GI Emergencies: GI Emergencies: Esophageal Emergencies

0:00Welcome to Board Pearls. This is episode three of four of the GI Emergencies chapter, in the Special Populations and Acute or Supportive Care module. This episode is the esophagus blocked, torn, and burned. The first patient is a man with steak stuck in his esophagus, and his case shows when a food impaction is an emergency measured in hours, why glucagon rarely helps and can hurt, why no one pushes a bolus blindly, and what an impaction says about the esophagus underneath. A woman who swallowed a hearing-aid battery shows why a battery runs on a two-hour clock, and the same rule, how fast an object must come out depends on how fast it can injure, then sets the window for sharp objects, long and wide objects, magnets, coins, and drug packets. The second patient is a man who vomited after drinking, and his case shows Boerhaave syndrome: the Mackler triad, the scan, the antibiotics, and why twenty-four hours changes the operation. The third patient is a woman who drank lye, and her case shows what comes first after a caustic ingestion, what never to do, and how the endoscopic grade decides where she goes.

1:08Here's the first patient. A thirty-four-year-old man was eating steak two hours ago when it stuck behind his lower sternum. Since then he can't swallow anything, including his saliva, and he's spitting into a cup. He's had two similar, shorter episodes in the past year that cleared on their own. He has seasonal allergies and asthma.

1:29He has an esophageal food bolus impaction, and because he can't swallow his own saliva, the obstruction is complete. Food bolus impaction is the most common foreign body presentation in adults. How quickly any swallowed object has to come out is set by the American Society for Gastrointestinal Endoscopy timing categories, which follow the mechanism of injury: objects whose injury escalates over hours come out within hours, objects that sit safely until they reach the duodenum come out within a day, and blunt objects beyond the duodenum in a patient without symptoms don't come out at all. Emergent removal, within six hours or sooner, is required for three situations: esophageal obstruction with inability to manage secretions, a disc battery in the esophagus, and a sharp pointed object in the esophagus. He's in the first group, so he needs endoscopy within six hours, and sooner is better. Secretions that overflow cause aspiration pneumonia and respiratory failure within hours, and sustained pressure from the bolus causes mucosal ischemia, deep ulceration, and eventually perforation. A bolus without complete obstruction, with secretions managed, is removed within twenty-four hours.

2:40Glucagon is often tried while he waits, and it rarely helps. One milligram intravenously has been used to relax the lower esophageal sphincter, but it succeeds in less than twenty percent of patients and must never delay endoscopy. Its main side effect is nausea and vomiting, and vomiting against a bolus that's already pressing on the wall can cause a perforation of the Boerhaave pattern, the injury the second patient in this episode shows. So for him, its small chance of success is weighed against a real chance of making him vomit against a blocked esophagus.

3:11No one pushes his bolus blindly either. Pushing it down with a nasogastric tube or bougie without seeing is contraindicated because of perforation risk, particularly in eosinophilic esophagitis, where the mucosa is friable and the esophagus may be narrow along its whole length rather than only at the impaction. At endoscopy, the bolus is extracted in one piece with a retrieval net, a snare, or an overtube with a grasper, or, when the distal esophagus is seen to be clear, advanced gently into the stomach under direct view. His endoscopy, ninety minutes after arrival, shows meat in the distal esophagus with linear furrows and concentric rings above it, and the bolus comes out whole in a net.

3:53His furrows and rings point to the disease underneath, so the procedure isn't finished when the meat is out. About half of adult food bolus impactions are due to undiagnosed eosinophilic esophagitis. When there's no prior diagnosis, at least four biopsies each from the proximal and distal esophagus are taken at the same procedure, because the diagnostic threshold of fifteen eosinophils per high-power field needs adequate sampling, and the patient may never return for an elective esophagogastroduodenoscopy. He's a young atopic man with two earlier episodes that cleared and furrows and rings at endoscopy, and his biopsies show forty eosinophils per high-power field. He has eosinophilic esophagitis, and he starts one of the equivalent first-line options, high-dose twice-daily proton pump inhibitor, a swallowed topical steroid, or an empiric elimination diet, with the response judged by biopsy at eight to twelve weeks, as chapter five covers.

4:48A battery runs on a faster clock than food, and the next patient shows why. An eighty-one-year-old woman with dementia in a care home has a missing hearing-aid button battery, slight drooling, and is reaching for her throat. Her chest film shows a round radiopaque object in the esophagus. An esophageal disc battery must come out within two hours. Against the mucosa it completes an electrical circuit that splits water and generates hydroxide ions, causing alkaline liquefactive necrosis at the negative pole within two hours. It can perforate within hours, and an aortoesophageal fistula has been reported up to weeks after a missed esophageal battery. In children, honey or sucralfate slurry may reduce mucosal injury before transport, but neither delays removal. She goes to endoscopy immediately, ahead of anything elective.

5:37What the object does if it's left in place sets the window for every other object too. Sharp pointed objects in the esophagus, such as chicken or fish bones, open safety pins, dental partials with hooks, and glass fragments, can lacerate the mucosa and cut adjacent vessels, including the aorta, so they come out within six hours. Other, non-sharp objects in the esophagus come out within twenty-four hours. Sharp objects in the stomach or duodenum come out within twenty-four hours, because once past the duodenum they can perforate small bowel beyond the scope's reach. Objects longer than six centimeters at or above the proximal duodenum come out within twenty-four hours, because they can't negotiate the duodenal C-loop. Objects wider than two and a half centimeters are removed while still in the stomach, because they're unlikely to pass the pylorus. High-power magnets within reach come out within twenty-four hours, because two or more magnets in different loops of bowel attract across the tissue between them and cause pressure necrosis, fistula, or perforation.

6:42At the far end of that scale, some objects are left alone. A coin or similar blunt object beyond the duodenum in a patient without symptoms is non-urgent and is followed with serial radiographs until it passes, not chased with a scope. Each window comes from the same reasoning: a battery burns, a sharp edge cuts, two magnets squeeze, a long or wide object can't make the next turn, and a smooth coin past the duodenum keeps moving.

7:10Drug packets are the one exception to removal, because retrieval itself is the danger. Packets of cocaine, heroin, or methamphetamine, whether swallowed by a body packer concealing large quantities or by a body stuffer swallowing small amounts to avoid arrest, are never removed endoscopically, because a packet that ruptures during retrieval releases a potentially fatal dose. The patient is observed under monitoring while the packets pass, and goes to laparotomy if symptoms of a leak develop.

7:39The danger of glucagon was vomiting against a blocked esophagus, and the second patient shows what forceful vomiting can do on its own. A fifty-two-year-old man drank heavily last night and vomited forcefully several times, and with the last episode felt sudden severe lower chest pain spreading to his back. Ten hours later he's short of breath, with a temperature of thirty-eight point four, a heart rate of one hundred sixteen, and crepitus at the base of his neck.

8:02He has Boerhaave syndrome, a spontaneous full-thickness perforation of the esophagus caused by forceful vomiting. The Mackler triad is forceful vomiting, severe chest pain, and subcutaneous emphysema, and he has all three, with fever and tachycardia that suggest mediastinitis is developing. The full triad is present in only about a third of patients, because subcutaneous emphysema may be absent or appear only after several hours, as mediastinal air dissects into the neck and chest wall, so an incomplete triad doesn't exclude it. The typical story is a recent episode of forceful vomiting, from binge drinking, an eating disorder, hyperemesis gravidarum, or vomiting after anesthesia, followed by retrosternal or epigastric pain radiating to the back, breathlessness, fever, and, as time passes, mediastinitis or sepsis. The classic tear is in the left posterolateral distal esophagus, three to five centimeters above the gastroesophageal junction, where the longitudinal muscle is thinnest and the wall has no support from neighboring structures. That's why the pleural effusion that follows is typically on the left.

9:14Boerhaave is the classic emergency, but it isn't the most common perforation. Esophageal perforation can be spontaneous, as in his case; iatrogenic, after esophageal dilation, pneumatic dilation for achalasia, stricture biopsy, or endoscopic mucosal resection or submucosal dissection; traumatic; or from a caustic ingestion or foreign body. Iatrogenic perforation accounts for most cases overall.

9:42His diagnosis is confirmed by scan, and the choice of contrast matters. Computed tomography, CT, of the chest with oral water-soluble contrast, or with intravenous contrast and an oral effervescent agent, is the preferred first study. It shows pneumomediastinum, the cardinal finding, a pleural effusion that's usually left-sided when the tear is below the carina, subcutaneous emphysema, and sometimes the perforation itself. A water-soluble contrast esophagram is the alternative when CT isn't available. Barium is avoided at first, because if it leaks into the mediastinum it causes granulomatous mediastinitis. A chest film may show pneumomediastinum or an effusion, but it's less sensitive than CT, and a normal film doesn't exclude perforation in a high-suspicion patient like him. His CT shows pneumomediastinum, a left effusion, emphysema in his neck, and contrast leaking from the left distal esophagus.

10:39His treatment starts at once, aimed at the flora that has contaminated his mediastinum. He's kept nothing by mouth, given intravenous fluids and broad-spectrum antibiotics, and has a nasogastric tube placed under fluoroscopy so it isn't pushed through the tear. Oral anaerobes and streptococci track down from the upper esophagus into the mediastinum, and gram-negative organisms reflux from the stomach, so coverage of both is needed, with regimens based on piperacillin-tazobactam or meropenem. In severe disease, antifungal coverage with fluconazole or micafungin is added from the start, because the mediastinum is a space with poor clearance where Candida, a normal oral commensal, overgrows once antibiotics suppress the bacteria, and adding an antifungal only after Candida grows in culture is too late. Febrile, tachycardic, and contaminated, he starts piperacillin-tazobactam and micafungin with a fluoroscopically placed tube.

11:36His operation is decided by how long ago he tore, along with the size of the tear and how stable he is. Mortality is about ten to twenty percent with intervention within twenty-four hours and over forty percent when diagnosis is delayed, and the twenty-four-hour threshold is mechanical. Within twenty-four hours, the mediastinal tissues can still be closed primarily, before dense fibrinous adhesions and friable inflammation destroy the operative planes, so primary surgical repair with mediastinal drainage and gastric or jejunal feeding access has the lowest mortality and is the historical standard for Boerhaave and large iatrogenic perforations. Beyond twenty-four hours, sutures pull through inflamed tissue and repairs leak again, and reopening contaminated planes spreads the contamination. So management shifts to a covered self-expanding metal stent that seals the leak from inside, combined with mediastinal or pleural drainage by interventional radiology or thoracic surgery. At ten hours, he gets primary repair with drainage and a feeding tube. At thirty-six hours, he'd have had a covered stent with drainage.

12:42An iatrogenic tear recognized during the procedure is handled differently, because it's caught before contamination sets in. A small perforation seen at the index endoscopy can be closed with through-the-scope or over-the-scope clips, because the defect is fresh, the surrounding tissue is uncontaminated, and the leak hasn't had time to track, the same reasoning that applies to a colonic perforation recognized during colonoscopy in chapter thirty. Conservative management, with antibiotics, drainage, and nothing by mouth, is reserved for very small contained perforations in stable patients whose leak has sealed on imaging.

13:19Caustic ingestion is the third way the esophagus is injured, and it can perforate too. A forty-five-year-old woman drank a mouthful from an unlabeled garage bottle that turned out to be lye drain cleaner. An hour later her voice is hoarse, she's drooling, and she has soft stridor.

13:35She has a caustic ingestion, a chemical burn of the esophagus and stomach, and her hoarseness, drooling, and stridor mean her airway comes first. Alkali in particular can cause swelling above and at the vocal cords that progresses over hours, so intubation is early for stridor, drooling, voice change, or extensive burns of the mouth and throat. She has three of the four, so she's intubated before her airway closes, then given intravenous access, resuscitation, and analgesia, and kept nothing by mouth.

14:06Several common reflexes would harm her, each for a specific reason. Induced vomiting re-exposes the mucosa to the caustic. Activated charcoal doesn't bind caustics and obscures endoscopy. Neutralizing agents add thermal injury through an exothermic reaction. A blind nasogastric tube provokes retching and can perforate a weakened wall. And a normal-looking mouth doesn't exclude esophageal or gastric injury. If perforation is suspected or she's unstable, CT comes first, because endoscopy is contraindicated with perforation, instability, or a swollen airway that hasn't been secured.

14:43Her endoscopy grades the burn, and the grade decides where she goes. Endoscopy is done within about twelve to twenty-four hours and not beyond forty-eight, when the softened wall tears more easily. The Zargar grades describe depth: grade zero is normal mucosa, grade one is edema and redness, grade two A is superficial ulceration with bleeding, blisters, or whitish exudate, grade two B is deep focal or circumferential ulceration, grade three A is focal necrosis, three B is extensive necrosis, and grade four is perforation. Grades zero to two A carry a low perforation risk, so liquids are started early and the diet advanced. Grades two B and three are transmural injuries and mean admission to the intensive care unit, nothing by mouth with nutritional support, early surgical involvement because necrosis or perforation may need emergency resection, and planning for strictures. Strictures are managed with gradual serial dilation, often with intralesional steroid. Systemic steroids aren't given to prevent strictures, and a proton pump inhibitor is reasonable.

15:49Her endoscopy at eighteen hours, with her airway secured, shows deep circumferential ulceration with white plaques in the mid-esophagus, Zargar two B. She stays in the intensive care unit, nothing by mouth, with nutritional support and early surgical input. When a stricture forms at six weeks, it's treated with gradual serial dilation. Surviving a severe caustic injury leaves a long-latency risk of squamous cell carcinoma, which warrants surveillance years later, and chapter five covers the chemistry and the long-term picture.

16:20Here are the traps the boards set in swallowed objects. A patient who can't swallow saliva needs endoscopy within six hours. An esophageal button battery comes out within two hours. Glucagon rarely works and never delays endoscopy. A bolus is never pushed blindly. A first impaction without a known diagnosis gets at least four biopsies from each level of the esophagus. A sharp object in the stomach isn't left to pass. An object longer than six centimeters or wider than two and a half isn't expected to pass. Two magnets are an urgent removal. A coin past the duodenum isn't chased. And drug packets are never retrieved endoscopically.

17:00For perforation and caustic injury, the traps are these. An incomplete Mackler triad or a normal chest film doesn't exclude Boerhaave. Barium isn't the first contrast. Severe mediastinitis gets antifungal coverage from the start. A nasogastric tube is placed only under fluoroscopy. Primary repair isn't attempted beyond twenty-four hours. A small tear seen at endoscopy is clipped. Stridor or drooling after a caustic means early intubation. Vomiting isn't induced, charcoal isn't given, and the caustic isn't neutralized. Endoscopy isn't done after forty-eight hours or through a suspected perforation. Systemic steroids don't prevent strictures. And survivors of severe injury need cancer surveillance.

17:46So, start to finish. Time object removal by mechanism. An esophageal button battery comes out within two hours. Complete esophageal obstruction with inability to handle secretions, or a sharp esophageal object, comes out within six. A partial bolus, other esophageal objects, sharp gastric or duodenal objects, objects over six centimeters, and magnets within reach come out within twenty-four. Objects over two and a half centimeters wide are removed from the stomach, blunt objects past the duodenum are allowed to pass, and drug packets are never retrieved endoscopically. For food impaction, glucagon rarely works and mustn't delay endoscopy, nobody pushes blindly, and at least four biopsies from each level are taken at the same session.

18:31The Mackler triad, complete in only a third, means Boerhaave until CT with water-soluble contrast says otherwise. Stop oral intake, give broad antibiotics with antifungals in severe disease, and place a nasogastric tube only under fluoroscopy. Repair surgically within twenty-four hours, and after that, seal with a covered stent and drain. Clip small iatrogenic tears seen at endoscopy. After a caustic ingestion, secure the airway first, and never induce emesis, give charcoal, neutralize, or pass a blind tube. Scope within about twelve to twenty-four hours unless perforation or instability is present. Zargar zero to two A is fed early, while two B and three go to the intensive care unit, nothing by mouth, with early surgical input and a stricture plan without systemic steroids.

19:22Episode four, the last of the chapter, is acute colonic pseudo-obstruction.

19:28For the full chapter, the practice vignettes, and the topic-tagged question bank, head to board pearls dot com. You'll find the rest of the series on Apple Podcasts, Spotify, or wherever you listen to podcasts. That brings us to the end of episode three of four of chapter thirty-one, and I'll see you in the next one.