Dysphagia and Food Bolus ImpactionAPPROACH

ABDOMINAL AND GASTROINTESTINAL · 19 SECTIONS

⚲

506 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Abdominal Distension Abdominal Pain, Undifferentiated Acute Abdominal Pain (general)Suspected Incarcerated Or Strangulated Hernia Pancreatitis Concern Biliary Colic And Cholecystitis Concern Appendicitis Concern Diverticulitis Concern Rectal Pain And Anorectal Complaints Dysphagia And Food Bolus Impaction Foreign Body Ingestion Refractory Vomiting And Recurrent Vomiting Syndromes Cannabis Associated Hyperemesis Upper Gastrointestinal Bleeding Symptoms (melena)Lower Gastrointestinal Bleeding And Hematochezia Constipation And Obstipation Diarrhea Acute Hepatitis And Jaundice Concern Right Upper Quadrant Pain Epigastric Pain Left Upper Quadrant Pain Right Lower Quadrant Pain Left Lower Quadrant Pain Suprapubic Pain

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx67

Presenting pattern

›Dysphagia history

›Solids only

›Solids and liquids

›Liquids only

›Odynophagia

›Globus sensation

›Food bolus impaction episode

›Complete obstruction

›Partial obstruction

›Inability to tolerate secretions

›Drooling

›Regurgitation

›Vomiting

›Aspiration event

OPQRST

›OPQRST

›Onset

›Sudden onset during meal

›Gradual onset over days to weeks

›Chronic progressive over months

›Provocation/Palliation

›Worse with solids

›Worse with liquids

›Worse with large bites

›Worse with dry foods

›Relief with sips of water

›Relief after regurgitation

›Quality

›Sticking sensation

›Choking sensation

›Burning retrosternal pain

›Sharp chest pain

›Region/Radiation

›Cervical

›Retrosternal

›Epigastric

›Severity

›Unable to swallow saliva

›Able to swallow liquids only

›Able to swallow solids with difficulty

›Timing

›Intermittent

›Progressive

›Recurrent similar episodes

Associated symptoms

›Associated symptoms

›Chest pain

›Shortness of breath

›Fever

›Neck pain

›Voice change

›Hematemesis

›Melena

›Weight loss

›Neurologic symptoms

›Heartburn

›Food allergies

›Atopy history

Exposures and precipitating events

›Exposures and events

›Meat impaction

›Pills

›Sharp foreign body

›Denture ingestion

›Fish bone

›Button battery

›Caustic ingestion

›Recent endoscopy

›Recent esophageal dilation

›Recent vomiting retching

02Alarm Features/alarm34

Airway and breathing threats

›Airway risk features

›Stridor

›Respiratory distress

›Hypoxia

›Inability to handle secretions

›Persistent drooling

›Suspected aspiration

Hemodynamic and systemic danger thresholds

›High risk vitals

›Hypotension

›Tachycardia out of proportion

›Fever

›Altered mental status

Perforation and mediastinal infection

›Perforation concern

›Severe chest pain

›Severe neck pain

›Subcutaneous emphysema

›Crepitus

›Hamman sign

›Persistent tachycardia

›Leukocytosis with toxicity

High risk ingestion categories

›High risk foreign body

›Button battery in esophagus

›Magnets

›Sharp pointed object

›Large object

›Denture with metal hooks

›Caustic ingestion

Immediate escalation triggers

›Escalation triggers

›Complete obstruction with drooling

›Any airway compromise

›Suspected perforation

›Button battery suspicion

›Multiple magnet ingestion

›Hemodynamic instability

03Medications/meds29

Current therapies and recent changes

›Medication history

›Anticoagulants

›Antiplatelets

›Diabetes therapies

›Opioids

›Anticholinergics

›Sedatives

›Recent antibiotic exposure

›Recent corticosteroid exposure

Impaction and symptom directed medications

›Pharmacologic options

›Glucagon IV

›Adult dose 1 mg IV once

›Repeat 1 mg IV once after 10 to 15 minutes if no response

›Nausea and vomiting risk

›Antiemetic

›Ondansetron IV 4 mg once

›QT prolongation risk

›Analgesia

›Fentanyl IV 25 mcg increments

›Titration every 5 minutes to comfort

›Acid suppression when mucosal injury suspected

›Pantoprazole IV 40 mg once

›Local protocol dependent

Contraindications and traps

›Medication cautions

›Avoid oral intake in complete obstruction

›Avoid effervescent agents

›Avoid blind instrumentation

›Increased bleeding risk with anticoagulation for endoscopy

›Aspiration risk with sedatives

04Diet/diet13

Recent intake and triggers

›Diet context

›Last oral intake timing

›Trigger food type

›Meat

›Bread

›Dry rice

›Hot dog

›Poor dentition or ill fitting dentures

Hydration and swallowing capacity

›Hydration and tolerance

›Able to tolerate liquids

›Unable to tolerate liquids

›Unable to tolerate saliva

›Dehydration indicators

05Review of Systems/ros25

Gastrointestinal

›GI

›Dysphagia

›Odynophagia

›Heartburn

›Regurgitation

›Nausea

›Vomiting

›Hematemesis

›Melena

›Abdominal pain

Respiratory and ENT

›Respiratory and ENT

›Cough

›Wheeze

›Dyspnea

›Stridor

›Voice change

›Sore throat

›Drooling

Constitutional and neuro

›Constitutional and neuro

›Fever

›Weight loss

›Night sweats

›Weakness

›Focal neurologic deficit

›Dysarthria

06Collateral History and Family History/chafh11

Collateral sources

›Collateral

›Witnessed choking event

›Caregiver report for baseline swallowing

›EMS report of secretions and airway status

Family history and atopy

›Family and atopy history

›Esophageal cancer family history

›Atopy

›Asthma

›Eczema

›Food allergy

›Eosinophilic esophagitis family history

07Risk Factors/rf27

Structural and inflammatory esophageal disease

›Esophageal risk factors

›Gastroesophageal reflux disease

›Prior esophagitis

›Prior stricture

›Schatzki ring

›Eosinophilic esophagitis

›Prior radiation

›Caustic injury history

Malignancy risk

›Malignancy risk

›Progressive dysphagia

›Weight loss

›Tobacco use

›Heavy alcohol exposure

›Barrett esophagus history

Neuromuscular and stroke risk

›Oropharyngeal dysphagia risk

›Prior stroke

›Parkinson disease (G20)

›ALS

›Myasthenia gravis (G70.00)

›Dementia

›Frailty

›Sedative use

Procedure and device related

›Iatrogenic and device risks

›Recent endoscopy

›Recent dilation

›Nasogastric tube placement

›Esophageal stent

08Differential Diagnosis/ddx56

Life threatening

›Life threatening causes

›Esophageal perforation (K22.3)

›Severe chest pain

›Subcutaneous emphysema

›Button battery in esophagus

›Drooling

›Chest discomfort

›Sharp foreign body with perforation risk

›Odynophagia

›Focal neck pain

›Mediastinitis (J98.51)

›Fever

›Toxic appearance

›Airway compromise from proximal obstruction

›Stridor

›Hypoxia

Common

›Common causes

›Food bolus impaction (T18.128A)

›Sudden onset with meal

›Prior intermittent solid dysphagia

›Peptic stricture from GERD (K21.9)

›Longstanding heartburn

›Progressive solids then liquids

›Schatzki ring (K22.2)

›Intermittent solid dysphagia

›Meat impaction history

›Eosinophilic esophagitis (K20.0)

›Atopy

›Recurrent impactions

Less common

›Less common causes

›Esophageal malignancy (C15.9)

›Progressive dysphagia

›Weight loss

›Achalasia (K22.0)

›Dysphagia to solids and liquids

›Regurgitation

›Pill esophagitis (K20.8)

›Recent doxycycline

›Recent bisphosphonate

›Infectious esophagitis

›Candida esophagitis (B37.81)

›HSV esophagitis

›CMV esophagitis

›Zenker diverticulum (K22.5)

›Regurgitation of undigested food

›Halitosis

Mimics and alternative diagnoses

›Mimics

›ACS (I21.9)

›Exertional chest pressure

›ECG changes

›Aortic dissection (I71.00)

›Sudden tearing pain

›Pulse deficit

›Foreign body sensation without obstruction

›Globus

›Anxiety

09Past Medical History/pmh15

Relevant chronic conditions

›Comorbidities

›GERD (K21.9)

›Barrett esophagus (K22.70)

›Prior esophageal stricture (K22.2)

›Eosinophilic esophagitis (K20.0)

›Esophageal cancer (C15.9)

›Prior stroke (I63.9)

›Parkinson disease (G20)

›Diabetes mellitus (E11.9)

Prior episodes and procedures

›Prior episodes and procedures

›Prior food impaction

›Prior endoscopic removal

›Prior dilation

›Prior barium swallow

›Prior aspiration pneumonia (J69.0)

10Physical Exam/exam35

General and airway

›General and airway

›Toxic appearance

›Work of breathing

›Stridor

›Voice quality

›Drooling

›Handling secretions

Vitals pattern interpretation

›Vitals patterns

›Fever pattern

›Tachycardia pattern

›Hypoxia pattern

›Hypotension pattern

Head and neck

›Head and neck

›Oropharynx foreign body

›Tonsillar swelling

›Uvular edema

›Trismus

›Neck tenderness

›Subcutaneous emphysema

Chest and cardiovascular

›Chest and cardiovascular

›Chest wall tenderness

›Hamman sign

›Breath sounds asymmetry

›Wheeze

›Crackles

›Murmur

Abdomen

›Abdomen

›Epigastric tenderness

›Peritoneal signs

›Distension

Neuro and swallowing mechanics

›Neuro

›Cranial nerve deficits

›Dysarthria

›Facial droop

›Gait instability

11Lab Studies/labs11

Baseline labs when escalation likely

›Core labs

›CBC for infection and anemia

›Electrolytes for dehydration

›Creatinine for contrast planning

›Glucose for diabetes management

Infection and perforation support

›Inflammation and sepsis support

›Lactate for sepsis physiology

›Blood cultures if febrile and toxic

Bleeding and procedure readiness

›Hemostasis and procedure considerations

›INR if on warfarin

›Platelets if thrombocytopenia concern

12Imaging/img35

Scoring Systems

›Decision and timing logic

›Button battery

›Immediate endoscopic removal when in esophagus

›Imaging to localize when uncertain

›Sharp object

›Urgent endoscopy when in esophagus

›Surgical consultation triggers when perforation concern

MRI

›MRI considerations

›Limited role in acute food bolus impaction

›Avoid delays in unstable patients

›Consider for neuro etiologies of dysphagia when stable

›Contraindications

›Ferromagnetic implants

›Unstable airway

›CT indications

›Suspected perforation

›Severe chest pain out of proportion

›Fever with toxicity

›Subcutaneous emphysema

›Suspected deep neck space infection

›CT protocol pearls

›CT neck and chest with IV contrast if perforation concern

›Water soluble oral contrast if esophageal leak evaluation and safe to administer

›Avoid barium when perforation suspected

›CT findings

›Pneumomediastinum

›Mediastinal fluid

›Pleural effusion

›Esophageal wall thickening

›Foreign body localization

Ultrasound

›Ultrasound role

›Limited for esophageal obstruction diagnosis

›Lung ultrasound for aspiration patterns

›POCUS for pleural effusion if perforation concern

›POCUS for volume status in dehydration

13Special Tests/spec14

Endoscopic evaluation

›Endoscopy

›Diagnostic and therapeutic for food bolus

›Removal techniques per GI

›Biopsies when eosinophilic esophagitis suspected after clearance

›Contraindications and precautions

›Unsecured airway with copious secretions

›Suspected perforation requires careful planning

Radiographic contrast swallow studies

›Contrast esophagram

›Water soluble contrast when perforation suspected

›Barium reserved when perforation excluded

›Aspiration risk considerations

Oropharyngeal assessment

›Swallow safety screening

›Bedside swallow screen in stable patients with neuro concern

›Speech language pathology evaluation when available

14ECG/ecg10

Indications

›ECG indications

›Chest pain

›Dyspnea

›Syncope

›Significant risk factors for ACS

High risk findings

›High risk patterns

›ST elevation

›Dynamic ischemic changes

›New bundle branch block with symptoms

›Significant QT prolongation before antiemetics

15Assessment/ax22

Problem representation

›Working problem

›Suspected esophageal food bolus impaction (T18.128A)

›Oropharyngeal dysphagia concern

›Complicated course concern

›Aspiration

›Perforation

›Sepsis physiology

Severity and risk stratification

›High risk features present

›Unable to manage secretions

›Airway compromise features

›High risk foreign body category

›Signs of perforation

›Lower risk features

›Partial obstruction

›Able to swallow secretions

›No systemic toxicity

Key alternative diagnoses

›Alternate diagnoses to address

›Achalasia (K22.0)

›Esophageal malignancy (C15.9)

›Pill esophagitis (K20.8)

›Infectious esophagitis

›ACS (I21.9)

16Plan/plan46

First 5 minutes

›Immediate stabilization

›Airway risk stratification

›Suction setup at bedside

›Oxygen if hypoxic

›Cardiac monitor if unstable or chest pain

›IV access criteria

›Two large bore IV if unstable

›One IV if stable

›NPO

›Aspiration precautions

›Immediate consult triggers

›GI emergent endoscopy for complete obstruction

›ENT for suspected proximal oropharyngeal foreign body

›Surgery for perforation concern

Reassessment loop

›Reassessment loop

›Vitals every 15 to 30 minutes until stable

›Airway and secretion tolerance trend

›Chest pain trend

›Vomiting and aspiration events

›Escalate if new fever or worsening pain

Diagnostic sequencing

›Diagnostic sequence

›Plain radiographs when foreign body possible

›Neck soft tissue radiograph

›Chest radiograph

›CT neck and chest when perforation concern

›Endoscopy pathway when food bolus likely and no perforation signs

Therapeutics

›Symptom and definitive management

›Antiemetic if nausea

›Analgesia titration

›Glucagon trial in selected stable patients

›Avoid oral liquids challenge in complete obstruction

›Antibiotics if perforation or mediastinitis suspected

›Piperacillin tazobactam IV 4.5 g every 6 hours

›Ceftriaxone IV 2 g daily

›Metronidazole IV 500 mg every 8 hours

›Local protocol dependent

›Acid suppression when esophagitis suspected

›Steroids not routine for acute impaction

Sedation and airway planning for endoscopy

›Procedure readiness

›NPO status documentation

›Airway protection planning when drooling or aspiration risk

›Anesthesia involvement criteria

›High aspiration risk

›Anticipated difficult airway

›Significant comorbidity

›Anticoagulation considerations for endoscopic intervention

17Disposition/dispo29

ICU and high acuity

›ICU or high acuity criteria

›Airway compromise risk

›Requiring intubation

›Hemodynamic instability

›Sepsis physiology

›Suspected perforation with deterioration

Inpatient admission

›Admission criteria

›Post endoscopy complications

›Aspiration pneumonia concern

›Inability to tolerate oral intake after clearance

›Significant dehydration requiring IV fluids

›Need for urgent inpatient diagnostic workup

›Suspected malignancy

›Severe esophagitis

Observation pathway

›Observation criteria

›Symptoms improving

›Able to tolerate oral liquids after intervention

›No systemic toxicity

›Reliable follow up

Discharge criteria and follow up

›Discharge criteria

›Complete symptom resolution

›Tolerating oral intake

›No perforation or aspiration concern

›Stable vitals

›Reliable supervision

›Follow up timing

›GI follow up within 1 to 2 weeks after impaction

›Earlier follow up when recurrent impactions

›Speech language pathology follow up when neuro concern

18Discharge Instructions/di21

Copy discharge instructions

›Patient instructions

›Diagnosis

›Symptoms improved after treatment in the emergency department

›Diet plan

›Soft foods for 24 to 48 hours

›Small bites

›Chew thoroughly

›Medications

›Take prescribed acid suppression if provided

›Avoid pills that previously caused pain when swallowing

›Follow up

›Gastroenterology appointment within 1 to 2 weeks

›Further testing may be needed to find the cause of the blockage

›Return to emergency department now for

›Trouble breathing

›Unable to swallow saliva

›New or worsening chest pain

›Fever

›Vomiting blood

›Severe neck pain

›Fainting

19References/r6

Guidelines and key sources

›Evidence sources

›American Society for Gastrointestinal Endoscopy guideline on ingested foreign bodies and food impactions

›European Society of Gastrointestinal Endoscopy guideline on management of ingested foreign bodies

›North American Society for Pediatric Gastroenterology Hepatology and Nutrition guidance for pediatric foreign body ingestion

›American College of Radiology appropriateness criteria for dysphagia and suspected esophageal perforation imaging

›National Capital Poison Center guidance for button battery ingestion

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Dysphagia and Food Bolus ImpactionAPPROACH

ABDOMINAL AND GASTROINTESTINAL · 19 SECTIONS

⚲

506 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx67

Presenting pattern

›Dysphagia history

›Solids only

›Solids and liquids

›Liquids only

›Odynophagia

›Globus sensation

›Food bolus impaction episode

›Complete obstruction

›Partial obstruction

›Inability to tolerate secretions

›Drooling

›Regurgitation

›Vomiting

›Aspiration event

OPQRST

›OPQRST

›Onset

›Sudden onset during meal

›Gradual onset over days to weeks

›Chronic progressive over months

›Provocation/Palliation

›Worse with solids

›Worse with liquids

›Worse with large bites

›Worse with dry foods

›Relief with sips of water

›Relief after regurgitation

›Quality

›Sticking sensation

›Choking sensation

›Burning retrosternal pain

›Sharp chest pain

›Region/Radiation

›Cervical

›Retrosternal

›Epigastric

›Severity

›Unable to swallow saliva

›Able to swallow liquids only

›Able to swallow solids with difficulty

›Timing

›Intermittent

›Progressive

›Recurrent similar episodes

Associated symptoms

›Associated symptoms

›Chest pain

›Shortness of breath

›Fever

›Neck pain

›Voice change

›Hematemesis

›Melena

›Weight loss

›Neurologic symptoms

›Heartburn

›Food allergies

›Atopy history

Exposures and precipitating events

›Exposures and events

›Meat impaction

›Pills

›Sharp foreign body

›Denture ingestion

›Fish bone

›Button battery

›Caustic ingestion

›Recent endoscopy

›Recent esophageal dilation

›Recent vomiting retching

02Alarm Features/alarm34

Airway and breathing threats

›Airway risk features

›Stridor

›Respiratory distress

›Hypoxia

›Inability to handle secretions

›Persistent drooling

›Suspected aspiration

Hemodynamic and systemic danger thresholds

›High risk vitals

›Hypotension

›Tachycardia out of proportion

›Fever

›Altered mental status

Perforation and mediastinal infection

›Perforation concern

›Severe chest pain

›Severe neck pain

›Subcutaneous emphysema

›Crepitus

›Hamman sign

›Persistent tachycardia

›Leukocytosis with toxicity

High risk ingestion categories

›High risk foreign body

›Button battery in esophagus

›Magnets

›Sharp pointed object

›Large object

›Denture with metal hooks

›Caustic ingestion

Immediate escalation triggers

›Escalation triggers

›Complete obstruction with drooling

›Any airway compromise

›Suspected perforation

›Button battery suspicion

›Multiple magnet ingestion

›Hemodynamic instability

03Medications/meds29

Current therapies and recent changes

›Medication history

›Anticoagulants

›Antiplatelets

›Diabetes therapies

›Opioids

›Anticholinergics

›Sedatives

›Recent antibiotic exposure

›Recent corticosteroid exposure

Impaction and symptom directed medications

›Pharmacologic options

›Glucagon IV

›Adult dose 1 mg IV once

›Repeat 1 mg IV once after 10 to 15 minutes if no response

›Nausea and vomiting risk

›Antiemetic

›Ondansetron IV 4 mg once

›QT prolongation risk

›Analgesia

›Fentanyl IV 25 mcg increments

›Titration every 5 minutes to comfort

›Acid suppression when mucosal injury suspected

›Pantoprazole IV 40 mg once

›Local protocol dependent

Contraindications and traps

›Medication cautions

›Avoid oral intake in complete obstruction

›Avoid effervescent agents

›Avoid blind instrumentation

›Increased bleeding risk with anticoagulation for endoscopy

›Aspiration risk with sedatives

04Diet/diet13

Recent intake and triggers

›Diet context

›Last oral intake timing

›Trigger food type

›Meat

›Bread

›Dry rice

›Hot dog

›Poor dentition or ill fitting dentures

Hydration and swallowing capacity

›Hydration and tolerance

›Able to tolerate liquids

›Unable to tolerate liquids

›Unable to tolerate saliva

›Dehydration indicators

05Review of Systems/ros25

Gastrointestinal

›GI

›Dysphagia

›Odynophagia

›Heartburn

›Regurgitation

›Nausea

›Vomiting

›Hematemesis

›Melena

›Abdominal pain

Respiratory and ENT

›Respiratory and ENT

›Cough

›Wheeze

›Dyspnea

›Stridor

›Voice change

›Sore throat

›Drooling

Constitutional and neuro

›Constitutional and neuro

›Fever

›Weight loss

›Night sweats

›Weakness

›Focal neurologic deficit

›Dysarthria

06Collateral History and Family History/chafh11

Collateral sources

›Collateral

›Witnessed choking event

›Caregiver report for baseline swallowing

›EMS report of secretions and airway status

Family history and atopy

›Family and atopy history

›Esophageal cancer family history

›Atopy

›Asthma

›Eczema

›Food allergy

›Eosinophilic esophagitis family history

07Risk Factors/rf27

Structural and inflammatory esophageal disease

›Esophageal risk factors

›Gastroesophageal reflux disease

›Prior esophagitis

›Prior stricture

›Schatzki ring

›Eosinophilic esophagitis

›Prior radiation

›Caustic injury history

Malignancy risk

›Malignancy risk

›Progressive dysphagia

›Weight loss

›Tobacco use

›Heavy alcohol exposure

›Barrett esophagus history

Neuromuscular and stroke risk

›Oropharyngeal dysphagia risk

›Prior stroke

›Parkinson disease (G20)

›ALS

›Myasthenia gravis (G70.00)

›Dementia

›Frailty

›Sedative use

Procedure and device related

›Iatrogenic and device risks

›Recent endoscopy

›Recent dilation

›Nasogastric tube placement

›Esophageal stent

08Differential Diagnosis/ddx56

Life threatening

›Life threatening causes

›Esophageal perforation (K22.3)

›Severe chest pain

›Subcutaneous emphysema

›Button battery in esophagus

›Drooling

›Chest discomfort

›Sharp foreign body with perforation risk

›Odynophagia

›Focal neck pain

›Mediastinitis (J98.51)

›Fever

›Toxic appearance

›Airway compromise from proximal obstruction

›Stridor

›Hypoxia

Common

›Common causes

›Food bolus impaction (T18.128A)

›Sudden onset with meal

›Prior intermittent solid dysphagia

›Peptic stricture from GERD (K21.9)

›Longstanding heartburn

›Progressive solids then liquids

›Schatzki ring (K22.2)

›Intermittent solid dysphagia

›Meat impaction history

›Eosinophilic esophagitis (K20.0)

›Atopy

›Recurrent impactions

Less common

›Less common causes

›Esophageal malignancy (C15.9)

›Progressive dysphagia

›Weight loss

›Achalasia (K22.0)

›Dysphagia to solids and liquids

›Regurgitation

›Pill esophagitis (K20.8)

›Recent doxycycline

›Recent bisphosphonate

›Infectious esophagitis

›Candida esophagitis (B37.81)

›HSV esophagitis

›CMV esophagitis

›Zenker diverticulum (K22.5)

›Regurgitation of undigested food

›Halitosis

Mimics and alternative diagnoses

›Mimics

›ACS (I21.9)

›Exertional chest pressure

›ECG changes

›Aortic dissection (I71.00)

›Sudden tearing pain

›Pulse deficit

›Foreign body sensation without obstruction

›Globus

›Anxiety

09Past Medical History/pmh15

Relevant chronic conditions

›Comorbidities

›GERD (K21.9)

›Barrett esophagus (K22.70)

›Prior esophageal stricture (K22.2)

›Eosinophilic esophagitis (K20.0)

›Esophageal cancer (C15.9)

›Prior stroke (I63.9)

›Parkinson disease (G20)

›Diabetes mellitus (E11.9)

Prior episodes and procedures

›Prior episodes and procedures

›Prior food impaction

›Prior endoscopic removal

›Prior dilation

›Prior barium swallow

›Prior aspiration pneumonia (J69.0)

10Physical Exam/exam35

General and airway

›General and airway

›Toxic appearance

›Work of breathing

›Stridor

›Voice quality

›Drooling

›Handling secretions

Vitals pattern interpretation

›Vitals patterns

›Fever pattern

›Tachycardia pattern

›Hypoxia pattern

›Hypotension pattern

Head and neck

›Head and neck

›Oropharynx foreign body

›Tonsillar swelling

›Uvular edema

›Trismus

›Neck tenderness

›Subcutaneous emphysema

Chest and cardiovascular

›Chest and cardiovascular

›Chest wall tenderness

›Hamman sign

›Breath sounds asymmetry

›Wheeze

›Crackles

›Murmur

Abdomen

›Abdomen

›Epigastric tenderness

›Peritoneal signs

›Distension

Neuro and swallowing mechanics

›Neuro

›Cranial nerve deficits

›Dysarthria

›Facial droop

›Gait instability

11Lab Studies/labs11

Baseline labs when escalation likely

›Core labs

›CBC for infection and anemia

›Electrolytes for dehydration

›Creatinine for contrast planning

›Glucose for diabetes management

Infection and perforation support

›Inflammation and sepsis support

›Lactate for sepsis physiology

›Blood cultures if febrile and toxic

Bleeding and procedure readiness

›Hemostasis and procedure considerations

›INR if on warfarin

›Platelets if thrombocytopenia concern

12Imaging/img35

Scoring Systems

›Decision and timing logic

›Button battery

›Immediate endoscopic removal when in esophagus

›Imaging to localize when uncertain

›Sharp object

›Urgent endoscopy when in esophagus

›Surgical consultation triggers when perforation concern

MRI

›MRI considerations

›Limited role in acute food bolus impaction

›Avoid delays in unstable patients

›Consider for neuro etiologies of dysphagia when stable

›Contraindications

›Ferromagnetic implants

›Unstable airway

›CT indications

›Suspected perforation

›Severe chest pain out of proportion

›Fever with toxicity

›Subcutaneous emphysema

›Suspected deep neck space infection

›CT protocol pearls

›CT neck and chest with IV contrast if perforation concern

›Water soluble oral contrast if esophageal leak evaluation and safe to administer

›Avoid barium when perforation suspected

›CT findings

›Pneumomediastinum

›Mediastinal fluid

›Pleural effusion

›Esophageal wall thickening

›Foreign body localization

Ultrasound

›Ultrasound role

›Limited for esophageal obstruction diagnosis

›Lung ultrasound for aspiration patterns

›POCUS for pleural effusion if perforation concern

›POCUS for volume status in dehydration

13Special Tests/spec14

Endoscopic evaluation

›Endoscopy

›Diagnostic and therapeutic for food bolus

›Removal techniques per GI

›Biopsies when eosinophilic esophagitis suspected after clearance

›Contraindications and precautions

›Unsecured airway with copious secretions

›Suspected perforation requires careful planning

Radiographic contrast swallow studies

›Contrast esophagram

›Water soluble contrast when perforation suspected

›Barium reserved when perforation excluded

›Aspiration risk considerations

Oropharyngeal assessment

›Swallow safety screening

›Bedside swallow screen in stable patients with neuro concern

›Speech language pathology evaluation when available

14ECG/ecg10

Indications

›ECG indications

›Chest pain

›Dyspnea

›Syncope

›Significant risk factors for ACS

High risk findings

›High risk patterns

›ST elevation

›Dynamic ischemic changes

›New bundle branch block with symptoms

›Significant QT prolongation before antiemetics

15Assessment/ax22

Problem representation

›Working problem

›Suspected esophageal food bolus impaction (T18.128A)

›Oropharyngeal dysphagia concern

›Complicated course concern

›Aspiration

›Perforation

›Sepsis physiology

Severity and risk stratification

›High risk features present

›Unable to manage secretions

›Airway compromise features

›High risk foreign body category

›Signs of perforation

›Lower risk features

›Partial obstruction

›Able to swallow secretions

›No systemic toxicity

Key alternative diagnoses

›Alternate diagnoses to address

›Achalasia (K22.0)

›Esophageal malignancy (C15.9)

›Pill esophagitis (K20.8)

›Infectious esophagitis

›ACS (I21.9)

16Plan/plan46

First 5 minutes

›Immediate stabilization

›Airway risk stratification

›Suction setup at bedside

›Oxygen if hypoxic

›Cardiac monitor if unstable or chest pain

›IV access criteria

›Two large bore IV if unstable

›One IV if stable

›NPO

›Aspiration precautions

›Immediate consult triggers

›GI emergent endoscopy for complete obstruction

›ENT for suspected proximal oropharyngeal foreign body

›Surgery for perforation concern

Reassessment loop

›Reassessment loop

›Vitals every 15 to 30 minutes until stable

›Airway and secretion tolerance trend

›Chest pain trend

›Vomiting and aspiration events

›Escalate if new fever or worsening pain

Diagnostic sequencing

›Diagnostic sequence

›Plain radiographs when foreign body possible

›Neck soft tissue radiograph

›Chest radiograph

›CT neck and chest when perforation concern

›Endoscopy pathway when food bolus likely and no perforation signs

Therapeutics

›Symptom and definitive management

›Antiemetic if nausea

›Analgesia titration

›Glucagon trial in selected stable patients

›Avoid oral liquids challenge in complete obstruction

›Antibiotics if perforation or mediastinitis suspected

›Piperacillin tazobactam IV 4.5 g every 6 hours

›Ceftriaxone IV 2 g daily

›Metronidazole IV 500 mg every 8 hours

›Local protocol dependent

›Acid suppression when esophagitis suspected

›Steroids not routine for acute impaction

Sedation and airway planning for endoscopy

›Procedure readiness

›NPO status documentation

›Airway protection planning when drooling or aspiration risk

›Anesthesia involvement criteria

›High aspiration risk

›Anticipated difficult airway

›Significant comorbidity

›Anticoagulation considerations for endoscopic intervention

17Disposition/dispo29

ICU and high acuity

›ICU or high acuity criteria

›Airway compromise risk

›Requiring intubation

›Hemodynamic instability

›Sepsis physiology

›Suspected perforation with deterioration

Inpatient admission

›Admission criteria

›Post endoscopy complications

›Aspiration pneumonia concern

›Inability to tolerate oral intake after clearance

›Significant dehydration requiring IV fluids

›Need for urgent inpatient diagnostic workup

›Suspected malignancy

›Severe esophagitis

Observation pathway

›Observation criteria

›Symptoms improving

›Able to tolerate oral liquids after intervention

›No systemic toxicity

›Reliable follow up

Discharge criteria and follow up

›Discharge criteria

›Complete symptom resolution

›Tolerating oral intake

›No perforation or aspiration concern

›Stable vitals

›Reliable supervision

›Follow up timing

›GI follow up within 1 to 2 weeks after impaction

›Earlier follow up when recurrent impactions

›Speech language pathology follow up when neuro concern

18Discharge Instructions/di21

Copy discharge instructions

›Patient instructions

›Diagnosis

›Symptoms improved after treatment in the emergency department

›Diet plan

›Soft foods for 24 to 48 hours

›Small bites

›Chew thoroughly

›Medications

›Take prescribed acid suppression if provided

›Avoid pills that previously caused pain when swallowing

›Follow up

›Gastroenterology appointment within 1 to 2 weeks

›Further testing may be needed to find the cause of the blockage

›Return to emergency department now for

›Trouble breathing

›Unable to swallow saliva

›New or worsening chest pain

›Fever

›Vomiting blood

›Severe neck pain

›Fainting

19References/r6

Guidelines and key sources

›Evidence sources

›American Society for Gastrointestinal Endoscopy guideline on ingested foreign bodies and food impactions

›European Society of Gastrointestinal Endoscopy guideline on management of ingested foreign bodies

›North American Society for Pediatric Gastroenterology Hepatology and Nutrition guidance for pediatric foreign body ingestion

›American College of Radiology appropriateness criteria for dysphagia and suspected esophageal perforation imaging

›National Capital Poison Center guidance for button battery ingestion

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.