Quick Case: Meat Bolus Impaction

^{by Reid Wasserman, DO and Klaus Klaus Mönkemüller, MD, PhD, FASGE, FJGES}

^{Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA}

Middle aged male presents with food bolus impaction. 

How would you remove this impacted meat bolus? 

In your hospital, do you use sedation, no sedation or general anesthesia for this endoscopic emergency?

There are multiple answers to both questions, and all are likely correct.

Food bolus or meat impaction is managed differently in different parts of the World, even within one country or state. Interestingly, in the hospitals in Germany where I (KM) have worked and in two where I still work, conscious sedation is used preferentially. I also know some hospitals in former Eastern Germany where no sedation is used at all. Their argument for not using conscious sedation is threefold: a) patient can "control" their secretions, b) lack of availability of staff to assist with sedation, c) lack of anesthesia services to perform intubation.

In our current practice in USA, airway protection with tracheal intubation and general anesthesia is standard for patients presenting with acute food bolus (i.e. meat impaction) or foreign body ingestion. The advantage of having anesthetist available for such an urgent procedure is a) tranquility that the patient’s airways are protected, b) endoscopist can fully focus on the endoscopic procedure.

We believe that protecting the airway (and general anesthesia) is quite practical and important for three reasons: a) patient safety (less risk of aspiration of any contents, including pieces of meat during retching, vomiting or endoscopic retrieval, and c) patient (and endoscopist) comfort. Occasionally, removal of the meat impaction can take 15 minutes or more. I know of cases where the procedure took as long as one hour.

Regarding preferred endoscopic technique, there are lots of utensils in the "toolbox", including distal transparent caps, snares, baskets, and tripod forceps. I like using the distal transparent caps, as they usually allow for suctioning the proximal part of the meat inside, and then it is removed by slowly pulling the scope back out of the esophagus. However, all methods mentioned above work pretty well. One utensil that I have also found quite practical for large or complex meat impactions is the overtube, which allows for repetitive endoscopic intubations, going back-and-forth, removing piece by piece of larger pieces of meat or food.

No COI by RW or KM with any of the companies/utensils or products mentioned in this article.

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