Can a Nitro Slurry Fix a Food Bolus Impaction?

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Background

Esophageal food impaction (EFI) occurs at an estimated rate of 13 episodes per 100,000 people annually. Medical management is typically attempted before resorting to endoscopy to reduce procedural risks and resource use. Glucagon remains the most widely used medication. Other treatments include carbonated beverages, benzodiazepines, and, more recently, nitroglycerin. Despite glucagon being the most commonly used agent, its supporting data are limited to small studies or case reports. One older study showing over 60% efficacy lacked a comparator group and had multiple confounders. Another study suggested only minimal benefit and significant adverse effects—up to 50% vomiting—highlighting the need for better treatment options.

Study Design

This prospective, single-arm feasibility study enrolled 20 adult patients presenting with EFI symptoms within 12 hours of onset. Each participant could receive up to three doses of oral nitroglycerin solution (0.4 mg dissolved in 10 mL of water). The primary outcome was the resolution of EFI-related symptoms; secondary outcomes included the need for additional interventions (e.g., glucagon, endoscopy) and the incidence of adverse effects.

Results

  • Enrollment and Intervention: Of 20 patients enrolled, 3 were removed from analysis for spontaneous symptom resolution or reclassification of diagnosis, leaving 17 who received at least one dose of nitroglycerin.

  • Symptom Relief: Two of these 17 patients (approximately 12%) experienced resolution of EFI symptoms, at 7 and 11 minutes after nitroglycerin administration.

  • Further Management: Eleven patients reported no symptom relief and went on to require other interventions, including endoscopy. Of those, 7 also received glucagon, but none had symptom resolution with glucagon.

  • Adverse Effects: Four participants withdrew before completing all doses: 3 due to difficulty swallowing and 1 due to headache. Two additional patients reported headaches, and 1 had transient hypotension that resolved spontaneously.

Limitations

  • Small Sample Size: With only 17 patients completing the intervention, the study lacks statistical power to draw definitive conclusions.

    Single-Arm Design: The absence of a control or comparison group limits ability to assess nitroglycerin’s true efficacy.

    Lack of Blinding: Both participants and researchers were aware of the intervention.

  • Subjective Outcomes: Reliance on patient-reported symptom resolution further limits objective assessment.

Take Home Points

  • Modest Efficacy: Oral nitroglycerin relieved EFI symptoms in around 12% of cases—on par with other medical options like glucagon, which also shows low success rates and may have more side effects.

  • Tolerability and Feasibility: Although some patients had difficulty swallowing the solution, nitroglycerin’s side effect profile (mostly mild headache) may be more favorable than glucagon.

  • Practical Considerations: Given the paucity of highly effective and safe medical therapies for EFI, a trial of nitroglycerin may be a reasonable and inexpensive initial step before proceeding to endoscopy.

  • Future Directions: Larger, controlled studies are needed to determine whether nitroglycerin can outperform or replace other agents in medical management prior to endoscopy.