Chapter 40. Esophageal Emergencies

Complaints of dysphagia, odynophagia, or ingested foreign body implicate the esophagus. Chest pain, upper gastrointestinal (GI) bleeding, malignancy, and mediastinitis may also be esophageal in nature. Many diseases of the esophagus can be evaluated over time in an outpatient setting, but several, such as esophageal foreign body and esophageal perforation, must be addressed emergently.

Dysphagia is difficulty with swallowing. Most patients with dysphagia have an identifiable, organic cause. The two broad pathophysiologic groups of dysphagia are transfer dysphagia (oropharyngeal) and transport dysphagia. (esophageal).

Clinical Features

A careful history is the key to the diagnosis of dysphagia. Determine whether solids, liquids, or both cause the symptoms and the time course and progression of symptoms. Dysphagia for solids that progresses to liquids suggests a mechanical or obstructive process. Dysphagia for both solids and liquids points to a motility disorder. A poorly chewed meat bolus may obstruct the esophagus and be the presenting sign for a variety of underlying esophageal pathologies. Esophageal filling proximal to the impacted bolus can cause inability to swallow secretions and can present an airway or aspiration risk. Physical examination of patients with dysphagia should focus on the head and neck and the neurologic examination although the examination is often normal.

Diagnosis and Differential

The diagnosis of the underlying pathology of dysphagia is most often made outside the emergency department (ED). ED evaluation may include anteroposterior and lateral neck and chest x-rays. Direct laryngoscopy may identify structural lesions. Structural or obstructive causes of dysphagia include neoplasms (squamous cell is most common), esophageal strictures and webs, Schatzki ring, and diverticula. Motor lesions causing dysphagia include neuromuscular disorders (cerebrovascular accident is most common), achalasia, and diffuse esophageal spasm.

Emergency Department Care and Disposition

1. Aspiration is a major concern with most causes of dysphagia.

2. Most causes of dysphagia can be further evaluated and managed in the outpatient setting. Barium swallow is usually the first test for patients with transport dysphagia. Oropharyngeal dysphagia is best worked up by video esophagography.

3. Many of the structural lesions ultimately will require dilatation as definitive therapy.

Differentiating esophageal pain from ischemic chest pain can be difficult or impossible in the ED. Patients with esophageal pain report symptoms that are also found in patients with coronary artery disease, and there is no historical feature that is sensitive or specific enough to differentiate the two. The best ED default assumption is that pain is cardiac in nature and not esophageal until proven otherwise.

Gastroesophageal Reflux Disease

Reflux of gastric contents into the esophagus causes a wide array of symptoms and long-term effects. It affects up to 20% of the adult population in the United States.

Clinical Features

Heartburn is the classic symptom of gastroesophageal reflux disease (GERD) although chest discomfort may be the only symptom. The association of pain with meals, postural changes, and relief of symptoms with antacids point to a diagnosis of GERD. Less obvious presentations of GERD include pulmonary symptoms, especially asthma exacerbations, and multiple ear, nose, and throat symptoms. GERD also has been implicated in the etiology of dental erosion, vocal cord ulcers and granulomas, laryngitis with hoarseness, chronic sinusitis, and chronic cough. Over time, GERD can cause complications such as strictures, inflammatory esophagitis, and Barrett esophagus (a premalignant condition).

Diagnosis and Differential

Diagnosis is suggested by history and favorable response to antacid treatment. However, some patients with symptoms due to cardiac ischemia also report improvement with the same therapy. Unfortunately, like cardiac pain, GERD pain may be squeezing or pressure-like and include a history of onset with exertion or rest. Both types of pain may be accompanied by diaphoresis, pallor, radiation, and nausea and vomiting. An ECG and chest radiograph can be obtained in patients with ambiguous presentations. Given the serious outcome of unrecognized ischemic disease compared with the relatively benign nature of esophageal pain, a cautious approach is warranted.

Emergency Department Care and Disposition

1. Comprehensive treatment of reflux disease is done on an outpatient basis and involves decreasing acid production, enhancing upper tract motility, and eliminating risk factors for the disease.

2. Mild disease often is treated empirically with an H2 blocker (eg, ranitidine 150 milligrams PO twice daily) or proton pump inhibitor (eg, omeprazole 20 to 40 milligrams PO daily).

3. Prokinetic drugs (eg, metoclopramide 10 to 15 milligrams PO 30 min before meals and at bedtime) may reduce symptoms; decrease dose 50% in elderly patients.

4. Patients should avoid agents that exacerbate GERD (ethanol, caffeine, nicotine, chocolate, or fatty foods), sleep with the head of the bed elevated (30°), and avoid eating within 3 hours of going to bed at night.

Esophagitis

Esophagitis can cause prolonged periods of chest pain and odynophagia. Esophagitis may be inflammatory (eg, GERD, NSAIDs, potassium chloride, doxycycline, tetracycline, clindamycin). Withdrawal of offending agent is generally curative with medication-induced esophagitis. Patients with reflux-induced esophagitis require acid-suppressive medications. Immunosuppressed patients can develop an infectious esophagitits, most commonly Candida. The diagnosis is established by outpatient endoscopy.

Esophageal Motility Disorder

Esophageal dysmotility is the excessive, uncoordinated contraction of esophageal smooth muscle. Patients usually complain of dull, colicky chest pain at rest. Onset is typically in the fifth decade. Pain from spasm may respond to nitroglycerin, as well as calcium channel blockers and anticholinergic agents. Nutcracker esophagus is a specific type of motility disorder of unknown origin that causes noncardiac chest pain. Manometry helps confirm the diagnosis.

Intraluminal procedures are the most common cause of esophageal perforation. Other causes include transient increase in intraesophageal pressure (Boerhaavesyndrome), trauma, foreign body, infection, tumor, and aortic pathology. Perforation of the esophagus is associated with a high mortality rate.

Clinical Features

Pain is classically described as acute, severe, unrelenting, and diffuse and is reported in the chest, neck, and abdomen. Pain can radiate to the back and shoulders, or back pain may be the predominant symptom. Swallowing often exacerbates pain. Physical examination varies with the severity of the rupture and the elapsed time between the rupture and presentation. Abdominal rigidity with hypotension and fever often occur early. Tachycardia and tachypnea are common. Mediastinal emphysema takes time to develop. It is less commonly detected by examination or radiography in lower esophageal perforation, and its absence does not rule out perforation. A Hammon crunch can sometimes be auscultated. Pleural effusions develop in 50% of patients with intrathoracic perforations and are uncommon in cervical perforations.

Diagnosis and Differential

Chest radiography can suggest the diagnosis. CT of the chest or emergency endoscopy is most often used to confirm the diagnosis. Selection of the procedure depends upon the clinical setting and the resources available. Pain resulting from esophageal perforation often is ascribed to acute myocardial infarction, pulmonary embolus, peptic ulcer disease, aortic catastrophe, or acute abdomen, which results in critical delays in diagnosis.

Emergency Department Care and Disposition

1. Rapid, aggressive management is essential.

2. In the emergency department, initiate fluid resuscitation (see Chapter 5), and give broad-spectrum parental antibiotics to cover aerobic and anaerobic organisms. Examples include single drug coverage such as piperacillin/tazobactam 3.375 grams intravenously (IV) or double drug coverage with cefotaxime 2 grams IV or ceftriaxone 2 grams IV plus clindamycin 600 milligrams IV or metronidazole 15 milligrams/kilogram IV once, then 7.5 milligrams/kilogram q6h (max 1 gram/dose).

3. Obtain emergent surgical consultation.

4. All of these patients require hospitalization.

Swallowed Foreign Bodies

Children (18 to 48 months old) account for 80% of all cases of ingested foreign bodies. Coins, toys, and crayons typically lodge in the anatomically narrow proximal esophagus. Adult candidates are those with esophageal disease, prisoners, and psychiatric patients. In adults, most impactions are distal. Complications include airway obstruction, stricture, and perforation. Once an object transverses the pylorus, it usually continues through the GI tract. Objects that become lodged distal to the pylorus are usually irregular, have sharp edges, are wide (>2.5 cm) or long (>6 cm)

Clinical Features

Objects lodged in the esophagus can produce retrosternal pain, dysphagia, coughing, choking, vomiting, aspiration, and the patient may be unable to swallow secretions. Adults with an esophageal foreign body generally provide unequivocal history. In the pediatric patient it may be necessary to rely on clues such as refusal to eat, vomiting, gagging, choking, stridor, neck or throat pain, dysphagia, and drooling.

Diagnosis and Differential

Physical examination starts with an assessment of the airway. The nasopharynx, oropharynx, neck, and chest should also be examined. Occasionally, a foreign body can be directly visualized in the oropharynx. Plain films are used to screen for radiopaque objects. Ingested, impacted bones can be seen on plain films only ≤50% of the time. CT scanning has replaced the barium swallow test to evaluate for nonradiopaque objects. Differential diagnosis includes dysphagia, esophageal carcinoma, and gastrointestinal (GI) reflux disease.

Emergency Department Care and Disposition

1. Patients in extremis or with pending airway compromise are resuscitated in standard fashion and may require active airway management.

2. Emergent endoscopy is indicated for complete distal obstruction of the esophagus with pooling of secretions (often distal esophageal food impaction).

3. Hospital admission is generally not needed if the foreign body is easily removed by endoscopy without complications.

4. In stable patients, indirect or fiberoptic laryngoscopy may allow removal of very proximal objects.

5. Consult surgery for worrisome foreign bodies that are in the more distal GI tract.

Food Impaction

Meat is the most common cause of food impaction.

1. Complete esophageal obstruction requires emergency endoscopy.

2. Uncomplicated food impaction may be treated expectantly but should not be allowed to remain impacted for >12 to 24 hours.

3. The use of proteolytic enzymes (eg, Adolph Meat Tenderizer, which contains papain) to dissolve a meat bolus is contraindicated.

4. Glucagon (1 to 2 milligrams for adults) may be attempted but success rates are poor.

Coin Ingestion

1. Obtain radiographs on all children suspected of swallowing coins to determine the presence and location of the object. Coins in the esophagus present their circular face on anteroposterior films, as opposed to coins in the trachea, which show that face on lateral films.

2. Coins should be removed by endoscopy if lodged in the esophagus.

3. Removal of a coin with a Foley balloon catheter should be done under fluoroscopy by experienced hands. Complications include aspiration, airway compromise, and mucosal laceration.

4. Once in the stomach, coins almost always pass spontaneously.

Button Battery Ingestion

A button battery lodged in the esophagus is a true emergency requiring prompt removal because the battery may quickly induce mucosal injury and necrosis. Perforation may occur within 6 hours of ingestion.

1. Resuscitate the patient as needed.

2. Obtain radiographs to locate position of the battery.

3. Emergency endoscopy is indicated if battery is lodged in the esophagus. Foley balloon catheter technique may be considered if reliable history of ingestion ≤2 hours is obtained.

4. Batteries that have passed the esophagus can be managed expectantly with 24-hour follow-up examination. Repeat x-rays at 48 hour to ensure passage through pylorus. Most batteries pass through the body in 48 to 72 hours but may take longer.

5. Consult surgery if the patient develops symptoms or signs of GI tract injury.

6. The National Button Battery Ingestion Hotline at 202-625-3333 is a 24-hours, 7 days-a-week resource for help with management decisions.

Ingestion of Sharp Objects

1. Sharp objects in the esophagus, stomach, or duodenum require immediate removal by endoscopy in order to prevent complications such as perforation.

2. If the object is distal to the duodenum at presentation and the patient is asymptomatic, obtain daily plain films to document passage.

3. Consider surgical removal if 3 days elapse without passage.

4. Consult surgery immediately if the patient develops symptoms or signs of intestinal injury (eg, pain, emesis, fever, GI bleeding).

Narcotic Ingestion

1. The packets (condoms containing up to 5 grams of narcotic) ingested by a narcotic courier (body packer) are often visible on plain x-ray.

2. Endoscopy is contraindicated because of the risk of iatrogenic packet rupture, which may be fatal.

3. Observation until the packet reaches the rectum is the favored treatment if the packets appear to be passing intact through the GI tract.

4. Whole-bowel irrigation may aid in the process of packet removal.