01Approach to the Critical Patient/attcp74

Immediate risk stratification for food bolus impaction

›Airway and obstruction triage

›Airway-compromising impaction

›Stridor

›Respiratory distress

›Inability to handle secretions

›Cyanosis

›Non-airway-compromising impaction

›Dysphagia with ability to swallow saliva

›Stable oxygenation and phonation

›Complete obstruction criteria

›Inability to swallow saliva

›Profuse drooling

›Retching without passage of contents

›If complete obstruction with inability to handle secretions, urgent endoscopy regardless of fasting status

›Time-to-endoscopy stratification

›Emergent endoscopy for airway compromise or complete obstruction

›Urgent endoscopy within 24 hours for partial obstruction tolerating secretions

›Risk of pressure necrosis and perforation rises once impaction persists beyond 24 hours

›Endoscopic removal should not be delayed beyond this window regardless of symptom fluctuation

Immediate actions if unstable

›Stabilization sequence

›If drooling with declining respiratory status, intubate for airway protection

›Intubation does not relieve the impaction and must not delay endoscopy

›Upright positioning if tolerated

›Continuous suction setup at bedside

›NPO status

›Two large-bore IV lines

›Cardiac monitor, pulse oximetry, blood pressure cycling

›Consultation triggers

›Emergent gastroenterology notification for airway compromise or complete obstruction

›Anesthesia involvement for impending airway loss

›Surgical consultation for perforation or mediastinitis concern

Key concepts and obsolete practices

›Framing principles

›Eosinophilic esophagitis is now the leading cause of esophageal food bolus impaction in adolescents and young adults

›Identified in roughly half of adults presenting with food impaction and no prior esophageal diagnosis

›Acute impaction is frequently the first recognized presentation of a chronic, previously unreported disease

›Definitive endoscopy addresses both the impaction and the diagnostic opportunity

›Biopsy at the index endoscopy when mucosa is adequately visualized and not obscured by bolus material

›Harmful and obsolete measures

›Meat tenderizer (papain) ingestion

›Mucosal digestion and necrosis risk

›Reports of esophageal perforation

›Obsolete and contraindicated

›Forceful blind bougienage without endoscopic visualization

›Perforation risk from blind advancement against a fixed stricture or ring

›Obsolete, superseded by visualized endoscopic disimpaction and dilation

›Carbonated beverage ingestion to force passage

›Aspiration risk

›Perforation risk with forceful retching

Iatrogenic harms in routine ED care

›Routine ED intervention review

›Intubation

›Does not relieve the esophageal obstruction

›Reasonable for airway protection with impending loss of airway control, but must not delay endoscopy

›Sedation for endoscopy

›Higher aspiration risk with a full esophagus and pooled secretions above the impaction

›Airway-protective technique considered when the airway is not already secured

›Fluid loading

›No specific contraindication

›Correct dehydration from poor intake and vomiting

›Oxygen

›Supplemental oxygen for hypoxemia is safe

›Does not relieve the obstruction

›Vasopressors

›Not routinely indicated

›Reserved for septic shock complicating mediastinitis after perforation

›Mechanical circulatory support, including intra-aortic balloon pump

›Not indicated in isolated food bolus impaction or eosinophilic esophagitis

›Anticoagulation

›Increases bleeding and mucosal injury risk during endoscopic removal or dilation

›Hold or reverse per bleeding-risk protocol before high-risk removal or dilation when feasible without delaying an emergent airway indication

›Fibrinolysis

›Not indicated, no thrombotic process in this disease

›Analgesia

›Safe when titrated to comfort and respiratory status

›Does not need to delay endoscopy

02History/hx48

Acute impaction presentation

›Symptom pattern

›Dysphagia

›Odynophagia

›Sensation of food stuck retrosternally

›Drooling

›Regurgitation of undigested food

›Chest pain

›Timeline

›Time since impaction onset

›Ability to tolerate liquids or saliva since onset

›Prior spontaneous or self-induced passage attempts

›Bolus characteristics

›Meat bolus

›Bread or dry starch bolus

›Pill impaction

Chronic dysphagia and food-avoidance behaviors

›Longstanding adaptive eating patterns

›Prolonged chewing before swallowing

›Cutting food into small pieces

›Lubricating solid food with sauces, gravies, or extra liquid

›Washing food down with large volumes of liquid between bites

›Avoidance of meat, bread, and other dry or dense foods

›Being consistently the last to finish a meal

›Avoiding meals in social settings due to embarrassment over eating pace

›Under-reporting pattern

›Symptoms present for years before presentation because compensatory behaviors mask dysfunction

›Patients frame the adaptations as personal habit rather than a symptom

03Physical Exam/exam23

Targeted exam

›Airway and breathing

›Work of breathing

›Stridor

›Voice quality

›Oxygen saturation trend

›Oropharynx and neck

›Drooling

›Oropharyngeal pooling

›Neck tenderness

›Subcutaneous emphysema

›Chest and abdomen

›Chest wall tenderness

›Mediastinal crunch

›Abdominal tenderness

›Peritoneal signs

›Growth and nutrition in children

›Weight and height trend

›Signs of chronic undernutrition

PITFALLS

›Common misses

›Attributing food impaction solely to a large bolus without considering underlying esophageal disease

›Minimal acute distress despite significant chronic dysphagia

›Normal exam does not exclude a fragile, inflamed esophagus at endoscopy

›Assuming pediatric feeding difficulty is purely behavioral without considering eosinophilic esophagitis

04Differential Diagnosis/ddx22

Life-threatening and esophageal mimics

›Obstructive and airway

›Epiglottitis

›Anaphylaxis

›Angioedema

›Esophageal structural disease

›Peptic stricture

›Schatzki ring

›Esophageal web

›Achalasia

›Esophageal malignancy

›Esophageal emergencies

›Esophageal perforation, including Boerhaave syndrome

›Caustic ingestion injury

›Inflammatory and infectious mimics

›Reflux esophagitis

›Infectious esophagitis, particularly candida, which can mimic exudates on endoscopy

›Pill-induced esophagitis

›Eosinophilic gastroenteritis with esophageal involvement

›Hypereosinophilic syndrome with esophageal involvement

Coding considerations

›ICD-10 alignment

›K20.0 eosinophilic esophagitis

›K22.2 esophageal obstruction for acute food bolus impaction

05Laboratory Tests/lt23

Labs for complication and procedural readiness

›Targeted laboratory evaluation

›Complete blood count for fever, toxicity, or bleeding concern

›Leukocytosis supportive of mediastinitis or aspiration

›Basic metabolic panel for dehydration and pre-sedation status

›Coagulation studies if anticoagulated or high-risk endoscopy planned

›Type and screen for suspected perforation or significant bleeding

›Venous blood gas for respiratory distress

›pH

›pCO2 mmHg

›Lactate mmol/l for shock or sepsis concern

Eosinophil and allergy-associated markers

›Supportive but non-diagnostic markers

›Peripheral eosinophil count

›Mildly elevated in a substantial minority of patients

›Does not reliably correlate with esophageal eosinophil density

›Not required for diagnosis

›A normal peripheral count does not exclude eosinophilic esophagitis, a lab-interpretation trap that can falsely reassure against the diagnosis

›A markedly elevated count should prompt consideration of hypereosinophilic syndrome rather than eosinophilic esophagitis alone

›Total serum IgE

›Frequently elevated with concurrent atopic disease

›Not diagnostic of eosinophilic esophagitis

›Skin prick and serum specific IgE food allergy testing

›Poor predictive value for identifying esophageal trigger foods

›Not recommended to select foods for elimination diet

06Diagnostic Tests/dt64

Scoring Systems

›Endoscopic reference score (EREFS)

›Domains

›Edema

›Rings

›Exudates

›Furrows

›Strictures

›Use

›Standardizes endoscopic severity documentation and treatment response tracking

›Does not replace histologic assessment for diagnosis

›Impaction urgency stratification

›Emergent endoscopy pathway

›Complete obstruction

›Inability to handle secretions

›Airway compromise

›Urgent endoscopy pathway

›Partial obstruction with persistent symptoms tolerating secretions

MRI

›MRI role

›No established role in acute food bolus evaluation

›No routine role in eosinophilic esophagitis diagnosis or monitoring

›Diagnosis requires histology, not cross-sectional imaging

CT

›CT indications and interpretation

›Indications

›Suspected perforation

›Severe pain with systemic toxicity

07Disposition/dispo19

Level of care and follow-up

›Admission and monitored care

›ICU or step-down triggers

›Airway intervention

›Perforation or mediastinitis

›Significant aspiration

›Inpatient admission triggers

›Deep mucosal laceration or necrosis on endoscopy

›Persistent dysphagia or inability to tolerate oral intake after removal

›Discharge criteria

›Complete symptom resolution after bolus removal

›Tolerating oral intake

›No red-flag exam findings

›Follow-up planning

›Gastroenterology follow-up for biopsy results and elimination diet or medication planning

›Repeat endoscopy for histologic reassessment after 8 to 12 weeks of therapy

Transfer criteria

›Transfer indications

›No endoscopy capability at the presenting facility with airway compromise or complete obstruction

›Suspected perforation requiring surgical or advanced endoscopic capability

›Pediatric patient requiring pediatric gastroenterology or anesthesia support not locally available

08Treatment/t139

Acute impaction: airway and supportive care

›Supportive measures

›NPO status

›No oral trials while impaction symptoms persist

›Suction and secretion control

›Yankauer suction at bedside

›Oxygen and ventilation support

›Supplemental oxygen for hypoxemia

›If respiratory fatigue, intubate for airway protection

›Antiemetic therapy

›Ondansetron IV 4 mg

›Repeat dosing per local protocol

›Analgesia

›Fentanyl IV 25 to 50 micrograms

›Titration every 5 to 10 minutes to comfort and respiratory safety

›Maximum initial dose 100 micrograms before reassessment

Acute impaction: endoscopic removal and timing

›Endoscopic removal strategy

›Timing targets

›Emergent endoscopy for airway compromise or complete obstruction

›Urgent endoscopy within 24 hours for partial obstruction tolerating secretions

›Endoscopic removal should not be delayed beyond 24 hours from impaction onset given rising perforation risk

›Technique considerations

›Gentle push or pull technique given underlying mucosal fragility

›Overtube use for multiple passes and aspiration reduction

›Retrieval devices

›Rat-tooth forceps

›Retrieval net

›Snare

›Distal advancement of food bolus only if no bone or sharp component and low perforation risk

›Diagnostic biopsy at the index or follow-up endoscopy once mucosa is visualized

Acute impaction: pharmacologic temporization and obsolete measures

›Glucagon IV 1 mg

›Administered slow IV push over 1 to 2 minutes

›Mechanism

›Smooth muscle relaxation at the lower esophageal sphincter

›Evidence

›Widely used at the bedside despite weak and inconsistent trial evidence of benefit over placebo

›Lower success expected with a fixed structural cause such as a ring, stricture, or eosinophilic esophagitis

›Safety

›Nausea and vomiting are common

›Aspiration risk with vomiting in a patient unable to clear secretions

›Must not delay definitive endoscopy if no prompt response

›If no response within a brief trial period, proceed to endoscopy without further dosing

›Harmful and obsolete measures

›Meat tenderizer (papain)

›Mucosal digestion, necrosis, and reported perforation

›Contraindicated

›Forceful blind bougienage

›Perforation risk against a fixed stricture or ring

›Obsolete, replaced by visualized endoscopic technique

›Carbonated beverages to force passage

›Aspiration and perforation risk

Maintenance pharmacotherapy: proton pump inhibitors

›Proton pump inhibitor trial

›Role

›First-line maintenance therapy alongside topical steroids and dietary elimination

›A subset of patients achieve histologic and symptomatic remission with acid suppression alone

›PPI response no longer excludes the diagnosis of eosinophilic esophagitis

›Omeprazole PO 20 to 40 mg twice daily

›Trial duration 8 to 12 weeks before repeat endoscopy and biopsy

›Reassess histologic response rather than symptoms alone

›Esomeprazole PO 20 to 40 mg twice daily

›Trial duration 8 to 12 weeks before repeat endoscopy and biopsy

›Maximum typical dosing 40 mg twice daily

›Escalate to swallowed topical steroid or diet if histologic response inadequate

Maintenance pharmacotherapy: swallowed topical corticosteroids

›Administration principle distinct from asthma inhaler technique

›For eosinophilic esophagitis, the metered-dose inhaler is sprayed into the mouth and swallowed, not inhaled into the lungs

›Exhale fully before actuation, then actuate into the closed mouth and swallow rather than breathing in

›No food, drink, or mouth rinsing for 30 minutes after dosing

›Rinsing or eating immediately washes topical drug off the esophageal mucosa before it can act

›Mouth rinse and spit after the 30-minute window, without swallowing the rinse, to reduce oral and esophageal candidiasis risk

›Fluticasone propionate metered-dose inhaler, swallowed

›880 mcg per day divided as 440 mcg twice daily for adults

›Delivered as multiple actuations per dose per device strength

›If inadequate histologic response at follow-up endoscopy, may increase per specialist guidance

›Maximum typical dosing 1760 mcg per day divided twice daily

›Budesonide oral viscous suspension

›Budesonide 1 mg twice daily mixed into a viscous slurry with a sucralose-based sweetener

›Slurry consistency allows esophageal contact time rather than rapid transit

›Maximum typical dosing 2 mg twice daily

›Monitoring

›Esophageal and oropharyngeal candidiasis surveillance

›Repeat endoscopy and biopsy after 8 to 12 weeks to confirm histologic response

Dietary elimination therapy

›Elimination strategies

›Six-food elimination diet

›Removes dairy, wheat, egg, soy, tree nuts and peanut, fish and shellfish

›Sequential food reintroduction with endoscopy and biopsy after each reintroduction step

›Four-food elimination diet

›Removes dairy, wheat, egg, soy

›Lower dietary burden than the six-food approach with similar reported remission rates

›One-food elimination diet

›Removes dairy only as a lower-burden step-up starting point

›Escalate to a broader elimination diet or other therapy if inadequate response

›Elemental amino-acid based formula diet

›Highest reported histologic remission rate

›Least practical for long-term adherence, reserved for refractory or severe pediatric disease

›Testing-guided elimination

›Empiric elimination without allergy testing is the preferred approach

›Skin prick and serum specific IgE testing do not reliably predict esophageal trigger foods

›Coordination

›Dietitian involvement for nutritional adequacy during elimination and reintroduction

›Endoscopic and histologic reassessment required at each reintroduction step, not symptoms alone

Biologic therapy: dupilumab

›Mechanism

›Monoclonal antibody against the IL-4 receptor alpha subunit

›Blocks IL-4 and IL-13 signaling in the type 2 inflammatory pathway driving eosinophilic esophagitis

›Indications

›Inadequate response to, intolerance of, or contraindication to PPI, topical steroid, or dietary therapy

›Adults and adolescents weighing 40 kg or more

›Dupilumab subcutaneous 300 mg once weekly

›No loading dose required at this indication and weight

›Pediatric patients weighing less than 40 kg

›Lower weight-tiered dosing regimen exists

›Verify exact weight-band dosing and interval against current prescribing information before use

›Safety and monitoring

›Injection site reaction

›Conjunctivitis

›Eosinophilia can transiently rise after initiation

›Monitor if marked or symptomatic

›Not a substitute for continued diet or topical steroid therapy unless histologic remission is confirmed off those therapies

Esophageal dilation for stricture

›Indications

›Persistent dysphagia or recurrent food impaction attributable to a fixed stricture or narrow-caliber esophagus despite anti-inflammatory therapy

›Technique

›Through-the-scope balloon dilation or bougie dilation

›Rule of 3s for bougie dilation

›Advance no more than 3 consecutive dilator sizes in one session once resistance is met

›Reduces perforation risk in a fibrostenotic esophagus

›Gradual, staged dilation over multiple sessions preferred over aggressive single-session dilation

›Peri-procedural considerations

›Anti-inflammatory therapy (topical steroid, diet, or PPI) continued before and after dilation

›Dilation treats the stricture but does not treat the underlying inflammation

›Expected post-dilation mucosal tears distinct from perforation

›Chest pain analgesia as needed

›Perforation risk counseling before the procedure given mucosal fragility

Perforation management

›Suspected perforation pathway

›Broad-spectrum IV antibiotics

›Piperacillin-tazobactam IV 4.5 g every 6 hours

›Ceftriaxone IV 2 g daily plus metronidazole IV 500 mg every 8 hours as the alternative for severe penicillin allergy

›Surgical consultation

›Immediate for free perforation or hemodynamic instability

›NPO status and IV fluids

›Imaging reassessment

›CT with IV contrast for mediastinal contamination extent

09Special Populations/sp35

Pregnancy

›Pregnancy considerations

›Imaging selection

›Plain radiographs with shielding when indicated

›CT reserved for suspected perforation or life-threatening complication

›Sedation for endoscopy

›Obstetric consultation for viable gestation when procedural sedation is planned

›Left lateral tilt positioning if supine intolerance

›Medication considerations

›PPI generally considered compatible with pregnancy when indicated

›Topical steroid therapy individualized with specialist input given limited pregnancy-specific data

›Dupilumab use in pregnancy individualized given limited pregnancy-specific data

Geriatric

›Geriatric considerations

›Higher prevalence of denture-related and polypharmacy-related impaction as competing causes

›Bleeding risk with mucosal trauma in anticoagulated patients

›Coagulation assessment when high-risk removal or dilation anticipated

›Atypical presentation

›Minimal pain despite significant mucosal injury

›New diagnosis of eosinophilic esophagitis is less common in older adults but does occur and should not be dismissed

Pediatrics

›Presentation differences

›Infants and young children

›Feeding refusal

›Vomiting

›Failure to thrive or poor weight gain

›School-age children and adolescents

›Abdominal pain

10Background/b22

Epidemiology

›Population burden

›Prevalence approximately 1 in 2,000 in the general population, with rising incidence over recent decades

›Male predominance, roughly 70 percent of cases

›Eosinophilic esophagitis accounts for roughly half of adult food bolus impactions presenting without a prior esophageal diagnosis

›Comorbid atopic disease present in roughly half to a majority of patients

›Increased risk with an affected first-degree relative compared with the general population

Pathophysiology

›Immune mechanism

›Type 2 helper T cell driven immune response to food and aeroallergens

›IL-5 and IL-13 mediated eosinophil recruitment and activation in the esophageal mucosa

›Chronic eosinophilic inflammation drives tissue remodeling

›Subepithelial fibrosis

›Smooth muscle hypertrophy

›Structural consequences

›Fibrostenotic remodeling produces rings, strictures, and a narrow-caliber esophagus

›Chronic inflammation produces a fragile, easily torn mucosa

›Structural narrowing predisposes to recurrent food bolus impaction

Therapeutic Considerations

›Treatment principles

›Goal is histologic remission, not symptom control alone, because symptoms adapt while inflammation persists

›First-line options (PPI, swallowed topical steroid, dietary elimination) have broadly comparable efficacy and are chosen based on patient preference and adherence capacity

›Endoscopic and histologic reassessment after each therapeutic change, since symptom improvement does not reliably track histologic response

›Dilation addresses fixed structural narrowing but does not substitute for anti-inflammatory therapy

›Biologic therapy reserved for refractory disease or intolerance of first-line options

11Patient Discharge Instructions/pdi25

Copy discharge instructions

›Diagnosis and expectations

›Food got stuck in the esophagus, and the underlying cause may be a chronic inflammatory esophageal condition requiring follow-up testing

›A biopsy may have been taken to check for this condition, with results discussed at follow-up

›Eating changes until follow-up

›Chew all food thoroughly before swallowing

›Take small bites and eat slowly

›Drink liquid with every bite of solid food

›Avoid dry, dense, or bread-type foods and tough meats until follow-up evaluation

›Sit upright while eating and for at least 30 minutes afterward

›Avoid rushed or distracted eating

›Medications

›Take proton pump inhibitor or swallowed topical steroid exactly as prescribed

›If a steroid inhaler is prescribed, spray it into the mouth and swallow it rather than breathing it in, and avoid food, drink, or rinsing for 30 minutes afterward

›Return to ED immediately

›Trouble breathing

›Drooling or inability to swallow liquids

›Another episode of food getting stuck

›Worsening chest pain

›Fever

›Vomiting blood

›Black stools

›Severe neck pain

›Follow-up

›Gastroenterology follow-up for biopsy results and long-term treatment plan

›Dietitian referral if dietary elimination therapy is planned

12References/r15

Guidelines and key sources

›American College of Gastroenterology clinical guideline on eosinophilic esophagitis

›Diagnostic criteria, biopsy protocol, and first-line treatment recommendations

›AGREE consensus statement on updated eosinophilic esophagitis diagnostic criteria

›Removal of PPI-responsive esophageal eosinophilia as a separate diagnostic category

›ASGE guideline on management of ingested foreign bodies and food impactions

›Endoscopic timing stratified by obstruction severity and airway risk

›NASPGHAN guidance on pediatric eosinophilic esophagitis

›Pediatric diagnostic and dietary elimination approach

Clinical trial evidence

›Landmark therapeutic trials

›LIBERTY EoE TREET trial program

›Phase 3 evidence supporting dupilumab efficacy in adolescents and adults with eosinophilic esophagitis

›Randomized trials of six-food, four-food, and one-food elimination diets

›Comparative histologic remission rates supporting a step-up dietary approach

›Randomized trials of swallowed fluticasone and budesonide versus placebo

›Histologic and endoscopic response supporting topical corticosteroid as first-line therapy

Evidence & Review

Evidence & Review