Assessing variability in predictors of adequate follow-up after esophageal food bolus impaction: a retrospective study and literature review

Introduction

Esophageal food bolus impaction (EFBI) is a common gastrointestinal emergency, with an estimated annual incidence of 13 per 100,000 individuals (1). It affects patients of all ages, especially those with underlying esophageal conditions such as eosinophilic esophagitis (EoE), esophageal achalasia, and peptic strictures (2). Prompt recognition and management are critical, as EFBI can result in significant morbidity, including esophageal perforation and aspiration (3).

Although randomized controlled trials evaluating ambulatory follow-up after EFBI are lacking and methodologically challenging, retrospective data demonstrates improved diagnostic identification of underlying pathology after outpatient evaluation, supporting European Society of Gastrointestinal Endoscopy (ESGE) recommendations for post-discharge follow-up (2,4). Follow-up strategies often involve a multidisciplinary approach including dietary modifications, pharmacologic therapy, and repeat endoscopic assessments, as underlying conditions such as EoE, peptic strictures, and malignancy are reportedly present in more than 75% of cases (2,3). Despite these recommendations, adherence to post-discharge care remains inconsistent, with reported rates of inadequate follow-up ranging from 16% to 55% across different hospital settings (4-9). Furthermore, esophageal biopsy rates during index endoscopy remain low, with only 28% to 34.4% of patients undergoing biopsies, potentially contributing to missed or delayed diagnoses, especially among patients who fail to return for follow-up (4-6). Delayed recognition of conditions such as EoE may increase the risk of recurrent food impactions and long-term complications, including esophageal stricture formation (6).

The reasons underlying poor follow-up adherence after EFBI remain incompletely understood, however, we hypothesize that healthcare-seeking behaviors—such as perceived symptom severity, access to care, and provider communication—play a key role in follow-up adherence (10). We believe a deeper understanding of these influences and inter-study variability is necessary to address barriers and improve adherence to post-EFBI care.

Our primary objective was to assess the rate and predictors of inadequate follow-up care among patients presenting with EFBI. We then identified comparable studies and compared their population characteristics, study designs, findings, and predictors of follow-up adequacy to explore sources of variability. We present this article in accordance with the STROBE reporting checklist (available at https://tgh.amegroups.com/article/view/10.21037/tgh-2026-0006/rc).

Methods

Study design and study population

We conducted a retrospective study of adults (≥18 years old) who presented to the emergency department (ED) with EFBI symptoms between June 2021 and October 2024. EFBI was defined as recent food ingestion followed by persistent chest discomfort, inability to tolerate secretions, or persistent globus sensation (11). The study encompassed two hospitals.

Patients were identified using the International Classification of Diseases (ICD) code T18.12 and related subcodes for “food bolus impaction”. Additional cases were identified by keyword searches for “impaction” or “food” in esophagogastroduodenoscopy (EGD) reports. Manual chart reviews confirmed inclusion criteria and gathered additional data. Patients with spontaneous resolution were still included.

We excluded patients who ingested foreign bodies, including impacted bones. To ensure accurate follow-up tracking, patients living outside the hospital’s county were excluded when no post-index presentation documentation appeared in the electronic medical record (EMR) or “Epic Care Everywhere”, given the inability to reliably verify care at outside facilities. We included all patients with documented follow-up within our health system or any follow-up information available in the EMR, regardless of residence. Patients residing in the same county as the hospital were included regardless of follow-up documentation, given the lower likelihood of receiving care outside our system.

Additionally, we conducted a structured literature review identifying studies evaluating the same research question. PubMed, Embase and Semantic Scholar were searched from inception to January 24^th, 2024, using the terms: “Esophageal food bolus impaction” OR “food bolus impaction” AND “follow-up”. The search was limited to full-text articles published in English and involving adult participants.

Normal flow of hospital course for EFBI

During the study period, EFBI management was based on clinician(s) discretion. ED providers evaluate patients and consult the in-patient gastroenterology/gastrointestinal (GI) team if the bolus does not pass spontaneously. The decision for emergent, non-emergent (within 24 hours) or no endoscopy is made by the attending gastroenterologist. If endoscopy is pursued, patients are transported to endoscopy, with potential same-day discharge from the ED depending on findings. Discharge orders, including follow-up referrals and prescriptions, are managed by the ED physician. No standardized EFBI discharge form or order set was in place. Follow-up appointments are scheduled by clinic staff after hospital discharge.

Outcome and covariables

Our primary outcome was the percentage of patients who achieved adequate follow-up after EFBI. Adequate follow-up was defined as having a follow-up EGD or a clinic visit with GI, foregut surgery, or an ear, nose, and throat (ENT) provider within six months of the index presentation. As society guideline recommendations on a definitive follow-up interval are lacking, we chose a 6-month timeframe based on prior studies showing it aligns with the lower end of the interquartile range of EFBI recurrence (a clinically significant event) and enabling comparison with existing literature choosing the same timeframe (4). To maximize the inclusiveness of potential follow-ups, we conducted manual reviews, including searches within “Care Everywhere”, a secure network that shares medical records across systems.

The secondary aim was to identify variables influencing post-EFBI follow-up. Variables examined included: patient demographics [age, gender, race, body mass index (BMI), residential county], pre-existing conditions (EoE, motility disorder, malignancy, prior anti-reflux surgery), index endoscopy details (date, time, intervention, suspected diagnoses), post endoscopy recommendations (medications, GI referral, outpatient EGD orders, clinic correspondences), and follow-up outcomes (timing of clinic visits and repeat EGD). Motility disorders were defined by the Chicago Classification v4.0 (12).

Finally, we conducted a literature review to compare our findings with prior studies by highlighting similarities and differences in predictors of follow-up across different patient populations and hospital settings. This research is reported in line with the STROCSS guidelines (13).

Statistical analysis

Patient characteristics were summarized using means and standard deviations for normally distributed continuous variables and medians with interquartile ranges for non-normal distributions. Categorical variables were summarized as counts and percentages. Group comparisons were performed using Student’s t-test or Mann-Whitney U test depending on data distribution for continuous variables. Categorical variables were compared using Fisher’s exact tests.

Univariable logistic regression assessed associations between individual variables and six-month follow-up. Variables with P<0.05 in univariable analysis were included in a multivariable logistic regression followed by backward elimination to identify the significant predictive factors. Secondary analyses, detailed in the results, explored underlying contributors to key predictors. Data were analyzed using R statistical package (version 4.3.1; R Foundation for Statistical Computing, Vienna, Austria).

Ethical consideration

This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was reviewed and approved by the Institutional Review Board of University of Kentucky (No. 95254). As this was a retrospective review of existing data, informed consent was waived.

Results

Study population

We initially identified 319 patients, of whom 137 met the inclusion criteria. A total of 182 patients were excluded for the following reasons: 98 patients had food bolus impaction documented as part of their past history rather than occurring within the study period, 48 patients resided outside of our hospitals county with no documented follow-up, 22 patients had food incidentally observed in the esophagus or stomach during an elective outpatient endoscopy, 12 patients presented with non-food foreign body ingestion, and 2 patients had fewer than six months of elapsed time since their index presentation, preventing equivalent assessment of follow-up completion relative to the rest of the cohort.

Most of our patients were Caucasian (89%) and male (60%), with a mean age of 48.6±18.8 years. The baseline patient characteristics are summarized in Table 1. Sixty-two patients (45%) presented with their first food impaction. Of those with previous food impactions, only 19% (14/75) were established with a GI provider. A documented history of dysphagia was present in 74% (101/137), while 34% (46/137) had pre-existing esophageal disease (six patients had two co-existing conditions). The most common esophageal conditions were esophageal ring or stricture (26%), EoE (7%), motility disorder (4%), and esophageal cancer (0.72%).

Fifty-five patients (40%) experienced spontaneous food bolus passage with 51% (28/55) of those receiving glucagon. GI consultation occurred in 70% (96/137) of cases. At the index presentation, 72% (98/137) of patients underwent an EGD, with 94% (92/98) of patients having the procedure performed by GI and 6% (6/98) by surgery. Of those undergoing EGD, 22% (22/98) had no food bolus at time of exam (spontaneous passage). Only 40% (39/98) had biopsies performed, of which 36% (14/39) revealed a new diagnosis of EoE (diagnosed based on peak eosinophil count of >15 eosinophils per high-power field in conjunction with clinical and endoscopic finding) (14). None of these findings were significantly different between adequate and inadequate follow-up groups. Eighty-four patients (61%) had a suspected esophageal disease identified during the index encounter, including suspected EoE in 46% (39/84), motility disorders in 14% (12/84), and structural abnormalities in 39% (33/84). Of note, 19 patients in the adequate follow-up group had no suspected diagnosis at the index encounter. Among these patients, 8 patients (42%) were subsequently found to have a diagnosis on follow-up EGD, including 5 with EoE and 3 with structural abnormalities (2 esophageal rings and 1 stricture).

Recurrent food bolus impaction occurred in 13 patients (10%), with a median time of 221 days [interquartile range (IQR): 136–545 days]. This included 4 patients (7%) in the inadequate follow-up group and 9 patients (12%) in the adequate follow-up group (P=0.39).

Follow-up adequacy

Among the 137 included patients, 56% (77/137) received adequate follow-up within six months, with the majority (87%) completing follow-up within the first three months. Most of these patients (77%, 59/77) fulfilled the follow-up adequacy by having a GI office visit within the timeframe, while the remaining 23% (18/77) of patients had an EGD. The median time for clinic follow-up or repeat endoscopy was 35 days, with an interquartile range of 18–74 days. Inadequate follow-up was encountered in 44% of the patients (60/137).

The adequate follow-up group included a significantly higher number of Caucasian patients, more patients with a history of dysphagia and more patients having GI clinic referrals before discharge (Table 1). In contrast, patient sex, insurance type, time of presentation, time to EGD, EGD interventions and treatment recommendations did not differ significantly between the two groups.

On univariable analysis, patients with history of dysphagia, prior anti-reflux surgery, and patients with suspected esophageal disease at index encounter were significantly more likely to have adequate follow-up [odds ratio (OR) 2.6, P=0.02; OR 4.8, P=0.02; and OR 5.29, P≤0.001, respectively]. Conversely, inadequate follow-up was more likely among those experiencing their first food bolus impaction (OR 0.44, P=0.02), patients with spontaneous passage of the food bolus (OR 0.42, P=0.02), and those discharged directly from the ED (OR 0.37, P=0.005).

After the stepwise backward elimination, six variables remained significant in the multivariable model. Patients who were Caucasian [OR 24.4, 95% confidence interval (CI): 4.64–171, P<0.001], had a history of anti-reflux surgery (OR 6.57, 95% CI: 1.36–50.3, P=0.03), had a suspected esophageal disease at index encounter (OR 3.09, 95% CI: 1.17–8.33, P=0.02), had a follow-up endoscopy ordered before discharge (OR 5.26, 95% CI: 1.54–21.6, P=0.01), or had a GI appointment scheduled (OR 10.7, 95% CI: 3.98–32.5, P<0.001) were significantly more likely to receive adequate follow-up. The regression model also showed that residing in the same county as the hospital has a low likelihood of having adequate follow-up (OR 0.31, 95% CI: 0.11–0.79, P=0.02). Univariable and multivariable data are outlined in Table 2.

To further explore our findings, we compared the characteristics of Caucasian (n=122) and non-Caucasian (n=15) patients, including Hispanic (n=2), Black (n=8), and “other” (n=5). A higher proportion of Caucasian patients had commercial insurance and a history of dysphagia. In contrast, more non-Caucasian patients were non-English speaking and already established with GI. No other variables showed significant differences. Notably, the prevalence of known EoE was similar (7% in both groups), as was the proportion of suspected EoE (20% vs. 30%, P=0.16).

Multivariable logistic regression also showed that patients residing in the same county as the hospital were less likely to receive follow-up. We acknowledged that this contradicts the initial hypothesis that closer proximity to the hospital would improve follow-up adherence. We suspected our exclusion criteria may have influenced this result; therefore, we conducted a sensitivity analysis by repeating the logistic regression model after excluding 13 patients residing in our county who had no documented data after the index encounter at our hospital or within the Care Everywhere network (Table S1). Despite this adjustment, the association between residing in the same county as the hospital and inadequate follow-up persisted (OR 0.32, 95% CI: 0.11–0.88, P=0.03). Figure 1 demonstrates the geographic distribution of patients by county, including the total number of patients from each county and the percentage of patients within each county who completed adequate follow-up.

Figure 1 Geographic distribution of patients by county. Numbers within each county indicate the total number of patients from that county, while county shading represents the percentage of patients who completed follow-up, according to the color scale shown in the upper right corner. The flag demotes Fayette County, where the hospital is located.

Literature review

Our literature review identified seven studies evaluating follow-up after EFBI, encompassing 1,663 patients (Table 3, Table S2). Five were retrospective, one prospective, and one mixed-design; six were single-center, and one was multi-center. Geographically, four studies were conducted in the USA, one in Canada, and two in Europe. Inclusion periods spanned one to 17 years [2000–2022]. Male patients comprised 59.2% to 83.3% of study populations. Only two studies reported racial demographics, with 93–95.8% of patients identified as Caucasian. Rates of inadequate follow-up varied from 16% to 54.5%. Biopsy rates ranged from 28% to 34.4%, and recurrence rates from 10% to 13.3%.

Across the studies, several key factors were associated with follow-up adherence after EFBI. Receiving a post-discharge recommendation was the most consistent predictor of adherence (OR 6.06, P<0.001) (7). Being established with a primary care provider and having a history of esophageal disease (OR 1.51, P=0.04) also improved follow-up rates (P<0.05) (5-7). Additionally, a suspected diagnosis of EoE (OR 0.14, 95% CI: 0.08–0.27, P<0.01), an esophageal ring or web (OR 0.08, 95% CI: 0.04–0.19, P<0.01), or a peptic stricture (OR 0.03, 95% CI: 0.01–0.10, P<0.01) was associated with higher adherence (lower OR reflects lower odds of inappropriate follow-up, thereby indicating greater adherence) (4). Conversely, prolonged endoscopy was slightly associated with reduced follow-up (OR 1.04, P=0.05) (4).

Discussion

Ambulatory follow-up after an ED visit for food impaction is essential for long-term management, yet existing literature consistently highlights suboptimal follow-up rates. Our study reinforces this, with 44% of patients failing to receive adequate follow-up within six months. We also identified modifiable predictors of inadequate follow-up, as well as demographic factors warranting further attention. Additionally, our comparative literature review revealed considerable variability in follow-up rates and significant predictors across studies, likely due to differences in study design, patient populations, and healthcare systems.

In our study, 44% of patients experienced inadequate follow-up within the six-month timeframe. While some studies reported rates as low as 16%, others documented rates up to 54.5% (5,6). This variability may be influenced by study designs, administrative workflows, or differences in patient populations and healthcare-seeking behaviors. Notably, unlike studies that excluded patients already established with GI or with known esophageal disease, our inclusive criteria aimed at inclusivity, recognizing that even patients with pre-existing esophageal conditions or established care are at risk for inadequate follow-up (4-7). This is demonstrated by 7% of our inadequate follow-up group already being established with GI, and although this was numerically lower than the adequate follow-up group, the difference was not statistically significant.

We identified six predictors of follow-up, one of which was Caucasian race. Interestingly, Caucasian patients had higher follow-up rates despite a lower percentage being previously established with gastroenterology. Similarly, Muir et al. (abstract only) reported significantly higher follow-up among non-Hispanic white patients compared to non-Hispanic Black patients (21.1–36.7% vs. 2.4–16.6%, respectively, P<0.01) (16). In contrast, two peer reviewed studies investigating race found it to be insignificant (6,7). Potential explanations for our findings include higher rates of private insurance, fewer self-pay patients, more pre-existing dysphagia, and the absence of non-English-speaking patients among our Caucasian cohort. Although these factors were not significant in our regression analysis, other studies have linked race and similar social determinants with differences in follow-up and readmission rates (10,16-18). Furthermore, it is intuitive that English-speaking patients may more easily schedule follow-up care. Additionally, the higher prevalence of esophageal conditions such as EoE among Caucasians may contribute to increased follow-up, though this was not statistically significant in our analysis (19). Importantly, the small proportion of non-Caucasian patients in our sample (10.9%), and the resulting wide confidence interval, may limit the precision and external generalizability of this finding; therefore, we would encourage readers to interpret this finding as exploratory rather than definitive. Still, the observed disparity underscores a need for further investigation in a prospective, more diverse cohort.

Our model showed that patients with prior fundoplication had higher odds of appropriate follow-up. We believe this may reflect prior engagement with specialty care, as these patients typically undergo extensive preoperative evaluation and counseling before surgery. Similarly, patients with suspected esophageal disease, particularly motility disorders and EoE, had higher odds of adequate follow-up. We hypothesize that patients and providers may place greater emphasis on outpatient follow-up when an underlying treatable etiology is identified. These findings are consistent with prior studies showing that suspected diagnoses such as EoE, esophageal rings or webs, and peptic strictures are associated with improved follow-up adherence (4,7). Collectively, these results underscore the importance of clearly communicating a suspected etiologic diagnosis during the index hospitalization to improve patient engagement and adherence to post-discharge care.

Another significant demographic predictor was the county of residence. Paradoxically, patients living closer to the hospital (i.e., within the same county) were less likely to receive adequate follow-up. This contradicts the “distance decay effect”, where increased travel distance reduces healthcare access (20). However, as noted in the systematic review by Kelly et al., some studies have reported similar counterintuitive findings or no clear association between distance and follow-up (21). While our study design may have influenced this finding—categorizing patients residing in the same county without follow-up as inadequately followed—this trend persisted in sensitivity analyses, with consistent ORs (0.31 vs. 0.32), suggesting a genuine effect. Notably, patients from the hospital county, which includes a population ~320,000, had higher rates of commercial insurance, thus may have sought care at private facilities not captured by our records (22). Additionally, patients in urban areas with greater provider availability may assume follow-up is easily accessible but delay it due to competing priorities or scheduling challenges. Emergency providers may also discharge local patients assuming easier access to care, leading to a false sense of security that reduces adherence. While our retrospective design limits deeper exploration of these hypotheses, it illustrates that proximity to the hospital does not guarantee improved follow-up, necessitating targeted interventions.

Our multivariable model also identified modifiable, system-related factors influencing follow-up. Notably, placing an upper endoscopy order before discharge had significantly higher odds of follow-up, an expected finding that could be standardized via protocols or automated order sets triggered by diagnosis codes. Given only 40% of our patients underwent biopsy at index presentation—despite studies showing underlying esophageal disease in up to 75%—scheduling a repeat endoscopy is essential to avoid missed diagnoses (2). Similarly, scheduling a gastroenterology appointment was strongly associated with follow-up adherence. While consistent with prior findings, few studies have specifically examined outpatient scheduling. Other studies show that having a regular outpatient provider, clear communication of a suspected diagnosis, and physician-recommended follow-up improves adherence (4-6). We hypothesize that physician recommendations and appointment scheduling are linked, as a provider’s suggestion often results in an appointment. These findings emphasize the need for proactive scheduling, clear discharge planning, and systems that facilitate timely outreach while addressing language and social barriers.

We recognize several limitations. First, our reliance on retrospective chart review introduces the possibility of missing patient data, including pre-existing esophageal disease or the underlying cause of EFBI. This design also increases the risk of incomplete follow-up documentation, which may affect both the final sample size and our classification of adequate follow-up. Nonetheless, structured sensitivity analyses were conducted to validate our findings when applicable. Second, the predominance of Caucasian patients in our sample reflects local demographics, limiting generalizability to more diverse populations. This pattern mirrors prior studies, where 93–95.8% of patients were Caucasian, underscoring the need for future research that includes more diverse cohorts (6,7). Additionally, exclusion of patients residing outside the county without documented follow-up may introduce selection bias, as these patients may differ in unmeasured socioeconomic factors, potentially limiting generalizability. Third, inconsistent electronic health record documentation and site-specific practices, including no standardized discharge protocols and clinic-based appointment coordination, may have limited assessment of barriers to follow-up and affected the generalizability of these findings to other practice settings.

Conclusions

Despite these limitations, our study offers meaningful contributions by using broad inclusion criteria and evaluating both patient and modifiable system-related factors influencing follow-up. Our structured literature review further highlights the heterogeneity in inclusion criteria, outcome definitions, and predictors across studies. This variability reinforces the need for tailored quality improvement efforts suited to individual healthcare settings. Future research should adopt standardized outcomes and integrate patient surveys to better understand barriers to follow-up and assess the effectiveness of targeted interventions. Table 4 outlines key recommendations.

Acknowledgments

This study was presented as a poster at the ACG conference on October 27th, 2025, in Phoenix, Arizona.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tgh.amegroups.com/article/view/10.21037/tgh-2026-0006/rc

Data Sharing Statement: Available at https://tgh.amegroups.com/article/view/10.21037/tgh-2026-0006/dss

Peer Review File: Available at https://tgh.amegroups.com/article/view/10.21037/tgh-2026-0006/prf

Funding: The project received assistance with data extraction from the Center for Clinical and Translational Sciences (CCTS), which is supported by the NIH National Center for Advancing Translational Sciences (grant No. UL1TR001998). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tgh.amegroups.com/article/view/10.21037/tgh-2026-0006/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of University of Kentucky (No. 95254), and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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