How to Manage Foreign Bodies in the Upper GI Tract

Educational Objectives

The goal of this program is to improve management of foreign bodies in the upper gastrointestinal (GI) tract. After hearing and assimilating this program, the clinician will be better able to:

1. Cite indications for emergent endoscopy in management of ingested foreign bodies.

Summary

Foreign bodies in upper gastrointestinal (GI) tract: there are several endoscopic emergencies, such as GI bleeding, potentially cholangitis, and esophageal foreign bodies (FB); FB of the upper GI tract pass spontaneously in 80% to 90% cases; endoscopic retrieval is required in 10% to 20% of cases and surgery in <1% cases; complications can occur <1% cases, and include perforation, fistula, aspiration, pneumothorax, lung abscess, and mediastinitis; be aware of the possibility of ingestion of >1 FB; their ingestion impacts at the sites of physiologic, anatomic, and pathologic narrowing; these areas include cricopharyngeus, aortic arch, left mainstem bronchus, distal esophagus, pylorus, and the duodenal sweep, and in the lower GI tract, the ileocecal (IC) valve, rectum, and anus

Disorders predisposing to food impaction: these may include eosinophilic esophagitis (EoE), Schatzki rings, peptic strictures, radiation-induced strictures, esophageal cancers, anchor diverticulum, postsurgical changes such as fundoplication, esophagectomy

Commonly ingested objects: most common objects in children include coins, toys, crayons, ballpoint pen caps, batteries; in adults, food items such as meat, beef, pork, fish, and chicken bones; commonly seen is dentures that are swallowed, stents, and Bravo pH probes

Symptoms after ingestion event: patients present with acute onset of dysphagia and odynophagia; may have neck tenderness, hypersalivation, regurgitation, and children often present with sudden refusal to eat

Examination of patients: examination involves physical examination to assess their mental status, respiratory status, airway compromise, drooling (indicates complete esophageal obstruction), checking for subcutaneous emphysema, indicative of esophageal perforation, and peritoneal signs; radiologic evaluation can help in determining complications such as subcutaneous air or free air under the diaphragm

Radiologic evaluation: most ingested FB are radiopaque, however, food bolus, chicken and fish bones, wood, plastic, and glass are not; one should avoid barium and diatrizoate (Gastrografin) is contraindicated in an obstructive esophagus, since it is extremely hypertonic; biplanar x-rays, including a posteroanterior (PA) and lateral of the neck and chest and computed tomography (CT) of chest and abdomen should be obtained if perforation is suspected or to locate the FB

Management after ingestion: airway management is of primary importance, includes oropharyngeal suction and maybe intubation; conservative management is appropriate for a majority of patients

Endoscopy: timing of the endoscopy is crucial; triage patients can be classified into 3 groups, including emergent endoscopy within 2 to 6 hr, urgent endoscopy within 24 hr, and nonurgent endoscopy within 72 hr; however, no FB should be allowed to remain in the esophagus for >24 hr from the time of presentation; indications for emergent endoscopy are respiratory distress or compromise, pain, complete obstruction of esophagus, inability to handle secretion; for visualizing sharp objects below upper esophageal sphincter (UES) PA and lateral neck x-ray can be obtained; indications for urgent endoscopy include esophageal FB that are not sharp or pointed, esophageal food impaction in patients without complete obstruction, sharp pointed objects in stomach or duodenum >5 cm in length at or above the proximal duodenum, and magnets within the reach of the endoscope; nonurgent endoscopy is indicated for coins, if asymptomatic, blunt objects in the stomach with a diameter <2.5 cm and <5 cm in length, and disc and cylindrical batteries in stomach, without the signs of GI injury, may be observed for up to 48 hr; batteries remaining in the stomach should be removed within 48 hr

Esophageal food bolus impaction: one should avoid papain or meat tenderizer; enzymatic digestion of meat leads to enzymatic digestion of esophagus, which is fatal; avoid cathartics and emetics; glucagon at 0.5 to 2 mg can be used, which relaxes smooth muscle and lower esophageal sphincter (LES); it has no effect on rings or strictures, but has low success rate of 30% to 50%; no downside, can be used to avoid having to respond in middle of night; follow-up endoscopy should also be done after the extraction of the FB to treat strictures and also evaluate for eosinophilic esophagitis (EoE); the food can be extracted through the mouth en bloc or piece meal; sometimes can be pushed into the stomach, but one should ensure that there is not a stricture or ring distally; one should also be aware of bone spicule within the bolus, which may cause perforation

Sharp pointed objects: includes toothpicks, nails, and fish and chicken bones; advancing points puncture, trailing points do not; while removing sharp pointed object, one should make sure that the object is facing distally as it is removed

Button batteries: they are 3V and ≥20 mm in size; lithium batteries can lead to necrosis, rapid injury, direct corrosion, and most damage is caused when the negative pole of the button battery is against esophageal mucosa; a study demonstrated the utility of honey in protecting the esophageal mucosa in children who swallowed button batteries; protect the airway; remove with using retrieval baskets and nets and avoid graspers or forceps, which could lead to esophageal puncture; button battery left in esophagus causes liquefaction, necrosis, possible perforation, and fistula formation; button batteries in stomach and small bowel pass spontaneously in 85% of cases; follow-up progress with daily X-rays; no role for ipecac or laxative; surgery to be done only if patient has abdominal pain or failure to evacuate after 72 hr

Ingestion of magnets: used to simulate piercings in the mouth and are accidentally swallowed; they can stick together, causing pressure, necrosis, perforation; 50% to 60% require endoscopy; 30% require surgery; currently magnets are being used in endoscopy to create anastomosis between different organs

Coins: coins <20 mm (dimes and pennies) usually pass spontaneously; coins >20 mm (nickels and quarters), do not pass; can be observed for 12 to 24 hr if asymptomatic; symptomatic patients should undergo emergency endoscopy; points lodged in the distal esophagus generally pass spontaneously; those in proximal esophagus do not; most coins leave the stomach and pass through the GI tract without obstruction

Narcotics packet: for narcotic packets, eg, cocaine (as with body packers), endoscopic retrieval is contraindicated; removal of these packets can lead to chance of puncturing, leading to life-threatening situation; generally, these patients are observed until they pass the packets; surgery is indicated if there is any evidence of hemodynamic instability, or obstruction

Readings

Anfang RR, Jatana KR, Linn RL, et al. pH-neutralizing esophageal irrigations as a novel mitigation strategy for button battery injury. Laryngoscope. 2019; 129:49-57; Bekkerman M, Sachdev AH, Andrade J, et al. Endoscopic management of foreign bodies in the gastrointestinal tract: a review of the literature. Gastroenterol Res Prac. 2016; 2016; Burke A. Flexible endoscopes: Cost savings through preventive maintanance. SSM. 2000; 6:42; Ooi M, Young EJ, Nguyen NQ. Effectiveness of a cap-assisted device in the endoscopic removal of food bolus obstruction from the esophagus. Gastrointest Endosc. 2018; 87:1198-1203; Webb WA. Management of foreign bodies of the upper gastrointestinal tract: update. Gastrointest Endosc. 1995; 41:39-51.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Coben was recorded at the 40th Annual Advances in Gastroenterology Conference, held June 18, 2022, in Atlantic City, NJ, and presented by the Sidney Kimmel Medical College at Thomas Jefferson University. For more information about upcoming CME activities from this presenter, please visit https://jefferson.edu. Audio Digest thanks the speakers and the Sidney Kimmel Medical College at Thomas Jefferson University, for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

GE370102

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.