Chapter 34. Gastrointestinal 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.
• 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.
• Many foreign bodies pass spontaneously, but certain objects (eg, sharp objects and batteries) need urgent intervention.

Gastrointestinal 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.

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.

Symptoms and Signs

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 years, the mentally ill, and in otherwise uncooperative patients. In such populations, symptoms and diagnostic studies are more critical to clarifying the diagnosis.

Most true foreign body ingestions are seen in children between the ages of 1 and 5 years 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 those with underlying esophageal disorders.

Presenting symptoms are determined by the type of foreign body ingested and its location.

Esophageal Foreign Bodies

Esophageal foreign bodies may result in symptoms of dysphagia, odynophagia, or signs of complete esophageal obstruction, including inability to swallow secretions, drooling, and regurgitation. Sudden onset of odynophagia following eating suggests impaction of a bone, sharp food fragment, toothpick, or similar objects in the esophagus. Respiratory symptoms such as coughing and stridor are common in younger children as their compliant tracheal rings are more easily compressed by an adjacent esophageal foreign body. Upper airway obstruction is a rare presentation for adults with an esophageal foreign body; however, meat bolus impaction at the level of the cricopharyngeus can result in respiratory obstruction, which has been referred to as "steak house syndrome." Subcutaneous emphysema in the supraclavicular area or the neck suggests perforation of the esophagus or hypopharynx. Esophageal perforation by sharp objects at the level of the aortic arch may also result in an aortoesophageal fistula. This typically presents with a herald bleed, followed by massive hemorrhage. Fortunately these presentations are rare.

Gastric Foreign Bodies

Gastric foreign bodies are generally asymptomatic, except when they are large enough to be associated with postprandial emesis and early satiety. Longstanding foreign bodies or those that are sharp and pointed may become impacted in the gastric wall and result in inflammation, ulceration, hemorrhage, or perforation. These patients often present with pain or bleeding.

Small Bowel Foreign Bodies

Foreign bodies that have made their way to the small bowel typically remain asymptomatic. Symptoms of small bowel foreign bodies are typically those of perforation or obstruction.

Physical Findings

Physical examination may yield important clues to identifying complications due to ingested foreign bodies. Crepitus in the supraclavicular and cervical areas suggests perforation of the hypopharynx or esophagus. Large gastric foreign bodies may occasionally be palpable on abdominal examination. Peritoneal signs often suggest gastric or intestinal perforation, and physical findings typical of bowel obstruction may occur with small bowel foreign bodies.

Imaging Studies

The plain film radiograph should be the initial diagnostic study. Both lateral and posteroanterior films should be obtained of the neck, chest, and abdomen. This is important in identifying small or flat objects that may overlie the spine, and in determining the exact location of a foreign body. The lateral film is often essential in differentiating between tracheobronchial and esophageal locations. Perforation may also be identified if the object is seen extending beyond the lumen wall, or if a soft tissue mass is seen adjacent to the object. Plain films should also be obtained to evaluate food bolus impactions, as the presence of bone fragments may alter the endoscopic management.

Objects that are relatively radiolucent, such as plastic, wood, most glass, and small bones, may not be seen on plain film, in which case xeroradiography or computed tomography may be helpful in making the diagnosis.

Contrast studies should be avoided. Gastrografin is contraindicated as it is very hypertonic and can result in a severe chemical pneumonitis if aspirated, and barium can obscure endoscopic visualization, thereby complicating therapy.

Endoscopic evaluation may also be required, even in the absence of imaging findings, for a possible radiolucent object and compelling history. Additionally, endoscopy is often the therapeutic method of choice.

Although the majority of foreign bodies pass spontaneously, certain objects need urgent intervention. The type of foreign body and its location determine management. In general, all esophageal foreign bodies, elongated and sharp gastric foreign bodies, and blunt objects should be removed from the stomach after persisting 2 weeks. Endoscopic removal may be technically challenging depending on the object shape and material, and several accessories are available to enhance procedural success. Details of management follow.

Foreign Body Classification and Management

A wide variety of ingested foreign bodies may be encountered by the gastrointestinal endoscopist. Roughly 75% of all foreign bodies pass spontaneously, with 1% resulting in serious complication or surgery.

Foreign bodies may be broadly classified as true foreign bodies or dietary foreign bodies. They may be further categorized as dull or sharp, blunt or pointed, long or short, toxic or nontoxic, and as food bolus impactions. These features are associated with prognosis, and depending on anatomic location may indicate when urgent removal is necessary.

Sharp and Pointed Objects

The most common sharp objects include fish or chicken bones and toothpicks; however, razor blades, hat pins, nails, and fragments of glass may also be seen (Figure 34–1 and Plate 84). Although the majority of such objects can pass safely through the gastrointestinal tract, perforation rates are as high as 35%. Thus, endoscopic removal is necessary if the object is within reach of the endoscope. When the object is above the cricopharyngeus, referral to an otolaryngologist for direct laryngoscopy is indicated. Otherwise, urgent flexible endoscopy should be considered. If the object has passed beyond the duodenum, daily radiographs should be obtained to determine its location and detect free air or other evidence of complications. If the object fails to progress for 3 consecutive days, then surgical intervention should be considered.

Long Objects

Long and narrow foreign bodies such as toothbrushes and stiff wires are associated with a high incidence of perforation as they have difficulty passing the fixed curves of the duodenum. Objects 6 cm in length or longer are particularly problematic, and early endoscopic intervention is recommended.

Blunt Foreign Bodies

This is perhaps the most diverse class of ingested foreign bodies and is the most common in the pediatric population. In a review describing the management of 242 foreign bodies, coins were the most common foreign body ingested by children. Other objects in this class include marbles, small toys, and disc batteries. Conservative outpatient management is indicated for the vast majority of blunt foreign bodies that have passed into the stomach. Rounded objects larger than 2.5 cm are less likely to pass the pylorus, and endoscopic removal should be considered if the object fails to pass the stomach within 2–3 weeks. If the object successfully passes through the stomach, a radiograph should be obtained every 3–4 days to assess passage. Surgical removal should be considered if the object remains in the same location for more than 1 week.

Button batteries or disc batteries require special consideration. The most common disc battery systems include silver oxide, manganese dioxide, and mercuric oxide. These typically contain alkaline solutions of either sodium hydroxide or potassium, which can cause direct corrosive effects or low-voltage burns. Liquefaction necrosis of the esophagus and perforation can also occur. Urgent endoscopic evaluation with battery removal is thus indicated. If battery disruption is noted, heavy metal levels should be monitored in the blood and urine. Mercury poisoning is a rare complication of battery disruption. Copper, nickel, and lead poisoning have also been reported after prolonged retention of various metallic foreign objects. If a disc battery successfully passes into the stomach, it will typically pass the gastrointestinal tract without consequence. Forceps should be avoided if endoscopic removal is attempted as they can lead to battery disruption. Cathartics and acid suppression have no proven role and should also be avoided.

Toxic Foreign Bodies

Internal concealment of illicit drugs wrapped in plastic or latex packages, also known as "body packing," is seen with higher frequency in regions of drug trafficking. Package rupture or leakage can be fatal, and such foreign bodies require special consideration. Endoscopic removal should not be attempted.

Drug packages can be subdivided into three types. Type 1 includes condoms and balloons. These typically appear as a density with surrounding halo of gas on radiography. Each condom can contain 3–5 g of cocaine, and ingestion of 1–3 g may be lethal. As these packages are very susceptible to breakage, surgical removal should be considered early.

Type 2 and type 3 packages consist of layers of tubular latex or plastic, with or without aluminum foil. Type 2 packages may appear similar to type 1 on radiography. Type 3 packages are typically smaller and may not be seen on radiographs. These packages are less susceptible to breakage and, if identified, they may be followed with daily radiographs. Indications for surgery include failure of the package to progress on the daily radiograph, evidence of intestinal obstruction, visualization of broken packages on radiograph, passage of broken packages, or development of consequential symptoms.

Food Bolus Impaction

Impacted meat is the most common esophageal foreign body in adults. Total esophageal obstruction is implied by drooling and inability to swallow secretions. This is an indication for urgent endoscopic intervention. Ideally all meat boluses should be extracted or advanced into the stomach urgently (within a few hours of ingestion) as patients are at risk for aspiration. Additionally, with prolonged bolus impaction there is risk for local esophageal ischemia and pressure ulceration, and with time the bolus may be partially digested, requiring piecemeal removal. The administration of glucagon (1.0 mg intravenously) may also be attempted prior to endoscopy to encourage spontaneous passage. This may be repeated at 10 minutes, however, if this is not effective further doses are not recommended. Glucagon has little effect on the proximal esophagus but causes substantial relaxation of the smooth muscle of the lower esophageal sphincter, allowing spontaneous passage of the bolus in up to 50% of cases. Patients with structural abnormalities are less likely to respond to this form of medical therapy. Glucagon is contraindicated in patients with underlying pheochromocytoma, insulinoma, and Zollinger-Ellison syndrome. Papain and other meat tenderizers should be avoided. Many impactions occur in the proximal esophagus and careful attention must be paid to this area on initial esophageal intubation. Additionally, many patients with food bolus impactions have underlying esophageal disease, such as peptic stricture, Schatzki ring, or eosinophilic esophagitis. Local trauma and edema often preclude an accurate diagnosis of such conditions at the initial endoscopic evaluation, and subsequent studies are typically required. This may include repeat upper endoscopy with biopsy several weeks after resolution of the food bolus impaction.

Rectal Foreign Bodies

Numerous objects, including bottles, vibrators, various fruits and vegetables, flash lights, light bulbs, and a propane tank, have been reported in the literature. Because of this wide variety of objects and the varying degree of trauma that may be seen, it is important to have a systematic approach to the diagnosis and management of retained rectal foreign bodies. Additionally, delayed presentations are common, due to embarrassment and reluctance to seek medical attention, and patients are often not entirely truthful regarding important details, further complicating management. Manual or surgical removal is commonly required, and colorectal surgeons are typically asked to manage these cases. It is important to exclude perforation in all patients with abdominal imaging/CT scan, prior to considering endoscopy. Surgery is indicated in all cases of perforation. In addition, objects that are 10 cm in diameter, have been in place for more than 2 days, and that are proximal to the rectum, typically require surgical removal. If a transanal approach is feasible, anal sphincter relaxation is critical. Perianal nerve block, and/or spinal anesthetic, should be considered in addition to intravenous conscious sedation. Perforation may only be noticed after extraction, and imaging after foreign body removal is also important.

Methods of Removal

The removal of esophageal foreign bodies dates back to the early 1900s with Chevalier Jackson, who published a series of over 3000 cases in 1936; however, foreign body extraction using the flexible fiberoptic endoscope was not reported until 1972. Throughout the 1980s and 1990s endoscopes evolved and several accessories were developed to assist in the removal of ingested foreign bodies. Methods of removal in current use are detailed in this section.

Prior to removal, a complete history and physical examination are essential to determine the need for removal and to assess the safety of the procedure. This will also help in selection of the correct instruments based on the type of foreign body and its location.

Sedation

When planning foreign body extraction, the first decision involves determining the type of sedation that is most appropriate for the patient. Many patients who have ingested foreign material are poor candidates for conscious sedation. History of alcoholism, drug abuse, or certain psychiatric conditions may render them difficult to sedate and increase associated procedural risk. General anesthesia with endotracheal intubation provides deeper sedation and additional airway protection that may be desirable in certain circumstances.

Choice of Endoscope

The second decision involves which type of endoscope to use. Forward-viewing (single-channel or double-channel) or side-viewing endoscopes may each have a role, and selection should not be arbitrary. The forward-viewing endoscopes have an advantage over side-viewing endoscopes in visualizing the esophagus and most parts of the stomach and small bowel. Double-channel endoscopes are also particularly useful for removing elongated objects as accessories may be passed through both channels, which may be helpful in positioning the object for capture or holding it in a straight position for extraction. The double-channel endoscope, however, is larger in diameter than the single-channel endoscope and may not be useable with all accessories, such as a hood or some overtubes. Additionally, the double-channel endoscope may be too large for use in infants or small children due to concern for tracheal compression. The side-viewing endoscope provides better visualization of the medial aspect of the lesser curve and the periampullary area in the small bowel, and may be useful in addressing foreign bodies lodged in these areas.

Choice of Accessories

Several accessories may facilitate the endoscopic management of foreign bodies. Various devices are available to protect the gastrointestinal tract or airway during extraction, and to grasp objects of different sizes and shapes.

Forceps and Snares

Different types of forceps or graspers are available, and certain varieties may be more or less useful for specific materials. Rat-toothed forceps and alligator forceps are more effective than standard biopsy forceps at grasping various foreign materials, including plastics and metal (Figure 34–2). Snares, biliary stone retrieval baskets, and snares fitted with netting may also be useful for contending with certain objects. Netted snares are particularly useful for dealing with objects that are prone to crumbling and button batteries.

The way the objects are grasped is also important. For elongated objects it is important to grasp them at one end and keep the long axis in line with the esophagus. For sharp objects it is critical to grasp the object such that the sharp end is trailing. Additionally, when planning a procedure it is recommended that various instruments be tested on a similar object, as this will reduce procedure time and could lead to improved outcomes.

Overtubes

An overtube is a plastic sheath with an inner diameter large enough to accommodate an endoscope, and several varieties are available (Figure 34–3). Use of an over-tube should be considered if multiple intubations are anticipated, additional if airway protection is desired, or sharp objects have been ingested.

Overtubes come in various lengths and may extend to the midesophagus or into the proximal stomach. There are two methods for placing overtubes. Reusable overtubes may be introduced over a snug fitting wire-guided Savary dilator, and single-use overtubes may be preloaded over the endoscope with the matching tapered-tip introducer. It is not acceptable to place a reusable overtube by preloading it over an endoscope as the resulting gap between the endoscope and the overtube could result in perforation of the hypopharynx. The inner diameter of the overtube varies depending on the specific product but is typically less than 14 mm in diameter. This feature can be limiting when dealing with large objects.

Hoods

The foreign body hood is an alternative to the overtube and is particularly useful when dealing with sharp foreign objects (Figure 34–4). The protective hood is attached to the bending segment of the endoscope and is folded back to avoid compromising endoscopic visualization. After the object is grasped using the appropriate endoscopic accessories, the endoscope is withdrawn. As the hood passes through the lower esophageal sphincter it is folded forward, covering the object and protecting the gastric cardia and esophagus from contact with the object. Unlike the overtube, the hood does not provide additional airway protection.

Alternatives to Removal

For food bolus impactions, it may be safer to push the object into the stomach rather than attempt removal. This must be done with care. It is essential to first evaluate the area beyond the foreign body, to make certain there is no stricture, or other anatomic defect. Gentle pressure may then be applied to the object to facilitate passage. This is typically not acceptable for large true foreign bodies.