Various foreign bodies in the stomach , including pencils, plastic silverware, soda can pop tops, and cylindrical batteries
In most adults, the history provided by the patient is most helpful in identifying the characteristics and quantity of the ingested foreign object(s). Children, patients with intentional ingestion for secondary gain, and those with psychiatric comorbidities may not cooperate or provide accurate clinical histories. Foreign body ingestion in cognitively impaired patients and children should be suspected if they show telltale signs and symptoms, such as refusal to eat, painful swallowing, blood-tinged oral secretions, drooling, choking, and vomiting. Without imaging or endoscopy, localizing ingested foreign objects in the GI tract is difficult. Table 7.1 summarizes the various physiologic and pathologic anatomical points in the GI tract where a delay in food transit or foreign body retention is most likely to occur . The utilization of the site of pain or sensation of obstruction is an inaccurate means to assess location. For example, neck or chest pain may persist with the foreign body (e.g., fish bone) having already migrated into the stomach or the small bowel.
Anatomical site for possible food or foreign body impaction
Site of possible obstruction
Aberrant right subclavian artery
Left main bronchus
Pathologic narrowing or stricture (e.g., Schatzki’s ring, peptic stricture, malignant stricture, eosinophilic esophagitis)
Junction of descending and horizontal duodenal segment
Pathologic narrowing or stricture (e.g., surgical adhesions, NSAID-induced diaphragm disease, Crohn’s stricture)
The initial physical assessment should search for signs of complications. Examination findings, such as neck swelling and crepitus, suggest esophageal perforation. The presence of abdominal guarding, rebound tenderness, and severe pain suggests perforation or peritonitis, warranting imaging (e.g., abdominal CT) and prompt surgical evaluation. The need for airway protection and the risk of aspiration should also be assessed prior to and during endoscopy .
Posterior-anterior and lateral films of the neck, chest, and/or abdomen should be obtained based on the swallowed object(s) and clinical presentation (Fig. 7.2). The lateral film is particularly important in identifying a faintly radiopaque foreign body that can easily be missed on posterior-anterior projection (e.g., partially calcified bone fragment overlying the spine). This is particularly useful for objects lodged in the esophagus. Some foreign objects, such as fish bones, plastic, aluminum, and wood, are translucent and may not readily be seen. In general, contrast material should be avoided due to the risk of aspiration and coating of the foreign body, which makes subsequent endoscopic retrieval difficult. CT scan is useful in selected cases but false negatives can occur with small or thin objects. In symptomatic patients and in those with suspected foreign body impaction in the esophagus, endoscopy should not be delayed despite a negative radiographic assessment .
(a) Posterior-anterior chest radiograph in a child shows a rounded metallic object (coin). (b) Lateral view confirms the object to be lodged in the esophagus (arrow), not the trachea
Management Overview of Specific Types of Foreign Bodies
The initial approach to ingested foreign bodies will depend on their type, size, and shape. Based on current guidelines and previous management algorithms by Selivanov and Henderson, an approach to ingested foreign bodies is proposed in Fig. 7.3 [1, 9, 10]. The management of specific types of ingested foreign objects is described below.
Suggested management algorithm for ingested foreign bodies (FB) (d diameter; l length)
The type and timing of intervention is largely influenced by the patient’s age, comorbidities, surgical history, clinical presentation, and location and characteristics of the ingested foreign body. Table 7.2 is a simplified matrix to guide the decision-making process in determining the timing of endoscopy based on the anatomical site of retention . Most ingested foreign bodies can be retrieved via flexible endoscopy under moderate sedation. Foreign body retrieval under general anesthesia is generally required in small children, uncooperative patients, anticipated lengthy procedures, need to retrieve multiple ingested objects, and use of rigid endoscopes or overtubes. Objects impacted in the hypopharynx or cricopharyngeal region may best be managed by an otorhinolaryngologist using a rigid endoscope .
Recommended timing of endoscopy for foreign body ingestiona
– Completely obstructing food bolus
– Disk batteries
– Sharp-pointed objects
– Incompletely obstructing food bolus
– Blunt objects
– Magnetic objects
– Coins may be observed for 12–24 h before removal if asymptomatic
– Sharp-pointed objects
– Magnetic objects
– Objects >2.5 cm diameter
– Disk and cylindrical batteries may be observed up to 48 h
– Sharp-pointed objects
– Objects >6 cm length
– Magnetic objects
A number of endoscopic accessories should be readily accessible, including short and long (≥55 cm gastric length) overtubes, snares, forceps (e.g., rat tooth, alligator), baskets, retrieval nets, and a protector hood for sharp objects [1, 3]. If endoscopic retrieval is contemplated, practicing and planning of endoscopic maneuvers on similar objects before the actual procedure may be helpful in rehearsing the appropriate maneuvers and identifying the best accessories for successful extraction .
Coins are the most common blunt objects swallowed by children . A coin impacted in the esophagus can be readily removed with a retrieval net, a basket, or an alligator or rat-tooth forceps. Indiscriminate removal of coins and other radiopaque esophageal foreign bodies with a balloon catheter under fluoroscopic guidance and without airway protection is not recommended. Because of the confined working space, objects in the esophagus may be difficult to grasp. They can be pushed into the stomach where they can be manipulated with ease and safely extracted afterwards (Fig. 7.4). If already in the stomach, coins and other small blunt objects (<2.5 cm in diameter) tend to pass through the pylorus and may progress down the GI tract uneventfully. A 2–4-week period of observation with interval radiographic imaging is suitable, unless the potential for small bowel retention exists, such as in patients with a history of intestinal obstruction, adhesions, or strictures . It is reasonable to remove foreign objects in patients with prior GI tract surgery as adhesions may complicate safe passage of ingested foreign bodies. Endoscopic retrieval is indicated for blunt objects that fail to pass the stomach after a week interval or in patients who are symptomatic .
Coin in gastric body
Long objects (>6 cm), such as pencils, toothbrushes, spoons, and other plastic utensils, usually cannot pass through the duodenal sweep and should be endoscopically removed . The use of any promotility agent to promote passage is not effective or safe in these cases. Retrieval of these objects can be challenging, particularly if the ends of the object are impacted against the gastric wall in a position perpendicular to the long axis of the esophagus. As a general approach, endoscopic retrieval of long objects may require patient repositioning, maximum air insufflation, and manipulation of the object with a large alligator forceps to free one of its ends so that it can be grasped with a snare, forceps, or basket, with or without the aid of a gastric-length overtube (Fig. 7.5).
(a) Fragmented pieces of a long plastic foreign body with sharp ends. (b) Safe extraction performed using a forceps through a gastric-length overtube. (c) Removed foreign body
This category includes items, such as fish bones, toothpicks, nails, needles, and open safety pins. These types of foreign bodies impacted in the hypopharynx or cricopharyngeus are best managed by an otorhinolaryngologist, using laryngoscopy or a rigid endoscope. For initial diagnosis, most metallic sharp objects can be demonstrated with either a chest or abdominal x-ray (Fig. 7.6). If x-rays are unrevealing as to the location of the object(s), endoscopy must be still performed to rule out an esophageal impaction in the presence of symptoms . Any sharp-pointed object lodged in the esophagus should be removed without delay due to the high risk of complications, including perforation and fistula formation (e.g., aortoesophageal or bronchoesophageal fistula) . Although most foreign bodies pass through the GI tract uneventfully, the incidence of perforation attributed to sharp-pointed objects has been as high as 35 % in reported case series . For this reason, it is recommended that sharp objects be removed endoscopically from the stomach or duodenum, if feasible. If sharp foreign objects are beyond the reach of the endoscope and fail to progress through the remainder of the GI tract within 3–7 days, surgical exploration and retrieval must be considered . Immediate surgical intervention is warranted if obstructive symptoms, bleeding, peritonitis, or perforation develops.
Straight pin detected on abdominal x-ray
Ingestion of batteries , especially disk batteries, represents an emergency that requires prompt endoscopic retrieval. Children are at highest risk of swallowing batteries with subsequent toxicity from chemical injury . Batteries that are more than 20 mm in diameter can embed in the esophagus, cause liquefaction necrosis, and lead to fistula formation or perforation. This process can occur within hours after ingestion. In contrast to disk or button batteries, cylindrical batteries that have migrated into the stomach need not be removed unless they are several in number, they do not traverse the pylorus within 48 h (Fig. 7.7), or the patient becomes symptomatic [1, 17]. The use of Ipecac syrup to promote expulsion of the battery via vomiting is considered ineffective and unsafe. This may lead to migration and impaction of the battery from the stomach into the esophagus .
Cylindrical battery retained in the stomach more than 48 h requiring endoscopic retrieval due to risk of chemical leakage
Ingestion of magnets deserves special attention given its unique property to attract another magnet or other ingested metallic objects. The intraluminal attachment of magnetic objects may cause pressure necrosis in the intervening luminal tissue . The degree of pressure necrosis will depend on the strength of the magnetic interaction. Multiple magnets clumped together will cause more serious consequences as compared to few magnets that are separated in different locations in the bowel. There are multiple case reports on complications related to magnet ingestion, including perforation, obstruction, fistula formation, volvulus, and GI bleeding [19–22].
A chest and abdominal x-ray should be obtained to verify the location and number of ingested magnet(s) and other metallic objects. Prompt removal is warranted if more than two magnets or other metallic objects are found in the esophagus or the stomach. A single small magnet may pass through the gut without causing problems. If several magnets are found in separate locations in the small bowel, the patient should be admitted and kept nil per os and undergo serial abdominal imaging. Surgical exploration and retrieval of the magnets should be performed with the onset of symptoms or failure to progress .
“Body packers” are persons used to inconspicuously transport illicit drugs by ingesting packed substances . A number of drugs have been smuggled this way, including cocaine, heroin, and ecstasy. Accidental leakage or rupture of drug packets can result in fatal toxicity. Nowadays, body packers are less prone to accidental packet leakage or rupture due to enhancements in the packaging process. Materials, such as latex, rubber, and other sealed wrappers, have been used for better handling. As a result, these drug packets are more likely to present with obstructive symptoms than toxicity .
Patients suspected or confirmed of body packing should be monitored for spontaneous passage of the packets. Diagnostic endoscopy may be helpful in selected instances, such as to document the presence of drug packets in the stomach when a high index of suspicion exists in the setting of an unreliable history and equivocal radiologic assessment. In asymptomatic patients, gut decontamination with activated charcoal and whole-bowel irrigation with a polyethylene glycol solution to promote evacuation are usually attempted . Surgery is indicated in individuals with suspected packet rupture and cocaine toxicity, failure of the packets to progress, intestinal obstruction, or perforation . Endoscopic removal of drug packets is ill advised as the risk of rupture during retrieval of the packets usually outweighs the benefit .
Ingestion of lead-containing products can cause acute lead toxicity and other chronic symptoms, such as abdominal pain, lethargy, and neurologic impairment, in addition to the risk of the actual foreign body ingestion . Lead is particularly hazardous in children due to its toxic effects on the developing nervous system . Common foreign objects with lead include lead weights, toys with leaded paint, and rifle pellets. There are multiple reports of ingestion of innocuous-looking products that are actually tainted with lead, resulting in lead poisoning in children [30–32]. After ingestion, the acidic gastric environment facilitates lead dissolution and absorption in the gut. Ingested foreign objects with high lead content in the esophagus or stomach should be removed to prevent further lead exposure. Elevated blood lead levels have been reported within 2 h of ingestion . While waiting for endoscopic retrieval, administration of a proton pump inhibitor may decrease the rate of metallic dissolution and lead absorption . Blood lead levels should be measured if there is suspicion of acute lead poisoning, especially in children.
Small Intestinal Foreign Bodies
Once foreign objects have migrated into the small bowel, there is very limited medical intervention that can be done in case symptomatic retention or obstruction occurs. In select cases, deep enteroscopy (e.g., double-balloon enteroscopy) can be considered for retrieval of obstructing foreign bodies as opposed to surgery [35, 36]. The use of deep enteroscopy for retrieval of small intestinal foreign objects should be assessed on an individual basis. It may be a reasonable approach for attempted removal of a retained capsule endoscope, but not for a sharp-pointed object since reduction maneuvers during deep enteroscopy may actually instigate perforation by the object at the site of impaction. Intensive care monitoring and prompt medical (e.g., antidote) intervention may be warranted for foreign objects that may leach toxic substances, such as in the case of drug packets, to curtail potentially lethal toxicity .
Retained Capsule Endoscopy
Unlike other foreign body ingestions, capsule ingestion is intended to be a diagnostic procedure for small bowel diseases. Given its rising utility in clinical practice, a detailed discussion on retained capsule merits a separate section. Capsule retention can be confirmed by abdominal imaging at least 2 weeks after ingestion (Figs. 7.8 and 7.9) . Capsule retention in the small bowel can be of significant concern due to its potential to cause intestinal obstruction. There is a wide range of reported incidence rates for capsule retention. Studies have reported incidence rates of 0–15 % depending on the patient population and indication for the procedure [39–41]. Capsule retention in the small bowel has been reported in patients with Crohn’s disease, small bowel adhesions, NSAID-induced enteropathy, surgical anastomosis, small bowel tumors, and, rarely, radiation enteritis [41–43]. In the event of capsule retention, medical therapy is largely ineffective. Prokinetic agents as well as treatment with infliximab for strictures associated with Crohn’s disease have been tested with limited effectiveness [40, 41]. Endoscopic therapy, specifically double-balloon enteroscopy (Fig. 7.10 and Video 7.1), and surgery have been shown to be effective options for the retrieval of retained capsules [42, 44].
Retained capsule on abdominal x-ray in a patient with NSAID-induced strictures
Retained capsule on abdominal CT in a patient with an indeterminate stricture
(a) Fluoroscopic view of retained capsule (arrow) in ileum, accessed by a double-balloon enteroscope. (b) Capsule retrieval using a net with visualization of ileal stricture (arrow). (c) Retrieved capsule endoscope
Food Bolus Impaction
Food bolus impaction is a common medical emergency. A survey from a national insurance database estimates an annual incidence rate of 13 per 100,000 with a male-to-female ratio of 1.7:1 . The incidence seems to increase with age. Persons at risk for food impaction include those who are intoxicated, with swallowing disorders, difficulty in mastication, inadequate palatal sensation, and underlying esophageal motility disorder . Impaction of food products (e.g., meat, nutshells, bones) and true foreign objects tend to occur at either physiologic and pathologic sites of narrowing or angulation in the esophagus . The most common food bolus is meat based on several population-based surveys [6, 45].
The initial evaluation of most patients presenting with food bolus impaction is similar to that for foreign body ingestion. Special attention should be given regarding any underlying swallowing disorders. Prior history of intermittent food impaction in a young male with a history of allergies should raise suspicion for underlying eosinophilic esophagitis (Fig. 7.11) . An elderly male with unexplained weight loss and progressive solid food dysphagia may prompt evaluation for an underlying esophageal malignancy or worsening esophageal strictures . In contrast, a first-time episode of food bolus impaction while binging on alcohol is likely to be an acute event precipitated by intoxication .
WordPress theme by UFO themes