Oesophageal food bolus impaction is a common and potentially serious medical emergency. During the holiday season, healthcare professionals frequently encounter a surge in cases, often linked to excessive eating and rapid consumption of food. This seasonal rise places an additional burden on emergency department and endoscopy staff, already managing high patient volumes.

Beyond causing significant discomfort, oesophageal food bolus impaction carries serious risks, including oesophageal perforation and aspiration. These complications necessitate swift medical intervention to prevent long-term damage or life-threatening outcomes.

Most patients who present with food bolus impactions have pre-existing oesophageal conditions, such as structural abnormalities or eosinophilic oesophagitis, which predispose them to this issue. The type of food most frequently implicated in these cases is meat, often due to its fibrous and dense texture, which makes it difficult to pass through the oesophagus when improperly chewed or swallowed quickly.

Current Guidelines for Managing Food Bolus Impaction

Management of oesophageal food bolus impaction varies depending on the severity of the obstruction. Guidelines established by the American and European societies for gastrointestinal endoscopy (ASGE and ESGE) recommend emergent or urgent endoscopy as the standard of care. For patients with complete obstruction, emergent endoscopy is advised within six hours of presentation to the emergency department. In cases of partial obstruction, urgent endoscopy is recommended within 24 hours.

While endoscopy remains the main form of treatment, medical management can be attempted before endoscopy, provided it does not delay intervention. Various pharmacological agents, such as glucagon, nitrates, and butyl scopolamine, have been evaluated as pre-endoscopic treatments. However, evidence supporting their effectiveness is limited or conflicting, leaving clinicians without a consistently reliable alternative to endoscopic removal.

Amid this phenomenon, cola ingestion has emerged as a potential non-invasive treatment option. Cola, a carbonated beverage, has been reported in some studies to dislodge food boluses with success rates ranging from 59% to 100%. However, these reports are largely based on retrospective cohort studies, which are prone to bias. The exact mechanism by which cola may work remains unclear, but researchers hypothesise that carbon dioxide in the beverage may reduce lower oesophageal sphincter pressure, facilitating the passage of the impacted food.

Investigating Cola as a Treatment

To address the lack of robust evidence, a recent randomised controlled trial was conducted to evaluate the efficacy and safety of cola as a pre-endoscopic treatment for complete oesophageal food bolus impactions. This trial aimed to compare cola ingestion with the current standard of care, which involves no pre-endoscopic treatment while patients await emergent endoscopy.

The study design included a diverse patient population recruited from multiple hospitals, enhancing the generalisability of the findings. Participants were randomly assigned to either the cola group or the control group, ensuring balanced baseline characteristics. This rigorous methodology was intended to provide a clear and unbiased assessment of cola’s effectiveness as a therapeutic option.

Key Findings of the Study

The trial demonstrated several important findings. In both the cola and control groups, 61% of patients experienced partial or complete symptom resolution in the emergency department. While complete passage of the bolus was reported more frequently in the cola group, the difference was not statistically significant.

One of the study’s most notable observations was the unexpectedly high rate of symptom resolution in the control group. All patients in the control group who achieved complete passage of the bolus did so within 40 minutes of randomisation. This finding suggests that spontaneous resolution may occur more frequently than previously thought, even without intervention.

No significant adverse events related to cola ingestion were reported, apart from mild discomfort in some patients. This safety profile supports the idea that cola is unlikely to cause harm when used as a trial treatment. However, the lack of a significant effect from cola raises questions about its true efficacy. Notably, the study found no evidence to suggest that cola’s ineffectiveness was related to insufficient dosage, as some patients in the intervention group consumed the maximum allowed amount without achieving bolus passage.

Strengths and Limitations

The trial had several strengths that lend credibility to its findings. The randomised design ensured that both groups were comparable in terms of baseline characteristics, reducing the risk of bias. Additionally, the multi-hospital setting allowed for a more diverse patient population, making the results applicable to a broader range of clinical scenarios. The study also maintained a high standard of data integrity, with no missing primary outcome data or deviations from the study protocol.

Despite these strengths, the trial had limitations that must be acknowledged. The non-blinded design may have introduced some degree of bias, as both patients and clinicians were aware of the treatment being administered. Furthermore, the sample size was relatively small, which limited the study’s statistical power to detect subtle differences between groups or to explore outcomes in specific subgroups.

Another limitation was the lack of follow-up endoscopy in some patients who experienced complete bolus passage in the emergency department. Of the six patients in this category, some refused follow-up, while others were lost to follow-up. In one case, a 76-year-old patient’s endoscopy was deemed unnecessary due to a perceived lack of benefit. While these deviations did not affect the primary outcomes, they limited the researchers’ ability to identify underlying oesophageal pathology in these patients.

Implications for Clinical Practice

Based on the findings of this study, cola cannot be recommended as a standard treatment for oesophageal food bolus impaction. However, clinicians may consider offering it as an optional trial treatment to patients, provided it does not delay endoscopic intervention. The lack of significant adverse events associated with cola ingestion makes it a safe option to discuss with patients who are willing to try a non-invasive approach before undergoing endoscopy.

The study also emphasises the importance of follow-up care in all cases of food bolus impaction, regardless of whether the bolus passes spontaneously or with intervention. Endoscopic follow-up can help identify underlying oesophageal conditions, which were present in 78% of patients in this trial. Early detection and management of these conditions are critical for preventing recurrence and improving patient outcomes.

Future Directions

The findings of this trial highlight several areas for future research. One potential avenue is to investigate cola’s efficacy in patients with partial oesophageal food bolus impactions, as this subgroup may respond differently to treatment. Studies conducted at the primary healthcare level could also provide valuable insights into cola’s role as an initial intervention before patients present to the emergency department.

Additionally, the study noted that patients with a shorter duration of impaction before arriving at the emergency department were more likely to experience successful bolus passage after cola ingestion. This observation suggests that timing may be a critical factor in determining the effectiveness of cola. Larger studies are needed to confirm this finding and to explore whether early intervention with cola could reduce the need for emergent endoscopy in certain cases.

Public Awareness and Practical Advice

The trial’s findings also have implications for public health messaging, particularly during the holiday season. While cola may appear to be a simple and appealing solution, it is important to note that no quick or universally effective treatment currently exists for oesophageal food bolus impaction. Individuals experiencing symptoms such as difficulty swallowing, chest pain, or an inability to eat or drink should seek immediate medical attention rather than attempting to self-manage the condition.

Healthcare providers can play a key role in educating patients about the risks of food bolus impaction and the importance of proper eating habits, such as chewing food thoroughly and avoiding rapid consumption. These preventive measures can significantly reduce the likelihood of impaction, especially during occasions when large meals are common.

Conclusion

Oesophageal food bolus impaction remains a challenging condition that requires prompt and effective management. While cola has shown promise as a potential treatment in previous studies, this randomised controlled trial did not find sufficient evidence to support its routine use. Nonetheless, cola may still be considered as an optional trial treatment in select cases, provided it does not delay endoscopic intervention.

The study also highlights the need for continued research to explore alternative treatments and to better understand the factors that influence the success of non-invasive interventions. For now, endoscopy remains the gold standard for managing oesophageal food bolus impactions, and follow-up care is essential for identifying and addressing underlying conditions.

As the holiday season approaches, raising awareness about the risks of food bolus impaction and promoting healthy eating habits can help reduce the incidence of this potentially serious condition. While cola may not yet be the solution healthcare providers are looking for, it offers an intriguing starting point for future exploration.

Reference

Tiebie, E. G., Baerends, E. P., Boeije, T., Frankenmolen, P. G., Lameijer, H., van den Berg, W., van Stralen, K. J., Ridderikhof, M. L., & Bredenoord, A. J. (2023). Efficacy of cola ingestion for oesophageal food bolus impaction: open label, multicentre, randomised controlled trial. BMJ (Clinical Research Ed.), 383, e077294. https://doi.org/10.1136/bmj-2023-077294