Question Tradition: Glucagon for Food Boluses

Background: How many of you have had this scenario…patient comes into ED, just ate a big steak and now they can’t swallow.  You call gastroenterology, who asks… “Did you try glucagon yet?” OK, well maybe not exactly like that, but you get what I am asking.  Esophageal foreign body impactions are a rare entity, that cause quite a bit of discomfort to patients and have the potential for esophageal necrosis and perforation.  The definitive treatment for removal is endoscopy with direct visualization and removal of the object causing the obstruction.  This procedure is invasive, time consuming, requires a gastroenterologist, as well as procedural sedation.  Due to the time it takes to set up for this procedure, many consultants will ask to try medical therapy first.  There are several options including carbonated beverages, calcium channel blockers, sublingual nitroglycerin, proteolytic enzymes, benzodiazepines, and last but not least intravenous glucagon. This review will focus on the use of glucagon for esophageal foreign bodies.

PICO:

• Population: Patients with Esophageal Foreign Body Food Impaction ≥18 years of age
• Intervention: Use of Intravenous Glucagon
• Comparison: Placebo
• Outcome: Relief of Food Bolus Obstruction

What We Did:

• A Pubmed search with “glucagon AND esophageal foreign body” as the search terms

Outcomes:

• Primary: Relief of Esophageal Obstruction
• Secondary: Adverse Events (nausea/vomiting)

Inclusion:

• Studies in English
• Patients Age ≥18 years

Exclusion:

• We excluded case reports, case series, and reviews from this analysis, but did look through each of them to ensure there were no additional studies missed

Results:

• This search turned up 35 publications
  • 10 Case Reports and Case Series
  • 2 Pediatric Studies
  • 11 Reviews and Editorials
  • 4 Prospective Cohort Trials (Robbins et al, Kaszar et al, Levine et al, and Colon et al) [9 – 12] didn’t pertain to the PICO
  • 8 Trials included in this review

• Most if not all the studies were of very low quality, small, retrospective and had no placebo arms
• Results from 3 trials with placebo arms:
  • Glucagon: 37/257 = 14.4% (Range: 9.4% – 37.5%)
  • Placebo: 29/164 = 17.7% (Range: 10.3% – 31.6%)
  • Esophageal Pathology: 94/421 = 22.3%
  • N/V: 16/151 = 10.6% (Range: 0% – 12.6%)

Discussion:

• The Robbins et al (1994) [9] and Kaszar et al (1990) [10] trials were both excluded from this review as well. Both studies used a combination therapy of glucagon, an effervescent agent and water to relieve acute esophageal food impaction in the distal 2/3rds of the esophagus.
• The Levine et al (1995) [11] trial was excluded due to the fact it was a review of effervescent agents during barium swallows
• The Colon et al (1999) [12] trial was excluded because this was 10 normal subjects with esophageal manometry measurements while differing doses of glucagon were given.

Clinical Take Home Point: Given the weak evidence for the benefits of glucagon, the potential side effect of nausea/vomiting, and the fact that nearly 1/4^th of patients will have an anatomic etiology to their obstruction, avoid the use of glucagon and consult your local gastroenterologist instead.

References:

1. Trenkner SW et al. Esophageal Food Impaction: Treatment with Glucagon. Radiology 1983; 149(2): 401 – 3. PMID: 6622682
2. Berggreen PJ et al. Techniques and Complications of Esophageal Foreign Body Extraction in Children and Adults. Gastrointest Endosc 1993; 39(5): 626 – 30. PMID: 8224682
3. Tibbling L et al. Effect of Spasmolytic Drugs on Esophageal Foreign Bodies. Dysphagia 1995; 10 (2): 126 -7. PMID: 7600855
4. Sodeman TC et al. Assessment of the Predictors of Response to Glucagon in the Setting of Acute Esophageal Food Bolus Impaction. Dysphagia 2004; 19 (1): 18 – 21. PMID: 14745641
5. Al-Haddad M et al. Glucagon for the Relief of Esophageal Food Impaction dos it Really Work? Dig Dis Sci 2006; 51 (11): 1930 – 3. PMID: 17004122
6. Thimmapuram J et al. Use of Glucagon in Relieving Esophageal Food Bolus Impaction in the era of Eosinophilic Esophageal Infiltration. Dysphagia 2013; 28 (2): 212 – 6. PMID: 23203568
7. Haas J et al. Glucagon Is a Safe and Inexpensive Initial Strategy in Esophageal Food bolus Impaction. Dig Dis Sci 2016; 61 (3): 841 – 5. PMID: 26500116
8. Bodkin RP et al. Effectiveness of Glucagon in Relieving Esophageal Foreign Body Impaction: A Multicenter Study. Am J Emerg Med 2016; 34(6): 1049 – 52. PMID: 27038694
9. Robbins MI et al. Treatment of Acute Esophageal Food Impaction with Glucagon, an Effervescent Agent, and Water. AJR Am J Roentgenol 1994; 162(2): 325 – 8. PMID: 8310919
10. Kaszar-Seibert DJ et al. Treatment of Acute Esophageal Food Impaction with a combination of Glucagon, Effervescent agent, and Water. AJR AM J Roentgenol 1990; 154(3): 533 – 4. PMID: 2106216
11. Levine MS. How concerned Should Radiologist be about Perforating the Esophagus by Administering an Effervescent Agent During a Barium Swallow to Treat a Foreign Body Impacted in the Distal Esophagus? AJR AM J Roentgenol 1995; 165(2): 480 – 1. PMID: 7618582
12. Colon V et al. Effect of Doses of Glucagon used to Treat Food impaction on Esophageal Motor Function of Normal Subjects. Dysphagia 1999; 14(1): 27 – 30. PMID: 9828271

For More On this Topic Checkout:

• Ken Milne at The SGEM: SGEM#169 – Stuck in the Middle with Food (Glucagon for Esophageal Foreign Body Impaction)

Post Peer Reviewed By: Scott Wieters (Twitter: EMedCoach)

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