Oral Nitroglycerin for Esophageal Foreign Body

As family and loved ones gather around the table for Thanksgiving dinner, we generally have a different experience in the ED. We sit and wait in the ED for the fork stabbing victims and alcohol-induced turkey fryer accidents. Office-pools thrive on the sort of things that come through the ED triage on turkey day. These unique cases present an opportunity to apply the enhanced drug therapy on a classic holiday presentation: esophageal foreign body.

I can’t blame folks for eating like The Simpson’s at the dinner table. Some may choke on the turkey that’s a tad on the dry side. In either case, food can become lodged in a non-airway obstructing position in the esophagus. Esophageal obstruction is certainly uncomfortable, inhibits further eating, and can be somewhat panic-inducing (rightfully so). So before subjecting the patient to an endoscopy, there are some drug therapy interventions that can be implemented.

Glucagon makes me sick 

While glucagon gets most of the attention here, it’s generally ineffective.(1-5) What it does do is induce nausea and vomiting. While this can help dislodge the obstruction, it can conversely lead to aspiration. Furthermore, it’s required to be given IV and despite the rapid administration, can take hours to work. So while weighing the value of glucagon is on the treating treatment mind, why not try something else.

Nitroglycerin: It’s dynamite

Enter nitroglycerin. This ubiquitous emergency medication can be a saving grace in the management of these patients.  Simply put, the administration of 0.4 mg in 10 mL of tap water by mouth can help resolve the obstruction within minutes. The action of nitroglycerin related to smooth muscle relaxation is via nitric oxide-induced guanylyl cyclase stimulation and the increasing cyclic guanosine monophosphate. While IV nitroglycerin could similarly give you the desired effect, it’s believed that oral administration leads to what some would call a local or topical effect.

Think about the opportunity to administer something like this in triage, before the patient even hits the room. This takes the “meet ‘em, greet ‘em, treat ‘em, and street ‘em” to a whole new level.

Before going all-in, let’s examine the evidence

The use of oral nitroglycerin for the esophageal foreign body has been reported in the literature a whopping 2 occasions describing 4 patients.(6, 7) The first case series describes two patients presenting to the ED with food boluses. Both patients were described with patent airways, hemodynamically stable, and otherwise in no distress. Patient #1 was given nitroglycerin 0.4mg dissolved in 10mL of tap water with subsequent resolution in 2 minutes. After administration, the patient did complain of a mild burning sensation in his chest and a headache (to be expected with nitro). This patient was discharged home shortly after this resolution of symptoms.

The second patient was given glucagon 1mg IV and waited 2 hours further, despite no change in the complaint. The patient then received (erroneously) nitroglycerin 0.4 mg SUBLINGUALLY with again, no change. Once the administration error was noted, the patient was given nitroglycerin 0.4mg dissolved in 10mL of tap water with subsequent resolution in 2 minutes.

In the most recently published case series, another set of two patients with the esophageal foreign body were reported. In this series, however, only one of the two patients successfully had resolutions of the foreign body symptoms. The patient who did not have a successful clearance of the foreign body later underwent successful endoscopic intervention. Mild flushing and nausea were the only reported adverse effects in patient 1 of this series.

Take home

While the evidence is certainly limited, the anecdotal success, ease of administration and adverse event profile make nitroglycerin an attractive option for these patients in the ED or urgent care setting.

 

More related to Oral Nitroglycerin for Esophageal Foreign Body

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Reference:

  1. Robbins MI, Shortsleeve MJ. Treatment of acute esophageal food impaction with glucagon, an effervescent agent, and water. Am J Roentgenol 1994;162:325–8.
  2. Weant KA, Weant MP. Safety and efficacy of glucagon for the relief of acute esophageal food impaction. Am J Health Syst Pharm 2012; 69:573–7.
  3. Arora S, Galich P. Myth: glucagon is an effective first-line therapy for esophageal foreign body impaction. CJEM 2015;11:169–71.
  4. Al-Haddad M, Ward EM, Scolapio JS, Ferguson DD, Raimondo M. Glucagon for the relief of esophageal food impaction does it really work? Dig Dis Sci 2006;51:1930–3.
  5. Tibbling L, Bjorkhoel A, Jansson E, Stenkvist M. Effect of spasmolytic drugs on esophageal foreign bodies. Dysphagia 1995;10: 126–7.
  6. Willenbring BA, Schnitker CK, Stellpflug SJ. Oral Nitroglycerin Solution May Be Effective for Esophageal Food Impaction. J Emerg Med. 2018 May;54(5):678-680. 
  7. Schimmel J, Slauson S. Swallowed Nitroglycerin to Treat Esophageal Food Impaction. Ann Emerg Med. 2019 Sep;74(3):462-463.