Transparent vacuum cap
Latex protector hood
Kelly or McGill forceps
Endoscopic retrieval devices for management of food impactions and foreign bodies (from left to right: basket, retrieval net, snare, rat-tooth forceps)
Esophageal (45 cm) and gastric (60 cm) length overtubes
When planning for extraction of complex objects, a valuable exercise is to go through an ex vivo simulation on a similar object to identify optimal retrieval devices and extraction techniques . Success and speed of retrieval of a foreign body have been shown to be directly related to endoscopist experience . When personnel or facilities are not available to accomplish safe and effective endoscopic retrieval, consideration should be given to transfer the patient to a more experienced center.
Prior to endoscopic intervention, assessment of the patient’s airway, ventilatory status, and risk for aspiration is crucial. A neck and chest examination that identifies crepitus, erythema, and swelling suggests a proximal perforation. Lung examination should be performed to detect the presence of aspiration or wheezing. An abdominal examination should be performed to evaluate for signs of perforation or obstruction. If there is evidence of potential aspiration or perforation on physical examination, chest and/or abdominal radiographs should be performed.
Given that food boluses may pass spontaneously, the need for endoscopic intervention is based on the persistence of symptoms. Patients with signs of complete or near-complete obstruction with drooling or excessive salivation should undergo urgent endoscopy. Endoscopic intervention should be achieved at the latest within 24 h of onset of symptoms and ideally within the first 12 h. The performance of endoscopy within hours of presentation may allow removal of the food bolus in one piece before it has a chance to soften, making extraction more challenging and time-consuming . The increased risk for complications is proportional to the duration of esophageal food impaction [46–48].
The primary method to treat food impaction is the push technique , with success rates over 90 % and with minimal complications (Video 16.1) . Before the food bolus is pushed into the stomach, steering the endoscope around the bolus into the stomach should be attempted. If the endoscope can be passed around the food bolus into the stomach, the latter can be safely pushed into the stomach without difficulty. This also allows assessment of any obstructive esophageal pathology beyond the food impaction. If the endoscope cannot steer around the food impaction, gentle pushing pressure with the tip of the endoscope can be attempted. If significant resistance is encountered, pushing should not continue. In a patient with a known hiatal hernia, the gastroesophageal junction may take a left turn, and thus, pushing the food bolus from the right side may allow easier and safer passage of the obstructing bolus into the stomach. Larger boluses of impacted meat can be broken apart with the endoscope or an accessory prior to pushing the smaller pieces into the stomach safely. When the food bolus cannot be dislodged with the push technique, a method has been described in which a Savary wire is passed into the stomach and the food is subsequently pushed into the stomach via the use of Savary-Gillard dilators . Although this method has been shown to be successful, it should be used with extreme caution because of the lack of visualization and risk of perforation.
Eosinophilic esophagitis has increasingly been associated with esophageal food impactions. Reports indicate that food impaction in patients with eosinophilic esophagitis can be treated effectively and safely with the push method (Fig. 16.3) . However, care should be taken to minimize the risk of dilation-induced mucosal tears . Caution is advised when using rigid endoscopes in the setting of suspected eosinophilic esophagitis since perforation rates with rigid instruments in this patient population have been reported to be as high as 20 % . If eosinophilic esophagitis is suspected, mucosal biopsies should be obtained after removal of the food bolus.
(a) Esophageal food impaction. (b) Meat bolus dislodged in the stomach using the push technique. (c) Esophageal rings and furrows noted, with biopsies confirming eosinophilic esophagitis
Food impactions that cannot be pushed into the stomach must be extracted via the mouth (Video 16.2). Removal can be achieved using various retrieval devices, including snares, baskets, nets, and alligator or rat-tooth forceps. When grasping the food bolus with a snare, basket, or forceps, the bolus should be pulled tight against the tip of the endoscope and then the retrieval accessory, endoscope, and food bolus should be withdrawn simultaneously. The use of a net may reduce the risk of a food bolus being dislodged in the hypopharynx during withdrawal and has been shown to result in fewer endoscope passes and to shorten overall procedure duration . A dedicated food bolus retrieval net can be useful for removing large pieces of food without the use of an overtube because the food can be satisfactorily secured within the net, thus reducing the risk of aspiration . For complicated food boluses, an esophageal overtube is useful because it protects the airway and allows for multiple passage of the endoscope for piecemeal extraction.
Transparent plastic hoods or caps , such as those used to perform variceal band ligation and endoscopic mucosal resection, have been used successfully for the removal of large, tightly impacted meat boluses. With the cap secured to the tip of the endoscope, the device can be used to suction the food into the vacuum chamber and to withdraw the bolus per os [55, 56]. The use of a Dormia basket within a transparent cap has also been used successfully in the extraction of difficult food impactions . Two large Asian studies have demonstrated that sharp food impactions, usually fish or chicken bones, are best retrieved with a rat-tooth forceps [58, 59].
More than 75 % of patients with food impactions have associated esophageal pathology [4, 60]. In addition, approximately half of patients with food bolus impactions have abnormal 24-h pH studies and/or esophageal manometry. If an esophageal stricture or Schatzki’s ring is present after the food bolus is cleared, it can be safely and effectively dilated concurrently if circumstances allow. More often, mucosal abrasions, edema, and erythema exist from the food dwelling in the esophagus for an extended period, and dilation is preferably delayed for 2–4 weeks during which time patients should be prescribed proton pump inhibitor therapy. When multiple esophageal rings and other findings suggestive of eosinophilic esophagitis are present, biopsies should be obtained. Lack of appropriate follow-up, particularly in patients with strictures or rings, has been shown to be a predictor for recurrent food impaction .
True Foreign Bodies
True foreign bodies (nonfood objects ) can occur from either intentional or unintentional ingestion. Children between the ages of 6 months and 6 years are the most common cohort to intentionally ingest foreign bodies [4, 62]. In adults, true foreign body ingestion is more common in patients who are acutely intoxicated from alcohol and in those who have a psychiatric disorder, are developmentally delayed, are seeking secondary gains, or are edentulous [4, 63]. Following one episode, a higher rate for recurrent ingestion of foreign bodies is found in male prisoners with psychiatric disorders .
Sharp and Pointed Objects
The ingestion of sharp and pointed objects carries a significant risk of complications, including perforation, which can occur in up to 35 % of patients . Sharp and pointed objects retained in the esophagus are considered a medical emergency and should be removed without delay. Objects lodged at the cricopharyngeus may be best visualized and removed with a laryngoscope. Due to risk of complications, any sharp or pointed object within reach of the endoscope should be removed urgently if this can be done safely. Chevalier Jackson’s axiom should be remembered during removal of sharp objects: “advancing points puncture, trailing points do not” . Thus, the sharp foreign body should be grasped and oriented so that the pointed end of the object trails upon withdrawal to reduce the risk of mucosal laceration or perforation (Fig. 16.4) . This sometimes entails pushing the object in an esophageal location into the stomach and then orientating the sharp edge of the object to be the trailing point upon withdrawal.
(a) Large plastic fork in the stomach swallowed by a patient with psychiatric illness. (b) Incorrect snare capture of the sharper and wider end of the fork instead of its blunt end. (c) Extensive mucosal damage of the proximal stomach noted during repeated attempts to pull the pointed end of the fork through the lower esophageal sphincter. The fork was subsequently rotated in the stomach, grasped at its blunt end, and pulled for retrieval
For sharp and pointed objects, retrieval is best achieved using a grasping forceps, such as a rat-tooth or alligator forceps, a tripod forceps, a polypectomy snare, or a biliary stone retrieval basket . Retrieval nets tend to shear during removal of sharp objects and may compromise visualization.
The use of an overtube should be considered to protect the esophagus and oropharynx (Video 16.3). Long pointed objects in the esophagus or stomach can be grasped and directed into the overtube; the entire assembly, including the sharp object, the endoscope, and the overtube, can then be removed in unison. An alternative to the overtube for the extraction of sharp and pointed objects is a retractable, bell-shaped, latex hood attached to the tip of the endoscope (Fig. 16.5). When the endoscope is pulled back through the lower esophageal sphincter, the hood flips over the grasped object and protects the esophageal mucosa during withdrawal (Video 16.4) [42, 67].
(a) Latex protector hood placed in an inverted fashion during insertion of the endoscope into the GI tract. (b) When the protector hood is pulled through the lower esophageal sphincter, it flips forward covering the sharp object and protecting the mucosa during instrument withdrawal
Despite the increased risk of perforation, most sharp or pointed objects that are beyond the reach of the endoscope will pass unimpeded and be eliminated through the GI tract without complication. However, serial daily radiographs should be obtained to ensure progression of these objects. If a sharp or pointed object fails to progress over 3 days or if there is evidence of a complication, such as abdominal pain, fever, bleeding, or overt signs of perforation, surgical evaluation is warranted.
Ingested objects longer than 5 cm (2 in.), and especially those longer than 10 cm (4 in.), such as toothbrushes and spoons, have difficulty passing through the pylorus and duodenal sweep. This can lead to obstruction or perforation at these locations. Removal is best attempted while the object remains in the stomach, as duodenal removal is more difficult. The most commonly ingested long objects are pens, pencils, toothbrushes, and eating utensils. Removal of these objects is challenging and caution to avoid mucosal injury or perforation should be taken. Grasping forceps and polypectomy snares are commonly used to secure and remove long objects. The use of snares can be problematic if the object orients horizontally rather than vertically. Horizontal orientation can make removal of the object difficult, particularly across the gastroesophageal junction, resulting in mucosal tearing. Long objects should be grasped at one end and oriented longitudinally to permit removal. For extraction of long objects, the use of a gastric length overtube can be beneficial. The object can be grasped at one end with a retrieval device and then brought into the overtube to align it along the axis of the esophagus.
Blunt Objects: Coins, Batteries, and Magnets
Small blunt objects, such as pieces of toys and coins, are the most commonly ingested objects in children. Disk (button) battery and magnet ingestions are uncommon but pose unique potential dangers. Blunt objects in the esophagus should be removed promptly with the use of a grasping forceps, snare, retrieval basket, or net. Coins impacted in the esophagus can result in pressure necrosis of the esophageal wall and lead to perforation or fistulization. A coin of any size can become lodged in the esophagus of children, but ingested coins, in particular dimes and pennies measuring 17 and 18 mm, will usually pass through the adult esophagus. Coins located in the distal esophagus on imaging are more likely to pass spontaneously than coins in the proximal esophagus .
Retrieval nets are the preferred retrieval devices as they allow capture and secure removal of coins and most small blunt objects (Video 16.5) . The net also allows for airway protection as the object is pulled through the cricopharyngeus. Grasping forceps and biliary stone retrieval baskets are also effective but with lesser control of the object. Standard biopsy forceps and snares are not recommended because they fail to secure coins reliably during extraction and can lead to airway compromise. If it is difficult to capture a blunt object in the esophagus, it is best to push it in the stomach where there is more room to facilitate its manipulation and removal. If there is concern regarding airway compromise, particularly for removal of coins in the esophagus, endotracheal intubation should be considered. Alternatively, an overtube can be used for airway protection.
Once a small blunt object enters the stomach, conservative outpatient management is appropriate in most patients . Exceptions to this include patients with surgically altered digestive tract anatomy, those with symptoms, and those who have ingested large blunt objects. In adults, the pylorus will allow passage of most blunt objects up to 25 mm in diameter, which include all coins except half-dollars (30 mm) and silver dollars (38 mm). If conservative management is deemed appropriate, a regular diet can be resumed with radiographic monitoring every 1–2 weeks to confirm progression or elimination of the object. If after 3–4 weeks, the blunt object has not passed the stomach, endoscopic removal should be performed .
Disk batteries are of special concern because they may contain an alkaline solution that can rapidly cause liquefaction necrosis of esophageal tissue, resulting in perforation or fistula formation. Disk batteries are present in many small toys and electronic devices that are accessible to young children. Disk battery ingestion occurs most commonly in younger children with approximately 10 % becoming symptomatic . Therefore, any clinical suspicion of a disk battery in the esophagus should prompt emergent endoscopy. Grasping forceps and snares are generally ineffective for disk battery removal, but the use of a retrieval net permits successful removal in almost 100 % of cases . Protection of the airway with an overtube or endotracheal intubation in pediatric patients is crucial in retrieval of disk batteries. Once in the stomach or small intestine, disk batteries rarely cause clinical problems and can be monitored radiographically. Once in the duodenum, 85 % will pass through the GI tract within 72 h. Batteries located in the stomach require endoscopy if the patient develops symptoms or the battery remains in the stomach for 48 h on repeat radiograph .
Cylindrical batteries appear to cause symptoms less frequently, with no reports of major life-threatening injuries and only approximately 20 % of patients having minor symptoms after ingestion . Cylindrical batteries should be removed from the esophagus. If in the stomach, batteries larger than 20 mm or those that have not progressed in 48 h should be removed by endoscopy.
Small coupling magnets have become popular as children’s toys. Ingested magnets within the reach of the endoscope should be removed on an urgent basis. Although a single magnet will rarely be a cause of symptoms, concern exists if multiple magnets are ingested or if magnets were ingested with other metal objects. This can result in magnetic attraction between the objects and coupling between interposed loops of bowel with subsequent pressure necrosis, fistula formation, and bowel perforation [73, 74]. Removal should be performed urgently when the magnets are more likely to be within reach of an endoscope and accessories such as grasping forceps, retrieval net, or basket can be used. Magnetic attraction to metallic retrieval devices may ease the task of removal [75, 76]. If multiple magnets have been ingested, a post-procedure x-ray can be performed to ensure that all magnets have been retrieved. If more than one magnet is not within endoscopic reach, surgical removal should be contemplated.
Endoscopic removal is contraindicated because of the high risk for package perforation with resultant drug overdose . Observation on a clear liquid diet is recommended with serial radiographs. Operative intervention is indicated when bowel obstruction, failure of the packets to progress, or drug leakage/toxicity is suspected. Up to 45 % of patients may require surgery, with gastrotomy, enterotomy, or colotomy performed based upon the location of the packets .
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Colorectal Foreign Bodies
Ingested objects infrequently become lodged in the colorectum (Fig. 16.6). More commonly, colorectal foreign bodies are inserted into the rectum intentionally or unintentionally. Males are much more likely than females to present with a rectal foreign body. Radiographs should be obtained prior to attempting removal of colorectal foreign bodies for visualization of the location, orientation, and configuration of the object. To avoid health-care provider injury, attempts at manual removal or digital rectal examination should be deferred until the presence of a sharp or pointed object has been excluded.
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