The purpose of this page is to take the notable study titled “Treatment of Acute Esophageal Food Impaction With Glucagon, an Effervescent Agent, and Water” (Robbins and Shirtsleeve, 1994, American Journal of Roentgenology) and distill down its major takeaways for clinical practice.
WHAT IS THE POINT OF THIS PAPER?
This paper was created to discuss the proper way to attempt the treatment of acute esophageal food impaction. It was meant to try and and promote a technique that would help patients avoid endoscopy by gastroenterologists (or other more invasive techniques) in order to resolve their obstruction.
WHAT ARE THE MAJOR TAKEAWAYS?
Overall there were a few things that this paper highlighted:
- Glucagon, an effervescent agent (such as E-Z gas), and water can be used to successfully treat esophageal food impaction: this paper goes through the proper technique for performing this procedure properly (more on this below). Conceptually glucagon relaxes the esophagus, while the effervescent agent and water build up pressure and relieve the impaction by forcing it down the esophagus (and in some cases up the esophagus).
- Glucagon relaxes the lower esophageal sphincter and smooth muscle in the esophagus: it does not work on striated muscle (making it ineffective for impaction in the more proximal portion of the esophagus).
- There are contraindications to this procedure, it can not be used for everyone: these are highlighted more below.
WHEN SHOUDL THIS PROCEDURE BE AVOIDED?
Below are some of the contraindications for this particular procedure:
- Impaction caused by a sharp foreign body (such as bone): in these cases this impaction should be addressed in an alternative manner for safety reasons (the risk of perforation/damage to GI tract increases under these circumstances).
- The presence of rigid obstruction (such as esophageal carcinoma) or a fixed stricture: this technique will not be effective in treating such obstruction.
- Impaction longer then 24 hours: if food impaction has occurred for longer then 24 hours ulceration of the esophagus likely has already begun. The risk of esophageal perforation increases and this technique is less safe at this time point.
- Presence of esophageal diverticulum/prominent cricopharyngeus muscle seen on prior studies: these physical characteristics of a patient may increase the risk of perforation in patients, and render this technique (which relies upon building up pressure in the esophagus) unsafe.
Below are some of the contraindications for using glucagon:
- Patients with pheochromocytoma: glucagon can stimulate the release of catecholamines. In the setting of a pheochromocytoma it can cause the tumor to release dangerous levels of catecholamines.
- Patients with an insulinoma: glucagon administration in the setting of insulinoma can cause severe hypoglycemia.
HOW IS THIS TECHNIQUE PROPERLY PERFORMED?
Below is a general overview highlighting the major points of how to conduct this technique:
- Conduct the initial esophogram using a small volume of water soluble, iso-osmolar contrast: in many cases, 5 ml of contrast is enough to diagnose the impaction (and this low volume decreases the risk of aspiration in the case of very proximal obstruction). A water soluble contrast is also recommended to be used because in the case of esophageal perforation it will not cause as many complications if leaked into the mediastinum/peritoneum. Furthermore, a contrast agent that is iso-osmolar to serum (such as omnipaque 180) should be used because IF it is aspirated in the lungs it will not cause pulmonary edema (compared to other hyperosmolar solutions). This is done in the upright position.
- Transition the patient into the supine position, and administer glucagon. 1 mg of glucagon is given IV over 30 seconds (this infusion rate produces less vomiting).
- Patient is immediately turned upright again and is kept there for 2 minutes: this is so the glucagon can begin to work on relaxing the esophageal sphincter/smooth muscle. It needs time to act on the body.
- Patient is given one pack of E-Z Gas II and a cup of water. the E-Z Gas II is dissolved in 30 mls of water and given to the patient, followed by 240 mls of water.
- If the patient feels relief, a second esohpagram is obtained: about 50 mls of the same contrast used initially is used to confirm that the foreign body has passed.
WHAT CAN WE CONCLUDE?
In the right patient population, the above described technique (if properly conducted) can be used to treat esophageal food impaction in an effective and safe manner. Proper usage of this technique can avoid more invasive and dangerous interventions to relieve the obstruction.
Page Updated: 07.31.2017