Esophageal obstruction is the name given to a medical emergency that results when a food bolus or other foreign body fails to pass through the esophagus and becomes lodged on its lumen instead. It is commonly known as "steakhouse syndrome", since meats such as steak, poultry or pork are among the most common foods that can trigger the syndrome. This is usually recognized by the abrupt onset of a difficulty in swallowing, which prevents the subsequent passage of food through the esophagus and results in the need for emergency care. Esophageal obstruction is directly associated with episodes of food ingestion and it occurs more frequently in adults, although it is occasionally observed in children too.
Treatment for esophageal obstruction varies according to the specific characteristics of the obstruction. While in some cases the problem can be solved with medications, in others it is necessary to perform an endoscopy to either push the food bolus into the stomach or remove it from the esophagus.
Esophageal obstruction is often associated with diseases that narrow the lumen of the esophagus and may represent an acute presentation of an underlying mechanical problem or motility disorder. In small epidemiological studies, a high proportion of the patients with esophageal obstruction presented evidence of esophageal pathology. Among the syndromes more commonly linked to esophageal obstruction are peptic esophageal stricture, Schatzki ring, esophageal webs, eosinophilic esophagitis, achalasia, nutcracker esophagus and esophageal malignancy.
In children, esophageal obstruction is less common and it is not usually caused by an anatomical disorder of the esophagus. Immature behavior such as the habit of eating quickly, inadequate chewing or "wolfing down" food has been blamed as the main cause of esophageal obstruction in this age group. In addition, eosinophilic esophagitis is increasingly recognized as a cause of obstruction-related dysphagia in children and young men.
Among the most clinical manifestations of esophageal obstruction are:
- Difficulty Swallowing/Choking (dysphagia)
- Chest Pain
- Neck Pain
- Abdominal Pain
- Gastroesophageal Reflux
- Painful Swallowing (odinophagia)
The sudden presentation of an acute difficulty in swallowing, in combination with one or more of the other symptoms listed above, and associated with an episode of food ingestion or swallowing of a foreign object constitutes strong indication of esophageal obstruction. Endoscopy is the standard method of choice to confirm a diagnosis for this syndrome.
Obstruction of the esophagus represents a potentially serious medical problem. The choice of treatment depends on the specific characteristics of the case, including the nature of the obstructing object. If the object presents sharp edges (such as bony material) or has a corrosive capacity (batteries, for example), it should be removed urgently. The standard method of removal in these cases is rigid oesophagoscopy under general anaesthetic. However, a proportion of esophageal obstructions in patients with a non-sharp food bolus are known to eventually pass spontaneously, and therefore management guidelines are less clear in this case. In many cases, therefore, the aim of treatment is initially to manage the patient medically to encourage resolution of the obstruction.
Numerous techniques have been proposed to induce spontaneous resolution of the obstruction without resorting to endoscopy, including the blind insertion of Maloney dilators and nasogastric tubes to push the object into the stomach. This is known as the "push technique". Another alternative to treating esophageal obstruction is the insertion of a Foley’s catheter in order to extract the foreign body.
Pharmacological techniques have also been advanced as a potential solution for esophageal obstruction. These include agents that alter the muscular tone of the esophagus, allowing the foreign body to pass, and enzymatic digestion of the bolus by the use of carbonated beverages such as Coca-Cola or mixtures of citric acid and sodium bicarbonate solutions.
In the event of a failure of medical management, endoscopic removal using either rigid or flexible techniques remains the mainstay of treatment for esophageal obstruction. A wide range of endoscopic devices, including rat-tooth forceps, Dormia baskets, polypectomy snares, and different sizes of Roth net are suitable for surgical removal of the obstruction. Roth nets are particularly useful in the case of obstructions provoked by food boluses because they can be contained completely within the net, thus avoiding the use of general anesthesia or an overtube and minimizing the risk of aspiration.
Most esophageal obstructions are resolved spontaneously or with the help of proper medical management without leaving any clinical sequela. Between 10 and 20 percent of the cases may require endoscopic intervention, and about one percent eventually require surgery. The wall of the esophagus is thin, and despite the best efforts of the physician, can tear during the procedure resulting in minor lacerations. A small amount of local bleeding is also to be expected.
Potentially serious complications such as esophageal perforation and mediastinitis are nevertheless a possibility. Long and sharp foreign bodies should be removed immediately before they pass from the stomach to the intestine, as 15 to 35 percent of them will lead to intestinal perforation. Acute mediastinitis is a serious medical condition with a mortality rate between 30 and 40 percent. Esophageal obstructions lasting more than 24 hours are associated with an increased incidence of complications.
Esophageal obstruction can be prevented by avoiding swallowing large chunks of food without proper chewing, especially when dealing with meat. In addition, a number of underlying conditions that contribute to the narrowing of the esophageal lumen increase the chances of an episode, and therefore careful monitoring and treatment for these conditions can prevent its occurrence. Reflux of stomach acid to the esophagus can cause inflammation and scarring, a condition known as acid peptic stricture. The fibrous scar then contracts and narrows the esophageal opening. Effective acid-suppressive therapy with proton pump inhibitors is an effective way to keep the symptoms under control and prevent a potential esophageal obstruction.
Accidental foreign body ingestion is another common cause of esophageal obstruction, particularly in children aged 6 months to 3 years. Careful monitoring of children during this developmental period and removing from their reach those objects that can pose a threat due to their size and shape are obvious measures to be taken in order to prevent obstructions. In particular, young children seem to be very prone to swallowing liquid lye and other caustic agents that can severely burn the esophagus, leaving it narrowed and prone to obstruction. Careful storage of these substances is thus recommended.
Esophageal obstruction is a medical emergency that requires acute treatment. The patient should be free from the obstruction, either by medical treatment or surgical intervention, in a matter of days. Therefore, there are no guidelines or recommendations for long-term management or adaptation to a life with the condition.
Self-expanding metal stents are often used to treat health conditions that underlie acute episodes of esophageal obstruction, such as achalasia or esophageal malignancy. One of the drawbacks of this therapy is the high percentage of recurrence due to stent migration and tissue growth. New stent designs have been recently developed and are being tried in a clinical setting in order to overcome this problem. These include the Polyflex stent, a silicone device developed in Germany with an encapsulated monofilament braid made of polyester, and the Niti-S, a Korean device consisting of an inner polyurethane layer over its entire length and an outer uncovered nitinol wire tube. These next-generation stents are a cost-effective and safer alternative to conventional prostheses and are associated with a lower percentage of recurrent dysphagia.
Manometric abnormalities such as achalasia can now be more easily diagnosed using high-resolution manometry (HRM) coupled with high-resolution esophageal topography plots (HREPT). This new methodology for assessing esophageal motility has allowed for a subcategorization of achalasia that correlates with its responsiveness to treatment. Unlike the technique it replaces (conventional manometry), the higher spatial resolution of HREPT allows for a more accurate prediction of successful bolus transports through the esophagus and depicts contraction patterns with greater reproducibility. This newly developed technique has improved the recognition of a functional obstruction esophagus and has thus become an important tool for diagnosis and choice of treatment for esophageal obstruction.
Novel endoscopic techniques for the management of esophageal obstruction are constantly being developed. For example, an antegrade-retrograde rendezvous technique with subsequent dilation demonstrated to be safe in a clinical trial and can obviate the need for esophageal resection.