Is it this?
- Sudden dysphagia or chest discomfort during a meal, usually meat.
- Complete obstruction: cannot swallow saliva, drooling, regurgitating secretions.
- Incomplete: handling secretions, discomfort persists.
- Look for perforation: severe chest or neck pain, crepitus, fever, tachycardia, ingestion of bones.
First hour
- Airway first. Sit the patient up, suction. Consider endotracheal intubation if aspiration risk is high (ESGE 2016).
- No X-ray for an uncomplicated, non-bony food bolus (ESGE 2016 Rec 2). X-ray if a bone or radiopaque object is possible.
- CT if perforation or another complication is suspected (Rec 3).
- No barium swallow: aspiration risk and poorer endoscopic view (Rec 4).
- No meat tenderiser (papain) or other proteolytic enzymes: erosion and perforation (Fung 2019).
Glucagon: don’t
- A 2024 double-blind RCT: glucagon 1 mg IV was no better than placebo (bolus already gone at endoscopy 23.6% vs 20.6%) (de Benito Sanz 2024).
- Meta-analysis: no difference in success (30% vs 33%), and more adverse events with glucagon (15% vs 0%), mainly vomiting (Peksa 2019).
- ESGE 2016: medical therapy must not delay endoscopy.
Scope: when
| Situation | Timing (ESGE 2016 Rec 7) |
|---|---|
| Complete obstruction (cannot handle secretions) | Emergent: preferably within 2 h, at the latest within 6 h |
| Incomplete obstruction | Urgent: within 24 h |
| Bolus has passed, symptoms resolved | No emergency scope. Arrange outpatient GI review and endoscopy (Canadian EoE consensus 2025) |
Scope: how
- Gently push the bolus into the stomach. If it will not move, retrieve it (piecemeal, net, snare, or forceps) (ESGE 2016 Rec 8).
- A clear cap can improve the view and shorten the procedure (Fung 2019).
- Consider endotracheal intubation if the aspiration risk is high (ESGE 2016).
- After clearance, look at the whole esophagus: rings, stricture, furrows, exudates, esophagitis, tumour.
Biopsies at the index scope
- Take esophageal biopsies at the same endoscopy. The Canadian EoE consensus (2025) strongly encourages it, and ESGE recommends a work-up including histology (Rec 9).
- Where and how many: at least 2 biopsies per level from at least 2 levels (distal, mid, proximal), at least 4–6 in total, regardless of how the mucosa looks. Target the most inflamed areas (Canadian consensus Statement 12).
- EoE diagnosis needs ≥15 eosinophils per high-power field (Statement 13). A PPI trial is not needed for diagnosis (Statement 10).
- If biopsies cannot be taken safely at the index scope, book a repeat endoscopy with biopsies.
Disposition
- Discharge after an uncomplicated removal (ESGE 2016 Rec 13).
- PPI after: PPI is a first-line EoE treatment (Canadian Statement 18) and treats reflux esophagitis. Dose and duration per local practice.
- Follow-up endoscopy: timing is at the endoscopist’s discretion, but usually within 2 months, on a PPI (KHSC practice). Book it sooner if dilation will obviously be needed. Repeat with biopsies if none were taken, and use it to assess response to treatment. GI clinic with the biopsy results.
- If EoE is confirmed: PPI, swallowed topical steroid (e.g. budesonide orodispersible tablet), diet elimination, biologic, or dilation as complementary (ACG 2025; Canadian consensus).
Red flags
- Drooling or stridor.
- Signs of perforation: urgent CT and surgical consult.
- Sharp objects or bones: a different pathway; not covered here.
Pitfalls
- Giving glucagon and waiting.
- Ordering barium.
- No biopsies: the patient comes back with another bolus.
- Forgetting outpatient follow-up when the bolus passes on its own.
Follow your local protocols.