophageal perforation. [2]
References
  1. KHAYYAT YASIR MOHAMMED. Pharmacological Management of Esophageal Food Bolus Impaction. Emergency Medicine International [online] 2013 December, 2013:1-6 [viewed 08 August 2014] Available from: doi:10.1155/2013/924015
  2. KO HH, ENNS R. Review of food bolus management Can J Gastroenterol [online] 2008 Oct, 22(10):805-808 [viewed 08 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2661297

Differential Diagnoses

Fact Explanation
Croup Children with croup presents with fever, drooling of saliva, barking cough, hoarseness and stridor which are acute onset. The child looks toxic. [2]
Carcinoma of the esophagus Esophageal carcinoma should be considered a differential diagnosis in patients presenting with dysphagia, especially in elderly.
Eosinophilic esophagitis Eosinophilic esophagitis is a possible cause for dysphagia which is common in young patients. These patients often have a history of atopy. [1]
Acute coronary syndrome Patients with acute coronary syndrome present with severe chest pain which radiates to the left arm. [4]
References
  1. KHAYYAT YASIR MOHAMMED. Pharmacological Management of Esophageal Food Bolus Impaction. Emergency Medicine International [online] 2013 December, 2013:1-6 [viewed 08 August 2014] Available from: doi:10.1155/2013/924015
  2. BROWN J. C. The management of croup. [online] 2002 March, 61(1):189-202 [viewed 08 August 2014] Available from: doi:10.1093/bmb/61.1.189
  3. STAHL M., BUDACH W., MEYER H.- J., CERVANTES A.. Esophageal cancer: Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology [online] December, 21(Supplement 5):v46-v49 [viewed 08 August 2014] Available from: doi:10.1093/annonc/mdq163
  4. KRISTIAN THYGESEN, JOSEPH S. ALPERT, HARVEY D. Universal definition of myocardial infarction. Eur Heart J. [online] 2007; 28 (20): 2525-2538. [viewed 07 August 2014] Available from: doi: 10.1093/eurheartj/ehm355

Investigations - for Diagnosis

Fact Explanation
X-ray films of the neck and chest X-ray films can demonstrate the presence of radio-opaque foreign bodies in the esophagus. Lateral view of the chest and neck is helpful in detecting foreign bodies in the esophagus as it shows the presence of the foreign body or an air-fluid level in the retrotracheal space. [1,3] Presence of air in the mediastinum, and peritoneum are indicative of esophageal perforation. [2]
Uppergastrointestinal endoscopy (UGIE) UGIE is helpful in visualizing the etiological factor for esophageal obstruction. [1]
CT scan CT scan of the neck and chest is also useful in detecting the presence and cause of esophageal obstruction. CT scan is not routinely recommended and it is done if the risk of esophageal perforation is high. [1]
References
  1. KHAYYAT YASIR MOHAMMED. Pharmacological Management of Esophageal Food Bolus Impaction. Emergency Medicine International [online] 2013 December, 2013:1-6 [viewed 08 August 2014] Available from: doi:10.1155/2013/924015
  2. KO HH, ENNS R. Review of food bolus management Can J Gastroenterol [online] 2008 Oct, 22(10):805-808 [viewed 08 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2661297
  3. THOMPSON H, ANDERSON JE, CANTWELL K, PRESS HC JR. Causes of esophageal obstruction. J Natl Med Assoc [online] 1979 Jan, 71(1):101-102 [viewed 08 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2537224

Investigations - Fitness for Management

Fact Explanation
Full blood count Iron deficiency anemia can be detected in patients with Plummer Vinson syndrome. Reduced hemoglobin, mean corpuscular volume and mean corpuscular hemoglobin concentration are diagnostic of iron deficiency anemia. [2]
Blood picture Hypochromic microcytic red blood cells, pencil cells and
References
  1. JOHNSON-WIMBLEY TD, GRAHAM DY. Diagnosis and management of iron deficiency anemia in the 21st century Therap Adv Gastroenterol [online] 2011 May, 4(3):177-184 [viewed 08 August 2014] Available from: doi:10.1177/1756283X11398736
  2. JOHNSON-WIMBLEY TD, GRAHAM DY. Diagnosis and management of iron deficiency anemia in the 21st century Therap Adv Gastroenterol [online] 2011 May, 4(3):177-184 [viewed 08 August 2014] Available from: doi:10.1177/1756283X11398736
  3. NOVACEK G. Plummer-Vinson syndrome Orphanet J Rare Dis [online] :36 [viewed 08 August 2014] Available from: doi:10.1186/1750-1172-1-36

Management - General Measures

Fact Explanation
Basic life support Assessment of the airway and breathing should be done. [1,2]
Management of esophageal perforation If the patient develop perforation endoscopic or surgical repair should be done as soon as the diagnosis is made. [2]
Management of iron deficiency anemia Plummer Vinson syndrome is treated with iron replacement. [3]
References
  1. KHAYYAT YASIR MOHAMMED. Pharmacological Management of Esophageal Food Bolus Impaction. Emergency Medicine International [online] 2013 December, 2013:1-6 [viewed 08 August 2014] Available from: doi:10.1155/2013/924015
  2. KO HH, ENNS R. Review of food bolus management Can J Gastroenterol [online] 2008 Oct, 22(10):805-808 [viewed 08 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2661297
  3. NOVACEK G. Plummer-Vinson syndrome Orphanet J Rare Dis [online] :36 [viewed 08 August 2014] Available from: doi:10.1186/1750-1172-1-36

Management - Specific Treatments

Fact Explanation
Antispasmodic drugs With esophageal obstruction due to a foreign body, the esophageal muscles spasm. Antispasmodic drugs relaxes the esophageal musculature, letting the impacted foreign body or the food bolus to pass down into the stomach. Hyoscine butylbromide, calcium channel blockers, nitrates and diazepam can be used in the management. Most of the patients respond to antispasmodics. [1,2]
Endoscopic treatment Impacted food boluses can be either removed or pushed down with upper gastrointestinal endoscopy. [1,2]
References
  1. KHAYYAT YASIR MOHAMMED. Pharmacological Management of Esophageal Food Bolus Impaction. Emergency Medicine International [online] 2013 December, 2013:1-6 [viewed 08 August 2014] Available from: doi:10.1155/2013/924015
  2. KO HH, ENNS R. Review of food bolus management Can J Gastroenterol [online] 2008 Oct, 22(10):805-808 [viewed 08 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2661297