Clinical scenario

A 35 year old man attends the emergency department with a history of oesophageal obstruction after an attempt at the 20 ounce house-special at the local steak house restaurant. The ENT doctor on-call will be in theatre for some time and suggests sips of fresh pineapple juice, which he informs you contains a proteolytic enzyme, bromelain. You recall the vet prescribing papain for your cat’s furball last year and decide to look for fresh pineapple juice in the department. Finding none, you admit the patient but wonder if it would have been effective.

Three part question

In [a patient with oesophageal meat impaction] are [proteolytic enzymes effective] at [inducing resolution and minimising complications]?

Search strategy

Medline 1966–10/04 and Embase 1980–10/04 using the OVID interface. Medline: [(pineapple$.mp OR bromelain.mp OR exp papain OR papain.mp OR trypsin.mp OR chymotrypsin.mp OR enzyme$.mp OR proteolytic.mp OR Adolph’s meat tenderi$.mp OR caroid.mp) AND (exp esophagus OR oesophag$.mp OR esophag$.mp) AND (food.mp OR bolus.mp OR exp foreign bodies OR foreign bod$.mp OR exp meat OR meat.mp OR impact$.mp OR obstruct$.mp OR dysphagia.mp OR steak$.mp)] LIMIT to human AND English language. Embase: [pineapple$.mp OR bromelain.mp OR exp papain OR papain.mp OR trypsin.mp OR chymotrypsin.mp OR enzyme$.mp OR proteolytic.mp OR Adolph’s meat tenderi$.mp OR caroid.mp] AND [exp esophagus obstruction OR {(oesophag$.mp OR esophag$.mp) AND (food.mp OR bolus.mp OR exp foreign body OR foreign bod$.mp OR exp meat OR meat.mp OR impact$.mp OR obstruct$.mp OR dysphagia.mp OR steak$.mp)}] LIMIT to human AND English language.

Search outcome

Altogether 98 papers were found in Medline and 80 in Embase, three of which were relevant to the question posed (table 2).

Comment(s)

Papers evaluating the effectiveness of proteolytic enzymes consist of case reports or case series only. Almost all used sips of a solution containing papain. Published cases up to 1977 report successful passage of the bolus in 89 of 90 cases treated with enzymes but with two fatalities. Since 1977, only two case reports of proteolytic enzyme use for meat oesophageal impaction have been published. One reported haemorrhagic pulmonary oedema (Hall) while the most recent (Maini) reported aspiration pneumonitis from papain use in a patient at a UK hospital in 2000. No reference to pineapple juice use was found in the literature.

CLINICAL BOTTOM LINE

There is no evidence to support the effectiveness of fresh pineapple juice in resolving meat impaction in the oesophagus. Proteolytic enzymes have been successful but afford an unacceptable risk of serious complications. Their use should be avoided by doctors in the emergency department.