Foreign bodies in the stomach and small bowel

The frequency and type of ingested sharp objects are highly dependent on cultural factors. Esophageal fish bones are most frequently encountered in patients living in Asian and Mediterranean areas, where it is customary to introduce fish into the diet at a young age [17].

Although safety pin ingestions have decreased greatly around the world with the advent of modern diapers [14], pin ingestions more generally remain prevalent in ethnic groups that use pins to fasten clothing or religious garments [18,19].

Toothpick ingestions are more prevalent among older age groups, but can occur not infrequently in young children as well [20,21].

If a sharp object becomes impacted in the esophagus, the patient may have overt symptoms, including pain, dysphagia, odynophagia, and drooling. However, delayed intestinal perforation, extraluminal migration, abscess, peritonitis, fistula formation, appendicitis, liver, bladder, heart, and lung penetration, and rupture of the common carotid artery have all been described in patients who have remained asymptomatic for weeks after ingesting a sharp foreign body [12,19,20,22–27].

Severe complications of swallowing a sharp object – including need for urgent surgery or death – are higher in patients who become symptomatic 48 hours after ingestion occurred [28] or who have swallowed a radiolucent foreign body, which can delay diagnosis of impaction [21,29]. Maintaining a high index of suspicion and performing timely endoscopic removal prior to passage beyond the distal duodenum remain the best ways to avoid these tragic outcomes.

Once an object has cleared the esophagus, indications for its removal will depend upon its size, as well as whether it is blunt or sharp. Large or long objects that do not pass the pylorus and become trapped in the stomach will need to be removed. Recent consensus guidelines suggest removal of blunt foreign bodies from the stomach or duodenum if the child is symptomatic or if the object is wider than 2.5 cm in diameter or >6 cm in length. Otherwise, blunt foreign bodies that have been localized in the stomach can be followed expectantly and retrieved only if they produce symptoms or do not pass spontaneously after four weeks. In contrast, sharp‐pointed objects in the stomach or proximal duodenum should be removed urgently (within two hours) to minimize their chance of passing out of endoscopic reach and perforating the distal small bowel 10–12].

Food bolus impaction

Food bolus impaction in children may indicate underlying esophageal pathology, such as eosinophilic esophagitis, peptic or other strictures, achalasia, and other motility disorders [37–41]. Hence, in contrast to other foreign body ingestions, it may be appropriate for the endoscopist to obtain biopsies after the food bolus has been removed [10–12]. On the other hand, dilation of any underlying stricture is best deferred for another date, after the biopsies have been reviewed and appropriate treatment instituted as needed. Dilation at the initial presentation is particularly best avoided if the impaction has been in place for a prolonged period of time, as acutely inflamed mucosa may increase risks of perforation [12].

Esophageal food bolus impaction in a symptomatic patient with drooling or neck pain is an indication for emergent endoscopic removal. If the child tolerates their secretions, endoscopic removal may be postponed and an urgent (<24 hours) endoscopic removal may be considered, allowing an elective procedure and providing additional time for spontaneous clearance [10–12].

The technique of removal can include piecemeal extraction, suction, and/or gentle pushing of the bolus down into the stomach, though visualization of the distal esophagus is necessary to ensure that there is no stricture distal to the bolus [10–12]. Use of glucagon to relax the lower esophageal sphincter to hasten spontaneous clearance may not be effective, particularly in children with underlying eosinophilic esophagitis [12,42,43].

Equipment and management approaches for foreign body removal

Optimal endoscopic management of foreign bodies depends on their location and type. Success rates of retrieval depend on the experience level of the endoscopist and device choice [1]. The best grasping tools for sharp objects include retrieval forceps, retrieval nets, and polypectomy snares [44]. It is good practice for a pediatric endoscopy unit to maintain a “foreign body retrieval box” that holds a variety of instruments and can be carried easily into a procedure room. Indeed, given the variety of objects that children may ingest, it is not uncommon for an endoscopist to switch to a different instrument after attempting with a first. When possible, the endoscopist should trial a chosen instrument’s effectiveness at grasping a foreign body similar to the one that has been ingested at the bedside, prior to inserting the instrument through the endoscope.

Of course, to some extent, size of the child will limit access to some devices, especially if a smaller endoscope is employed. For example, a 6 mm gastroscope has a 2 mm channel and will only accommodate small polypectomy retrieval nets (diameter of 20 mm), polypectomy snares, or Dormia basket devices [45,46]. A number of instruments have been developed specifically for foreign body removal. In particular, baskets or nets are very useful and come in different sizes. Generally speaking, removal of long, thin, and/or sharp objects using rat‐tooth forceps can be accomplished easily [46]. Polypectomy snares may also provide a good option, particuarly for longer sharp objects such as toothpicks, and can be used to close open safety pins in the stomach prior to withdrawal. If the sharp end of an object is facing cephalad, it may be safest to push the object into the stomach with rat‐tooth forceps and rotate the sharp end caudally prior to removal.

Table 29.1 lists equipment that can fit in the single small working channel of most pediatric endoscopes.