the steak is stuck…

the case.

a 36 year old male presents to your ED at 2am with retrosternal pain and concern that last nights steak “got stuck and didn’t go down”. He has vomited once and now continues to spit out saliva as he feels he cannot swallow anything. Despite this, he is not particularly distressed and looks well.He was given a can of Coke from triage and spat most of it up again.

Whilst we have previously discussed oesophageal foreign body on thebluntdissection, today we wonder if glucagon may help our patient with esophageal food bolus obstruction ??

[DDET The theory…]

Glucagon is a smooth muscle relaxant & is thought to relax the lower oesophageal sphincter, allowing passage of the previously impacted food bolus.

It is recommended for use amongst Gastroenterology literature and frequently insisted upon by our Gastroenterologist’s as a ‘must try’ prior to committing to endoscopy.

[/DDET]

[DDET What does the evidence say…?]

Gastrointest Endosc. 2011 Jun;73(6):1085-91

• A standard of practice document from the American Society of Gastrointestinal Endoscopy.
• “The administration of glucagon 1.0mg intravenously has been advocated to induce relaxation of the distal esophagus.”
  • Data arises from;
    • 3 patients who received benefit from IV glucagon. [Radiology. 1977 Oct;125(1):25-8]
    • 19 patients (prospectively). 7 of whom had FB-clearance post glucagon. [Radiology. 1983 Nov;149(2):401-3]
• Conclusion: “Glucagon is relatively safe & thus remains an acceptable option. Its use, however, should not delay definitive endoscopic removal of a food impaction”.

 Intravenous glucagon with foreign body impaction in the oesophagus

• 4 studies assessed.
• Small study sizes (n=10-43).
  • Some non-blinded. One experimental (manometry study without FB).
  • Often combination therapy (w/ gas-forming agents).
• Highlights the high-rates of oesophageal abnormalities (strictures, rings, oesophagitis) found in patients who have FB-impaction.
• Conclusion: “The use of intravenous glucagon for the relief of impacted food is worth attempting as it is a relatively safe procedure”.

• Double-blinded, placebo-controlled. [1mg IV glucagon vs placebo]
• Children (1-8 years old) w/ oesophageal coin impaction.
  • Very different population to my question – however, similar concept.
• Placebo; 3/5 success (60%) vs Glucagon; 2/15 (15%).
  • Additional ‘open-label’ glucagon trial (as 2nd line therapy). No responders out of these 6 patients (5 of whom had come from the initial glucagon group).
• Conclusion: “Glucagon does not appear to be effective in the dislodgment of esophageal coins in children.“

Finally….

• A literature review highlighting the lack of solid RCT-style data on this area of interest.
• Lack of overwhelming strong evidence supporting the use of glucagon.
• Raises concern regarding blunting of oesophageal motility and impeding disimpaction as well as the possible implications of glucagon’s famous reputation for inducing emesis !!

[/DDET]

[DDET In summary…]

We lack solid evidence that convincingly demonstrates a clear benefit  for the use of glucagon in patients with impacted oesophageal food boluses.

Given…

1. the lack of  overwhelming benefits of glucagon,
2. the presence of its potential well-known side-effects and
3. the fact that a portion of patients who have oesophageal FB impactions have anatomical/pathological abnormalities on endoscopy

…why not leave the glucagon in the drug-cupboard and get your gastroenterologists on the phone early. Their endoscopes can be both therapeutic & diagnostic.

What’s your take ???

[/DDET]

[DDET References]

1. Ikenberry SO et al, ASGE Standards of Practice Committee. Management of ingested foreign bodies and food impactions. Gastrointest Endosc. 2011 Jun;73(6):1085-91
2. Shetty R. Intravenous glucagon with foreign body impaction in the oesophagus. BestBets.org
3. Arora S & Galich P. Myth: glucagon is an effective first-line therapy for esophageal foreign body impaction. CJEM 2009;11(2):169-171.
4. Lee K & Anderson R. Effervescent agents for oesophageal food bolus impaction. Emerg Med J 2005;22:123-124.
5. no bones about it… thebluntdissection.org

[/DDET]

Chris Partyka