Cue Jeopardy Music...
So this guy comes in with a chief complaint of chest pain. He's spitting in a cup, unable to swallow after eating some steak earlier. My diagnosis: esophageal food impaction (I'd never heard the term "Steakhouse Syndrome" before, but I like it).
Him: "I don't think so. I only nibbled at my food. It just feels like a big bubble in my stomach."
Me: "Well let's see. Here, have a drink of water."
He takes a sip, and there is a pregnant pause where we stare at each other for a few seconds: "What are you staring at?"
Me: "I'm just waiting. If I'm right, you're gonna puke any second now."
Him: "Oh, really? RAAAAAAALPH! (vomits violently)"
One sublingual nitroglycerine fixed him.
Him: "I don't think so. I only nibbled at my food. It just feels like a big bubble in my stomach."
Me: "Well let's see. Here, have a drink of water."
He takes a sip, and there is a pregnant pause where we stare at each other for a few seconds: "What are you staring at?"
Me: "I'm just waiting. If I'm right, you're gonna puke any second now."
Him: "Oh, really? RAAAAAAALPH! (vomits violently)"
One sublingual nitroglycerine fixed him.
posted by scalpel at 10:47 PM
21 Comments:
Good job. I can't recall if ntg or glucagon has ever been dramatically successful for me
I love this. Believe it or not, there's great comfort in what you said to this guy. Even though it's scary, you nailed his condition quickly.
anyone know if there is incrased risk of esophageal tear in such a situation? Boehaave's or Mallory-Weiss like tears?
did you consider a cxr or soft tissue neck or something?
clueless, but curious med student
I would never put a blind tube down the esophagus of someone with this condition as advocated in the article I linked. I've never seen an esophageal tear from a meat impaction though.
I've had glucagon work a couple of times, but only after the second dose of 2 mg made the patients vomit up the chunk of meat. This was the first time I ever tried NTG, and it worked really quickly.
The first thing I tried in this patient was a carbonated beverage, but it was ineffective. The theory is that the gas expands the esophagus so that the food might pass. Usually these patients are going to have to get scoped, with removal by EGD under direct visualization. This patient wanted to try various noninvasive maneuvers in order to avoid any procedures.
Once you've seen a couple of these, the diagnosis is easy. Any nontoxic afebrile patient spitting in a cup after eating meat has this condition until proven otherwise in my experience. I never even order barium swallows. The GI docs are always willing to come in and do their thing.
Scalpel-
Congrats (I think), you've been tagged.
I know a guy that happens too when he eats meat sometimes and he refers to it as being stuck. He eventually gets relief but I don't know what he does.
Must be scary for these people and darn uncomfortable.
I enjoy your blog. :)
Stake house Symdrome? I'm going to have to remember that
SeaSpray- Your friend should be scoped if he hasn't already been. A significant portion of people who have food impactions have pathologic causes. I would imagine that multiple impactions would increase his chance of having a structural abnormality. Or maybe he just gets excited and forgets to chew. Steve
I had never heard "Steakhouse Syndrome" either, but as an enjoyer of significant esophageal stricture, it occurs to me that steakhouses constitute about 95% of my my incidents.
Do folks frequently come to the ER with this? I never had one I couldn't clear myself. I remember wonderful trips to the restroom to vomit the offending piece (along with some dinner). It does ruin your appetite. . .
Seaspray - your friend should definitely consider an endoscopy if it happens frequently. Quite possibly scar tissue (stricture), is causing it. Once you realize what it is, it's not scary. It does suck when you take a drink and your throat fills up though.
Thank you Steve and Ian. I will be sure to pass this info on.
My husband is one of those guys that forgets to chew. He enjoys meat so much that I think he tries to inhale it. The way to his heart is definitely with a good home cooked roast of something. :)
Sadly, I know of a man that choked on steak at a wedding reception. There was a doctor there but he was unable to help him.
This stricture thing or steakhouse syndrome - could a person actually choke to death with it because it could get dislodged or is it something that causes great discomfort but will come out?
I've always liked the term "cafe coronary." But I think "steakhouse syndrome" is more to the point.
Dr. Wes, I appreciate the thought, but that meme makes me a bit uncomfortable, for various reasons. Again, thanks for thinking of me though.
Seaspray-
From personal experience, it's in your esophagus, not your trachea. You can still breathe.
I believe they worry more about esophageal tears/punctures than anything else. Your esophagus isn't designed to hold food, just move it.
Of course, I should just shut up and let a doctor answer the question.
I guess that would be my job, since I brought it up. Sorry.
These food impactions are typically lower in the esophagus, nearer the stomach than the throat, so the possibility of airway compromise is minimal (unless they aspirate it while vomiting it up).
The pressure of the food on the wall of the esophagus can cause perforation of the esophagus even without instrumentation, however, so expeditious removal (within 12 hours) is recommended.
Thank you :)
hey nice picture miss price!
had this myself. had the stricture dilated with endoscopy... versed really is an amnestic.
i've had very little success with nitro, versed, or glucagon. maybe 10%.
cheers.
Here in the north it is cariboo syndrome.....a patient of mine with the same presentation finally managed to hack up 2 huge cubes of cariboo after nitro, glucagon, and being left in the room for a long time while the ER was crazy busy.....The lesson? Remember to chew your cariboo stew.....
Hi there,
I've actually been living with this for years, first memory goes back to before I was a teenager - I'm now 31. At one point I had x-rays and a barium swallow performed but failled to show any abnormality.
I assumed it was just something I had to live with, until recently. Just today I had an Endoscopy performed, it's comforting to read the comments here describing exactly what I've been living with, but never knew a name or reason for it.
The Doctor passed a Dialator, which resulted in two mucosal tears in my oesophagus, but as I understand it, this isnt really anything to worry about and it will heal. The result is my narrowing has been opened and my symptoms should now be alleviated.
My own method of dealing with the problem, has traditionally been to run through a resturaunt searching for the toliet holding my hand over my mouth... upon finding the loo, I eject the water (which failed to wash it down) and then proceed to poke my finger down my throat to make myself vomit the food up... a few times it's taken me 30 mins of gagging on my own syliva before it finally clears... worse part is, I could never explain the problem to anyone, and no one seemed to know what I was talking about.
I will ask my doctor, but should I be concerned about the mucosal tear?
If anyone wants to know more about the proceedure I had today, or let me know of anything else I should be warey of, please email me at pjmackay76@hotmail.com
Cheers,
Paul from Australia.
I suffer from Steakhouse syndrome and have just been diagnosed with having a schatzki ring and mild hiatus hernia. It affects me approx once a month and always seems to happen with that first mouthful of meat from a Sunday roast.
I also think the condition is aggravated if I take a sip of red wine before taking that first mouthful. I have realised that the first mouthfulls have to be very well chewed and swallowed with water then the restriction seems to relax or maybe the juices are flowing and help with the swallowing process.
Good luck to all out there with similar problems, we're the lucky ones could have been cancer!
Dear INSANE person,
YOU ARE CRAZY!!!!
You could have killed the guy.
An esophageal tear will cause internal bleeding and the only way to save someone from an esophageal tear is openning his chest up.
I was just MEDEVAC'd from Iraq because of a condition called Eosinophilic Esophagitis (EE) BECAUSE if I would have had an esophageal tear FROM A FOOD IMPACTION they would not have been able to save my life.
All food impactions should be taken VERY seriously. If the person can not swallow the food down on their own, and they are not choking, then they should see an ER and have an Endoscopy done.
The spitting in a cup is a sure indicator that your 'patient' has EE because this is what I have to do when I have a food impaction so I don't gag on the saliva.
Here is more info:
http://www.curedfoundation.org/
I've experienced something similar. I'm 25 years old, and this has happened twice in the last 2.5 years, but never before. Each time I retch a little but the obstruction passes after 10-15 minutes. Once every week or two I'll eat a big bite of something and feel like its moving a bit slowly and have to drink something to wash it down relatively painlessly, but I've only had food get genuinely stuck twice.
Given my age and the relative mildness and short duration of the symptoms, how likely is it I have some kind of underlying pathology like a Schatzki ring or EE? Or do I just have a lazy/lethargic esophagus?
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