History is the most important element in diagnosing a gastrointestinal foreign body. Swallowing poorly chewed food, intentionally ingesting a true foreign body, or a history of gastrointestinal device placement can direct diagnostic and therapeutic approach. This is especially important in cases where a foreign body can cause mucosal injury or is unlikely to pass spontaneously [10].

The symptoms of foreign body esophageal impaction include dysphagia 47%, nausea and vomiting 21%, “feeling of food getting stuck” 20%, and chest or epigastric pain 15% [3]. Patients who are present with drooling and inability to manage secretions may have complete esophageal obstruction, which requires emergent endoscopic treatment [10]. Intentionally ingested foreign body may present more often with epigastric pain (55%) or without symptoms at all in 30% of cases [9].

Physical examination should first inspect the oropharynx and assess for hypoxia or respiratory distress, which would suggest a foreign body located in the respiratory tract. Further examination needs to evaluate for complications necessitating surgical intervention, such as acute abdomen, peritonitis, or subcutaneous emphysema of the chest.

Plain radiography (X-rays) of the chest, or abdomen, is generally the initial diagnostic test. X-rays can often confirm the presence of a foreign body and characterize the shape, size, and number of objects ingested [11]. Combining posterior-anterior and lateral X-ray views is critical, as this adds another reference point to better localize a foreign body. Foreign bodies diagnosed on a single-view X-ray, on the other hand, may be misleading and delay retrieval (Fig. 4.2). The sensitivity of X-ray is variable (42–90%), with improved sensitivity in the cervical esophagus and intra-abdominal regions [11–13]. The composition of the foreign body must also be considered as radiopaque materials (metal, glass, or stone) can be detected by X-ray, while radiolucent materials (animal bones, food, or plastic) may not [14].

X-ray can also detect signs such as a new pleural effusion, hydrothorax, subcutaneous emphysema, or free air in the abdomen, all of which may indicate a perforation [11]. A prompt surgical consult is indicated if any of these are seen.

CT scans have a much higher sensitivity (97%) than X-ray in detecting foreign bodies [11] and may offer more information in complicated cases. However, even with CT scans, radiolucent materials may still not be visualized [11, 14]. Oral contrast studies are not recommended due to associated risk for aspiration in the setting of a high-grade esophageal obstruction. In addition, oral contrast can coat or cover the foreign object which may impair endoscopic removal by obscuring its visibility [10, 15].

Endoscopy simultaneously confirms the diagnosis and location of a foreign body, as well as providing therapeutic management. Intentionally ingested foreign bodies may require endoscopic intervention up to 76% of the time [10]. Determining the indication and time for endoscopy are the most important aspects of management, and this is a complex, multistep process. In the following sections, the approach to managing foreign bodies will be discussed in detail.

The initial evaluation of a gastrointestinal foreign body should focus on identifying the need for immediate surgical management. A prompt surgical consult and initiation of antibiotics is necessary for gastrointestinal tract perforation with signs of peritonitis, acute abdomen, pneumomediastinum, or pneumoperitoneum. If there are symptoms of respiratory distress or signs of hypoxia, then airway management with elective intubation may be warranted, as well as consultation with otolaryngology or pulmonary for bronchoscopy. After assessing the need for surgical or pulmonary consultation, the next step is to determine the indication and timing for endoscopic intervention (Fig. 4.3).

Emergent endoscopic intervention is required in three types of cases (1) patients presenting with drooling and inability to manage secretions, suggesting complete esophageal obstruction [10]; (2) ingestion of disk batteries, which may cause electrochemical mucosal damage in the esophagus within hours of impaction [10, 16, 17]; (3) sharp objects located in the esophagus, as these are at high risk for mucosal injury [10].

Time for endoscopic retrieval of a foreign body in non-emergent cases is best before 12–24 h [18, 19]. Waiting to intervene on foreign esophageal impactions longer than this increases complications and reduces the rates of successful endoscopic retrieval [18, 19].

Esophageal foreign bodies are generally an urgent matter [10]. The esophagus is a delicate structure adjacent to vital structures including the pericardium, aorta, and lung pleura. Compromise of the esophageal mucosa integrity can lead to substantial complications from leakage of gastric juices into the mediastinum, to arterial perforation [17]. Special care should be taken in cases of impacted animal bones and objects larger than 3 cm, as these are predictive of esophageal perforation [19]. Blunt objects impacted in the esophagus that are causing symptoms may be the result ongoing ischemic pressure injury and these require expedited removal as well [10]. On the other hand, observation for 12–24 h to monitor for spontaneous passage is appropriate in asymptomatic patients who have ingested blunt objects, such as coins [10].

In the stomach or duodenum, some foreign bodies are still managed urgently [10]. Sharp or pointed objects are associated with the increased risk of perforations up to 35% of the time if left to pass spontaneously [10, 20]. Magnets may lead to mucosal pressure ischemia, perforation, or fistulization if they come into contact with other magnets, or metals, in the gastrointestinal tract [10, 21]. Batteries causing active mucosal injury or objects that may not pass the duodenal sweep (length >6 cm) should also be removed urgently [10].

Allowing spontaneous passage is appropriate when a foreign body does not meet criteria for timely removal, has passed the esophagus, and is at low risk to cause obstruction or mucosal injury, as demonstrated in Fig. 4.4 [10, 21, 22]. Monitoring for signs of peritonitis and obtaining periodic X-rays are important to assess the need for retrieval and assure adequate passage over time [10]. The general time intervals indicating that a foreign body has failed to pass and requires retrieval are 3–4 weeks in the stomach and 48 h in the intestines [9, 10]. Exceptions to this apply to batteries (both disk and cylindrical types) in the stomach where failed passage requiring retrieval is at 48 h [10]. Additionally, objects that are wider than 2.5 cm may not pass the pylorus and close monitoring, or non-urgent endoscopic retrieval, should be considered [10].

Medical therapies can be used specifically for managing esophageal food impactions, albeit they have a limited role in contemporary practice due to lack of efficacy. Various agents have been used to facilitate the passage of impacted food bolus (including benzodiazepines, calcium channel blockers, anticholinergic, nitrates, and effervescent agents) with the most studied being papain and glucagon [23].

Papain is a proteolytic, trypsin-like enzyme that is diluted in water and administered by mouth to treat meat impactions through its digestive properties [23]. Recently, Morse et al. [24] showed that 87% of protein bolus impaction cases can be successfully treated with oral administration of papain without adverse events [24]. However, papain is not recommended in current guidelines due to historical evidence showing inconclusive efficacy, along with serious adverse events such as aspiration pneumonitis [23, 25].

Glucagon is a polypeptide hormone that can relax the lower esophageal sphincter and, thereby, potentially relieve an impacted esophageal food bolus [26]. Glucagon has been shown to be successful in up to 39.5% of cases, without adverse events [27]. Glucagon alone is not recommended due to its moderate efficacy, but it may be used in combination with endoscopy [10]. The current ASGE guidelines recommend administration of IV glucagon while preparing for endoscopic retrieval to allow a trail of passage prior instrumentation [10].

Esophageal food impactions are managed endoscopically by two methods: The push technique describes the advancement of a food bolus into the stomach with an endoscope. This technique has been advocated in the past, and it has a low rate of complications if done with extreme care [5]. The pull technique is the preferred approach, however, given that pushing a food bolus blindly through a potential stricture may result in mucosal injury or perforation. The pull technique involves retrograde extraction of a food bolus. In some cases piecemeal removal is used if a bolus is large or has a soft consistency (Fig. 4.6). Some endoscopists prefer a hybrid “pull-push” technique that employs piecemeal extraction to reduce the size of a food bolus, so it can be safely advanced into the stomach. The most commonly used devices for food impactions are rat-toothed forceps, snares, or nets [3–5]. None of these devices have been shown to be superior to one another.

Other devices and techniques are an option for difficult cases of esophageal food impaction. Endoscope caps used for band ligation, or mucosectomy can be used for suctioning onto a food bolus for extraction [30]. Another method involves guiding an esophageal dilation balloon distal to an impacted food bolus, inflating the balloon slightly to capture the food bolus, and then pulling it out of the esophagus [31]. Even electrocautery has been described to fracture an impacted pill in the esophagus, although this method clearly carries risks to mucosal injury [32].

Sharp foreign bodies encountered include razor blades, safety pins, glass, broken plastic, or pens (Fig. 4.7a) and special care must be taken during retrieval. Protective devices, such as a latex hood or an overtube, are designed to cover the sharp ends of forgein bodies and they are necessary tools for retrieving sharp foreign bodies. (Fig. 4.7b–d). Latex hoods are simple devices that are fitted over the scope end to cover sharp objects [29]. Once the object is secured, the scope is withdrawn and the retracted hood will be pushed forward into a covering position as it passes through the lower esophageal sphincter [29]. Overtubes are used to remove sharp objects when latex hoods are not indicated or cannot be used (Fig. 4.7d). An overtube is essentially a long plastic tube that works as a channel for the endoscope to pass through the oropharynx, esophagus, and into the stomach [33]. The overtube housing protects the mucosa when retrieving a sharp foreign body. It also serves to protect the airway and facilitate repeated reintroduction of the endoscope if needed [29]. Deciding to use an overtube should be judicious, however, as they can cause mucosal injury or other complications including esophageal rupture, ulceration, and bleeding [29, 33, 34].