46 Gastrointestinal Foreign Bodies
James H. Tabibian and Gregory G. Ginsberg
Foreign bodies of the digestive (gastrointestinal [GI]) tract include nonfood objects that are intentionally or unintentionally ingested or inserted in the body, food impactions, and bezoars. Although the precise incidence of foreign bodies of the GI tract has not been well studied, this clinical scenario is frequently encountered in practice. 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 Given the frequency of the problem and its potential for morbidity and mortality, it is important to understand the proper methods of diagnosis and management.
46.2 Clinical Epidemiology
Esophageal food impaction is the most common foreign body type in the GI tract, with an estimated annual incidence of 16 episodes per 100,000 adults. 9 The majority of esophageal food impactions occur in patients with preexisting esophageal pathology, including benign peptic strictures, rings, eosinophilic esophagitis, surgical anastomoses, motility disorders, and (rarely) esophageal malignancy, as shown in ▶Table 46.1. 10 , 11 , 12 Types of food impaction differ by geographical region. In the United States, beef, chicken, and pork are common, whereas fish bones are more frequent in Asia and coastal areas.
Zenker’s (or other) diverticulum
Postsurgical (e.g., fundoplication)
Other dysmotility condition
True foreign body (i.e., nonfood body) ingestion occurs most frequently in the pediatric population, ages 6 months to 3 years, accounting for 80% of all true foreign body. This is attributable to children’s natural oral curiosity and naiveté. 13 Typical foreign objects in this population include coins, marbles, pins, and small toys. 3 , 7 Adult patients at highest risk of true foreign body ingestion include those with dentures, who may accidentally ingest their own prostheses (▶Fig. 46.1) and other foreign bodies because of decreased oral tactile sensation and swallowing control, and those with altered judgment, including patients who have dementia or are intoxicated. Intentional ingestion occurs most commonly in prisoners or persons with psychiatric problems who may swallow objects for secondary gain. These patients frequently are multiple/recurrent ingestors of complex and/or hazardous foreign bodies (▶Fig. 46.2a, b). Finally, certain occupations such as roofers, carpenters, tailors, and glassworkers are at risk of accidental ingestion during work with objects such as pins, nails, or glass fragments (▶Fig. 46.3a–d) that they may temporarily hold in their teeth.
Retrograde insertion of foreign objects per ano is usually related to sexual activity and sexual assault (▶Fig. 46.4). Rectal foreign objects can also be seen in patients with psychiatric disorders, individuals who inadvertently lose an object when trying to relieve constipation (e.g., performing mechanical disimpaction), and in cases of illicit drug smuggling.
Bezoars can form in a variety of settings and are more common in individuals with impaired gastric or transit, be it due to congenital or acquired (e.g., postoperative) motility or mechanical abnormalities. The most common types of bezoars are phytobezoars (composed of vegetable matter), trichobezoars (composed of hair), and pharmacobezoars (composed of medication), as discussed further below.
46.2.1 Overview of Pathophysiology
The majority of foreign bodies pass through the GI tract without causing symptoms or complications. 14 However, 10 to 20% cause symptoms that require intervention, in some cases surgical. Perforation and obstruction are the most serious complications of foreign objects and occur most frequently at anatomical sphincters and areas of angulation (▶Fig. 46.5). Foreign bodies can also impact and lead to complications at sites of acquired stenosis, in particular, surgical anastomoses, be these due to stricture formation, edema, or retained anastomotic sutures or staples (▶Fig. 46.6a, b).
Esophageal foreign bodies, including both esophageal food impactions and true foreign bodies, generally result in the most substantial morbidity. Esophageal foreign bodies can cause chest pain and pulmonary aspiration and can result in esophageal perforation, mediastinitis, and/or thoracic fistulization. The complication rate is directly proportional to the time the object remains in the esophagus beyond 24 hours. The esophagus has four areas of anatomical narrowing: the upper esophageal sphincter, the impression of the aortic arch, the crossing of the left main stem bronchus, and the lower esophageal sphincter. Foreign body impaction occurs preferentially in these areas of physiologic narrowing as well as in individuals with underlying esophageal pathology (structural and/or motor), as mentioned earlier. 15 Such pathology is often unrecognized or undiagnosed up until an index episode of foreign body impaction.
Once reaching the stomach, most foreign objects will pass through the GI tract within 1 to 2 weeks. Exceptions to this are sharp, large, and long objects: sharp/pointed objects have an associated perforation rate of up to approximately 35%; large objects (> 2 cm in diameter) have difficulty passing through the pylorus; and objects longer than 5 cm have difficulty negotiating the pylorus and the superior and inferior duodenal angles. 16 , 17 The fixed angulation of the ligament of Treitz and the ileocecal valve are sites of small bowel impaction for objects that have traversed the gastric and duodenal lumen.
With respect to bezoars, phytobezoars develop with the ingestion of fibrous, poorly digestible foods such as persimmon, celery, or potato peel, etc. Trichobezoars develop classically in younger females with a psychiatric disorder that leads to ingestion of a large amount of hair. Pharmacobezoars are often the result of polypharmacy or ingestion of large, fibrous capsules/tablets.
Colorectal foreign bodies can result from anterograde passage of ingested objects or from direct retrograde insertion. The latter can cause similar complications to those that are ingested. The valves of Houston (i.e., plicae transversae recti) impede spontaneous passage after forceful insertion. Moreover, the internal and external anal sphincters can become spasmodic and the anal canal mucosa edematous after foreign body insertion, posing further impediment.
46.3 Patient Presentation
Clinical presentation of foreign objects in children may be subtle. Symptoms may include drooling, poor feeding, failure to thrive, or stridor/aspiration. In approximately 40% of cases, the patient is asymptomatic, and there is no report of foreign body ingestion from the patient or caregiver. 18
In adults, esophageal obstruction is nearly always symptomatic, with partial obstruction causing substernal chest pain, dysphagia, gagging, or a sense of choking. More complete obstruction leads to additional symptoms, namely drooling, sialorrhea, and inability to handle secretions. Small sharp objects may cause a persistent sensation of something “being stuck” in addition to chest or (referred) throat pain. Foreign bodies that have passed into the stomach infrequently cause symptoms, as mentioned above, and when they do, they are typically the direct result of a complication such as perforation, obstruction, or bleeding.
Gastric bezoars may be asymptomatic or may present with abdominal discomfort, nausea, vomiting, early satiety, or weight loss. 19 Small bowel bezoars are usually symptomatic, with obstructive symptoms.
Patients with colorectal foreign objects may be asymptomatic or present with GI bleeding, obstruction, peritonitis, or perforation. Cases of retrograde insertion generally have a distinct history, if provided. 16 , 17
Obtaining a careful history is vital in the diagnosis and management of GI foreign bodies, as the majority of adults can accurately identify the timing and type of foreign body ingestion. Past medicosurgical history is important for identifying individuals at increased risk of sustaining GI tract foreign bodies as well as documenting dysphagia, previous food impaction or foreign body ingestion, and congenital or acquired anatomical abnormalities. Physical examination is generally unhelpful for determining the presence or absence of a foreign object, but it can identify complications related to a foreign object. For example, the neck and chest should be auscultated for wheezing or signs of aspiration or esophageal perforation and inspected for the presence of crepitus. Similarly, the abdomen should be examined for signs of perforation or obstruction.
Imaging of the suspected region of involvement should be considered as part of foreign object evaluation. Radiography can aid in identifying the presence, type, location, and number of foreign objects as well as complications such as perforation, subcutaneous emphysema, and obstruction. 3 Plain films have obvious diagnostic limitations in patients with esophageal food impaction and ingested foreign bodies that are not radiopaque (notably most fish bones) 20 ; false-negative and false-positive rates with plain films are as high as 47 and 20%, respectively. If there is any suspicion of radio-opacity with respect to ingested foreign bodies, anteroposterior and lateral chest and neck films should be considered (▶Fig. 46.7a,b). As many foreign objects are not readily visible by plain film radiography, computed tomography (CT) imaging may be considered in lieu of simple radiographs and may be more cost-effective (▶Fig. 46.8). 21 , 22 , 23 , 24 , 25 The sensitivity and accuracy of CT are superior to plain films and can be further improved with three-dimensional reconstruction. 21 , 22 , 23 , 25 , 26 Additional details regarding initial and follow-up imaging modalities are provided in recent Radiology Society clinical guidelines. 27 Of note, barium contrast should be avoided because of the risk of aspiration with esophageal obstruction and its interference with subsequent therapeutic endoscopy (▶Fig. 46.9).
In the pediatric population, mouth-to-anus radiologic evaluation has been advocated because of the difficulty of obtaining an adequate history, especially in young children. Alternatively, and to avoid radiation, handheld metal detectors may be considered and have been shown to have a greater than 90% sensitivity and specificity in identifying the presence and location of metallic foreign bodies. 28 , 29 , 30
Endoscopy is the most accurate diagnostic modality for food impactions, true foreign bodies, and bezoars, with an accuracy of approximately 100%. Endoscopy also offers identification of concomitant pathology such as esophageal strictures, esophagitis (reflux or eosinophilic), and mucosal trauma caused by the foreign body. Of note, foreign bodies impacted at or above the cricopharyngeus should be removed by laryngoscopy, while those below this level can be managed by flexible upper GI endoscopy. 31 , 32 , 33
Foreign bodies should be treated with the knowledge that 80 to 90% will pass spontaneously without complication. 2 The need to intervene is thus predicated on the individual patient, in particular symptoms, size, type, and location of the foreign body in the GI tract. While endoscopy is generally the preferred modality of intervention, other options do exist, as discussed below.