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ESSENTIALS OF FOREIGN BODIES

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ESSENTIALS OF FOREIGN BODIES

  • Plain films should be the initial diagnostic study; obtain both lateral and posteroanterior films of the neck, chest, and abdomen as indicated.

  • Avoid oral contrast as this may obscure endoscopic visualization.

  • Endoscopic evaluation may be required for objects that are potentially radiolucent in patients with a compelling history but negative imaging findings.

  • Impacted meat is typically radiolucent and is the most common esophageal foreign body in adults; perform endoscopy promptly in all cases with clinical evidence of obstruction and failure to pass on initial medical management.

  • Consider endotracheal intubation prior to foreign body extraction to protect the airway from both secretions and risk of aspiration of the foreign body upon retrieval.

  • Many foreign bodies pass spontaneously, but some objects (eg, sharp objects and batteries) require urgent intervention.

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GENERAL CONSIDERATIONS

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Gastrointestinal (GI) foreign bodies occur in all age groups and are commonly seen by the gastroenterologist, as well as by those in various surgical disciplines. The endoscopic removal of foreign bodies dates back to the early 1900s, with more widespread adoption following the advent of the fiberscope in 1957. Methods of diagnosis and treatment have continued to evolve since that time with the development of specialized accessories and improved procedural efficacy.

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Foreign body ingestion, including dietary foreign bodies or food bolus impaction, currently represents the second most common indication for emergent gastrointestinal endoscopy, after gastrointestinal hemorrhage. Patients with foreign body ingestion typically present to their primary care physician or the emergency department, and the majority of foreign bodies pass spontaneously. Nevertheless, significant complications may arise resulting in approximately 1500–1600 deaths in the United States annually. Therefore, it is essential for the endoscopist to efficiently determine which patients require therapeutic intervention, and to be comfortable with proper methods of extraction. This chapter reviews indications for foreign body removal, the typical diagnostic evaluation, and endoscopic techniques for foreign body management.

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CLINICAL FINDINGS

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A. Symptoms and Signs

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Following foreign body ingestion patients may present in a variety of ways, ranging from asymptomatic to having signs and symptoms of complete esophageal obstruction or frank perforation. In the majority of cases a careful clinical history provides the correct diagnosis. Clinical history may be less reliable in children younger than age 5, the mentally ill, and in otherwise uncooperative patients. In such populations, symptoms and diagnostic studies are more critical to clarifying the diagnosis.

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Most true foreign body ingestions are seen in children between the ages of 1 and 5 who swallow small household items or toys. Fortunately, most of these objects are small and blunt, and they typically pass spontaneously. Adults who ingest true foreign bodies often have psychiatric disturbance, mental retardation, alcoholism, or identifiable reasons for secondary gain, such as prisoners. Dietary foreign bodies and food bolus impactions typically occur in older adults, denture wearers, and ...

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