Oesophageal Food Impaction

When a piece of food gets stuck in the tube that carries food from your mouth to your stomach, it creates a frightening situation that sends thousands of people to the emergency room each year. While many cases resolve on their own, some require urgent medical attention to prevent serious complications.

Table of contents

• What is oesophageal food impaction?
• How to recognize the symptoms
• Why does food get stuck?
• Conditions that increase the risk
• How doctors identify the problem
• Treatment options
• Possible complications

Food bolus impaction, Steakhouse syndrome, Backyard barbeque syndrome

• Oesophagus
• Lower oesophageal sphincter
• Upper oesophageal sphincter

What is oesophageal food impaction?

Oesophageal food impaction is a medical emergency that occurs when food becomes stuck in the oesophagus, which is the tube that connects your mouth to your stomach. This condition happens suddenly and is usually recognized immediately by the person experiencing it^[1]. The annual incidence is approximately 13 cases per 100,000 people, making it the third most common non-biliary emergency in gastroenterology^[2][4].

The condition is colloquially known as “steakhouse syndrome” or “backyard barbeque syndrome” because it often occurs when people are eating meat, particularly in social settings where they may eat too quickly or not chew their food thoroughly^[1][4]. In many cases, the impacted food will pass on its own or the person will regurgitate it. However, when symptoms persist or are accompanied by substantial chest discomfort, medical attention is necessary^[1].

How to recognize the symptoms

The main symptom of oesophageal food impaction is acute dysphagia, which means sudden difficulty swallowing^[3][7]. People with this condition typically experience a sensation of squeezing or fullness in the chest, which can be frightening because it is difficult to distinguish from heart attack pain^[1][4].

A distinctive feature of food impaction is excessive salivation, also called sialorrhea, which accompanies the blockage^[1]. Patients with complete obstruction cannot swallow their saliva and may drool or spit frequently^[2][3]. They are also unable to eat or drink anything further when experiencing an impaction^[1].

Other symptoms include regurgitation of food, painful swallowing (called odynophagia), blood-stained saliva, and gagging or choking sensations^[3][7]. It is crucial to understand that food impaction is different from true choking. Patients with food stuck in the oesophagus can still breathe, talk, and cough, whereas a person who is truly choking cannot do any of these things because the food has blocked the airway rather than the food pipe^[1][10].

Why does food get stuck?

Food becomes stuck in the oesophagus most commonly when people swallow large pieces of food without chewing them sufficiently. The most frequently impacted foods are meat such as beef, chicken, and pork, as well as vegetables cooked al dente^[1][4]. Large, smooth food pieces like steak and hot dogs are particularly easy to swallow inadvertently before being chewed enough^[3][7].

Several factors can contribute to food impaction. These include poor teeth or ill-fitting dentures, which make it difficult to chew food properly, the use of alcohol during meals, and a tendency to eat too quickly^[1]. Bones, particularly fish bones, may also become stuck if the meat containing them is not chewed sufficiently^[3][7].

Foreign bodies in the oesophagus usually lodge in areas where there is narrowing of the tube. This narrowing may be caused by natural structures like the upper or lower oesophageal sphincter (muscular rings that control the opening and closing of the oesophagus), or by various disease conditions^[3][7].

Conditions that increase the risk

In most adults with food impaction, there is an underlying condition affecting the oesophagus. Research shows that between 88% and 97% of adult cases involve some form of oesophageal pathology^[2].

The most common mechanical cause is a Schatzki ring, which is a ring of tissue in the lower oesophagus that narrows the passage. Food becomes jammed at the point where this ring creates a bottleneck^[1][4]. Another common cause is peptic stricture, which is a narrowing that occurs from long-standing, uncontrolled acid reflux disease^[1][10].

Eosinophilic oesophagitis is an increasingly recognized cause of food impaction. This is an inflammatory disorder of the lining of the oesophagus of unknown cause^[4]. Many changes caused by eosinophilic oesophagitis can lead to food becoming stuck, including the presence of multiple rings and narrowing of the passage^[4]. When considering procedures to widen the oesophagus in patients with food impaction, doctors must look carefully for features of eosinophilic oesophagitis, as these patients are at higher risk of complications from such procedures^[4].

Other conditions that can predispose to food impaction include oesophageal webs (thin membranes that partially block the passage), benign and cancerous tumours, achalasia (a condition where the lower oesophageal sphincter fails to relax properly), distal oesophageal spasm, previous oesophageal surgery, and external compression from blood vessels^[3][4][7]. Rarely, disorders of oesophageal movement can cause transient food impaction. In these patients, the impaction generally passes after the muscles of the oesophagus relax and allow the food to move forward^[1][10].

How doctors identify the problem

Most patients can clearly describe what happened when the food became stuck^[3][7]. Those with significant symptoms suggesting complete blockage should receive immediate treatment with endoscopy, which is a procedure using a flexible tube with a camera to look inside the oesophagus^[3][7].

Patients with minimal symptoms and no high-risk factors who are able to swallow normally may not have an impacted food bolus and can be watched to see if symptoms resolve. Other patients may require imaging studies^[3][7].

Plain X-rays of the chest and neck can be helpful, particularly for detecting bones or signs of perforation (a hole in the oesophagus)^[1][2]. A chest X-ray may show air in the lower part of the oesophagus^[2]. Fluoroscopic examination, also called an oesophagram, can provide a definitive diagnosis by showing the location and extent of the blockage^[2]. Although computed tomography (CT) scans have largely replaced fluoroscopic examinations, fluoroscopy can still provide valuable diagnostic information^[2].

It is important to distinguish food impaction from true foreign object ingestion. This should be possible through an honest and accurate medical history. Ingested foreign objects may be intentional or accidental, and most are visible on X-rays^[1]. One concern with meat impaction is whether there may be unrecognized bones in the food. Careful examination of X-ray films can help identify this possibility^[1].

Treatment options

Many food impactions resolve without intervention, either by moving forward to the stomach or by the patient regurgitating the food^[1]. In an emergency room setting, patients may be observed for a period to see if the food passes spontaneously^[4][6].

Various medications have been tried to help dislodge food impactions. Glucagon, a smooth muscle relaxant thought to relax the lower oesophageal sphincter, has been commonly used^[5][13]. However, studies show that medications are successful in relieving impactions only about 34.5% of the time when tried^[6]. Current evidence does not strongly support the use of glucagon, and it should not delay proper endoscopic intervention^[4][13]. Other medications that have been studied include nitrates, calcium channel blockers, and benzodiazepines, but none have shown convincing effectiveness^[5].

Non-medicinal approaches include drinking carbonated beverages such as Coca-Cola. Research suggests that carbonated drinks may help dislodge food stuck in the oesophagus, although doctors are not certain exactly how this works. It may be that carbon dioxide gas helps break up the food, or that some of the beverage enters the stomach and releases gas that creates pressure to dislodge the blockage^[4]. One study described a new treatment approach using a combination of Coca-Cola and Creon (an enzyme) delivered through a tube for 2-3 days in cases where endoscopic removal was judged difficult or unsafe^[11].

The definitive treatment for persistent food impaction is endoscopic intervention. Urgent endoscopy is common, occurring in about 74% of cases, and endoscopic therapy is needed in approximately 67% of patients^[6]. During endoscopy, the doctor can either push the food into the stomach or remove it by pulling it out. The push technique has become the most common approach and has been shown to be as safe as retrieval^[6]. Endoscopic treatment is successful as a first attempt in about 95% of patients^[14].

Medical attention within 12 to 24 hours is advised to prevent complications. Delayed intervention after 24 hours often requires longer endoscopic procedure time and can result in more painful oesophageal ulcerations^[5]. Complete obstruction is poorly tolerated, and even a smooth object can cause pressure damage and risk of perforation if allowed to remain in the oesophagus for more than about 24 hours^[3][7].

Possible complications

The main complications of oesophageal food impaction are obstruction and perforation (a hole in the oesophageal wall)^[3][7]. Obstruction may be partial, where patients can swallow liquids or at least their saliva, or complete. Partial obstruction is less urgent unless it involves a sharp object embedded in the wall, which can lead to perforation^[3][7].

Patients with food impaction are also at risk of aspiration, where food or saliva enters the lungs, as well as dehydration if the blockage prevents them from drinking^[2][9]. Studies show that oesophageal complications such as deep injury to the lining or perforation have increased over time but remain rare, with a peak rate of about 11%^[6]. Complications from endoscopic treatment occur in approximately 2.8% to 7% of cases and mostly consist of bleeding, perforations, and tears^[6][14].

The incidence of oesophageal food impaction has been increasing over time, which may be related to the emergence of eosinophilic oesophagitis as a more commonly recognized condition^[6]. Despite the increase in cases, endoscopic therapy remains safe and effective, with minimal complications when performed by experienced practitioners^[14].