Endoscopic Management of Foreign Bodies of the Upper Gastrointestinal Tract
Dustin A. Carlson, MD
Ingestion of foreign bodies or food impaction is a common cause of gastrointestinal emergency.1 The majority of foreign bodies pass spontaneously through the alimentary tract, but endoscopic intervention is required in 10% to 20% of cases. Generally, food bolus disimpaction or foreign body retrieval by endoscopic means is successful in over 90% of cases with surgical intervention being potentially required if an object fails to progress over several days or symptoms of obstruction or perforation develop.2,3 While foreign body ingestion carries substantial morbidity, the rate of fatality is low.1,2,4,5
Foreign body ingestions occur more commonly in the pediatric than adult population, with the peak incidence between 6 months and 6 years.5 In adults, foreign body ingestion may occur more frequently among patients with psychiatric disorders, mental impairment, alcohol intoxication, or those seeking secondary gain with access to a medical facility. Food bolus impaction is most often observed in those with underlying esophageal pathology, such as peptic strictures or eosinophilic esophagitis (EoE).
INDICATIONS FOR ENDOSCOPY
Indications for endoscopic intervention, as well as timing of intervention, are dependent on both the nature of the object, its particular location within the GI tract, and the patient’s clinical status.1 Risks of aspiration and GI perforation are the primary factors related to recommendations regarding endoscopic intervention with ingested foreign bodies and are focuses of the initial evaluation (e.g., assessment of airway, ventilatory status, and evaluation for possible perforation, such as peritoneal signs or subcutaneous crepitus in the thorax or neck). In general, foreign objects requiring removal include any item lodged in the esophagus and items within upper endoscopic reach (i.e., in the stomach or proximal duodenum) that are sharp, long (>6 cm), magnets, or batteries.1
1. Esophageal obstruction with any object (recognized by inability to tolerate oral secretions)
2. Sharp object in the esophagus
3. Disk battery in the esophagus
Urgent (i.e., Within 24 Hours)
1. Esophageal impaction not meeting criteria for emergent endoscopy as above (i.e., incomplete obstruction of a nonsharp, non-disk battery foreign body)
a. All esophageal foreign bodies should be removed prior to 24 hours from occurrence
2. Sharp object within stomach or proximal duodenum that can be safely removed
3. Objects >6 cm in length at or above the proximal duodenum
4. Magnets within endoscopic reach
1. Objects in stomach >2.5 cm in diameter
2. Disk and cylindrical batteries within the stomach when signs/symptoms of gastric mucosal injury are present or without sign of GI injury if not expelled from the stomach within 48 hours
3. Blunt objects that fail to pass out of stomach within 3 to 4 weeks
CONTRAINDICATIONS FOR ENDOSCOPIC INTERVENTION
1. Evidence of free mediastinal or peritoneal air
2. Narcotic packets. Endoscopic recovery should not be attempted due to the risk of rupture, as leakage of contents can be fatal
3. Same as standard upper endoscopy
1. Upper esophageal stricture
2. Zenker diverticulum
3. Postligament of Treitz position of foreign body (as the majority of these will pass spontaneously)
4. Same as standard upper endoscopy
1. High esophageal impaction
2. Esophageal impaction of prolonged or unknown duration (prolonged impaction may result in tissue necrosis, increasing the risk of major adverse events)
In both instances consider anesthesiology +/- surgical consultation. General endotracheal anesthesia is helpful for airway protection in these cases, or when overall risk of aspiration is deemed to be high (e.g., large amounts of food within the esophagus).
1. Assess circumstances (e.g., object, timing) of suspected ingestion.
2. Obtain a replica of a foreign body for inspection if it is a nonfood object.
3. Determine the presence of known esophageal pathology (anatomic or dysmotility).
4. Characterize prior symptoms of dysphagia or a history of any previous food impaction.
5. Determine the presence of any neurologic impairment (e.g., cerebrovascular accident, multiple sclerosis) that may increase risk of aspiration.
1. Assess ventilation, airway compromise, and risk of aspiration.
2. Assess swelling, tenderness, or crepitus in the neck region and thorax to assess for esophageal perforation.
3. Assess the abdomen for evidence of peritonitis or small bowel obstruction.
1. Impaction or obstruction most often occurs at areas of acute angulations or physiologic narrowing.
a. Cricopharyngeus muscle
b. Aortic arch
c. Esophagogastric junction
e. Ligament of Treitz
f. Ileocecal valve
1. Exclude perforation by assessing for the presence of mediastinal, subdiaphragmatic, or subcutaneous air.
2. Identify and localize the object with radiographs.
3. Only radiopaque objects may be visualized, e.g., metal objects and steak bones
a. Commonly encountered objects that are radiolucent (and thus will unlikely be observed on radiography) include chicken bones, most fish bones (depends on type of fish), wood (e.g., toothpicks), plastic, and most glass.
4. Biplane radiographs will commonly be sufficient to localize and identify objects.