By Monzur Ahmed
A 40 year old man was enjoying an evening meal of steak with his wife. Whilst eating his well done steak, he developed “choking” and then dysphagia. His wife slapped his back but to no avail. Initially, the dysphagia was at the level of the high sternum and then the mid-sternum. The dysphagia persisted such that he was unable to keep down water. He presented to hospital several hours later. A lateral cervical X-Ray and chest X-Ray were unremarkable. He did not respond to iv Glucagon. Hence an urgent endoscopy was performed, some 16 hours after the onset of symptoms (see video)…
First described in 1963 by Norton et al, "the steakhouse syndrome" is a condition in which food impaction of the oesophagus occurs after eating a piece of food, especially a meat bolus, without adequate chewing . Most food bolus impactions resolve without intervention, either by moving forward to the stomach or by the patient regurgitating the ingested contents. When symptoms of obstruction persist and/or are accompanied by substantial chest discomfort, patients will seek medical attention.
In the classic presentation of the steakhouse syndrome, not surprisingly, impactions occur more often when patients are eating meat and generally when they do not chew their food sufficiently. Contributing conditions could be poor dentation, ill-fitting dentures, the use of alcohol, or a predisposition to eat too quickly . The most commonly impacted foods are beef, chicken, pork, and al dente-cooked vegetables.
Patients with a food bolus impaction that persists to the extent that they present in the emergency department should receive a chest radiograph to rule out evidence of perforation or a radiopaque object in the oesophagus. Once a foreign object is ruled out, endoscopy should be considered. Several factors should be considered regarding the timing of the endoscopy. The status of the patient's airway and ventilation needs to be evaluated to ensure adequate control and assess the risk of aspiration. Patients experiencing excessive sialorrhea who are unable to handle their secretions have an indication for urgent or emergent endoscopy. Further, it is known that food bolus impactions that persist more than 12–24 hours confer more risk for serious complications, including oesophageal perforations.
Small doses of glucagon administered intravenously can be given to patients who are under evaluation for management of a food bolus impaction. This may help to relax the oesophagus and allow spontaneous passage. However, it should not delay definitive investigation and management by endoscopy. Placement of an oesophageal overtube or endotracheal intubation should be considered when copious oesophageal contents are encountered to minimise risk of aspiration. Regarding food bolus impaction, the ESGE guidelines  recommend:
-Oesophageal foreign objects and food bolus impacted in the oesophagus should be removed within 24 hours because delay decreases the likelihood of successful removal and increases the risk of complications. The risk for major complications (i. e., perforation with or without mediastinitis, retropharyngeal abscess and aortoesophageal fistula) increases 14.1 times with foreign bodies impacted for more than 24 hours in the oesophagus.
-ESGE suggests treatment of food bolus impaction in the oesophagus by gently pushing the bolus into the stomach. If this procedure is not successful, retrieval should be considered (weak recommendation, low quality evidence).
-The effectiveness of medical treatment of oesophageal food bolus impaction is debated. It is therefore recommended, that medical treatment should not delay endoscopy (strong recommendation, low quality evidence).
- In cases of food bolus impaction, ESGE recommends a diagnostic work-up for potential underlying disease, including histological evaluation, in addition to therapeutic endoscopy (strong recommendation, low quality evidence).
An underlying oesophageal pathology is found in more than 75 % of patients presenting with food bolus impaction. The most frequently associated abnormalities are oesophageal (mainly peptic) strictures (more than 50 %) and eosinophilic oesophagitis (about 40 %). Less frequently, oesophageal cancer or oesophageal motility disorders, such as achalasia, diffuse oesophageal spasm, and nutcracker oesophagus, are causes of food bolus impaction. Lack of appropriate follow-up for patients has been shown to be a predictor for recurrent food impactions. Therefore, in all patients a diagnostic work-up after extraction of foreign bodies is recommended to detect any underlying disease.
1.Norton RA, King GD. “Steakhouse Syndrome“: The Symptomatic Lower Esophageal Ring. Lahey Clin Found Bull. 1963;13:55–59. https://pubmed.ncbi.nlm.nih.gov/14078124/
2.Enomoto S, Nakazawa K, Ueda K et al, World J Gastrointest Endosc. 2011 May 16; 3(5): 101–104. Steakhouse syndrome causing large esophageal ulcer and stenosis
3.Birk M, Bauerfeind P, Deprez P et al , ESGE Practice Guideline, 2016 May;48(5):489-96.Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline
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Monzur Ahmed, Consultant Gastroenterologist