CHAPTER 25 Foreign Bodies, Bezoars, and Caustic Ingestions
GASTROINTESTINAL FOREIGN BODIES
GIFBs are a fairly common problem encountered by gastroenterologists. Most resolve without serious clinical sequelae.1 Older studies have suggested that between 1500 and 2750 deaths occurred in the United States secondary to GIFBs.2–4 More recent studies have suggested the mortality from GIFBS to be significantly lower, with no deaths reported in over 850 adults and only one death in approximately 2200 children with reported GIFB.5–11 However, regardless of imprecise morbidity and mortality rates, serious complications and deaths occur as a consequence of foreign body ingestions.12–14
EPIDEMIOLOGY
GIFBs may result from unintentional or intentional ingestion. The most common patient group that unintentionally ingests foreign bodies is children, particularly those between ages 6 months and 3 years. Children account for 80% of true foreign body ingestions.15 Children’s natural oral curiosity leads to placing objects in their mouth and occasionally swallowing them. Coins are the most common objects swallowed by children but other frequently swallowed objects include marbles, small toys, crayons, nails, and pins.6,10,16
Accidental ingestion may also occur in adults with dental covers or dentures because of loss of tactile sensation during swallowing.17 A not uncommon occurrence is a patient mistakenly ingesting one’s own dentures.18 Patients with altered mental status or sensorium, including the very old, demented, or intoxicated, are at risk for accidental foreign body ingestions (Fig. 25-1). Accidental coin ingestion has been noted in college-aged adults during a tavern beer drinking game called “quarters,” in which the coin becomes lodged in the esophagus.19 Finally, those in certain occupations, such as roofers, carpenters, seamstresses, and tailors are at risk of accidental ingestion when nails or pins are held in the mouth during work.
Figure 25-1. Endoscopic image of a bottle opener (in the stomach) ingested by an intoxicated patient.
The most common groups that intentionally ingest foreign bodies are psychiatric patients and prisoners.20 Ingestion in these groups of patients is often done for secondary gain; they often ingest multiple objects, multiple times, and often the most complex foreign bodies.
Iatrogenic foreign bodies are increasing in prevalence because of complications from capsule endoscopy, migrated stents (esophageal, enteral, and biliary), and migrated enteral access tubes and bolsters.21,22
Esophageal food impaction is the most common GIFB requiring medical attention in the United States, with an incidence of 16/100,000.23 The vast majority (75% to 100%) of patients with an esophageal food impaction have an underlying predisposing esophageal pathology,24–25 most often peptic strictures, Schatzki’s rings, and, increasingly, eosinophilic esophagitis.26 Other causes that contribute to esophageal food impactions include altered surgical anatomy following esophagectomy, fundoplication, or bariatric surgery and motility disorders such as achalasia and diffuse esophageal spasm.27
Food impactions most commonly occur in adults in their fourth or fifth decade of life but are becoming more prevalent in young adults because of the rising incidence of eosinophilic esophagitis. Cultural and regional dietary habits influence GIFBs. Fish bone injury is common in Asian countries and the Pacific rim, whereas impactions caused by meats, including hot dogs, pork, beef, and chicken, are common in the United States (Fig. 25-2).28,29
Symptomatic rectal foreign bodies are more often the result of insertion through the anus rather than oral ingestion and transit. This is reported most commonly in young adult males.30 Rectal foreign bodies that come to medical attention are most commonly inserted with the intention of autoeroticism but may present following consensual sexual acts or sexual assault.31 Less common, but still prevalent, causes of rectal foreign bodies include concealment of illegal drugs during smuggling efforts, loss of objects during attempts by the patient to relieve constipation, and even reports of falling on objects.32
PATHOPHYSIOLOGY
The vast majority (approximately 80% to 90%) of gastrointestinal foreign bodies pass through the gastrointestinal (GI) tract without any clinical sequelae and cause no harm to the patient.1,33 The remaining 10% to 20% of GIFBs will require endoscopic intervention and 1% of GIFBs may require operative therapy.5,34 True foreign bodies and food impactions can cause significant morbidity, with the most serious complications being bowel perforation or obstruction and ensuing death.3 Thus, it is important to understand the conditions in which complications associated with GIFBs are apt to occur to help stratify therapeutic interventions.
Perforation and obstruction from GIFB can occur in any part of the digestive tract, but are more apt to occur in areas of narrowing, angulation, anatomic sphincters, or previous surgery (Fig. 25-3).35 The posterior pharynx is the first area in which foreign bodies may become entrapped and cause complications. In the hypopharynx, short sharp objects such as fish bones and toothpicks may lacerate the mucosa or become lodged.36,37
Figure 25-3. Gastrointestinal areas of luminal narrowing and angulation that predispose to foreign body impaction and obstruction.
Once in the esophagus, there are four areas of narrowing at which food boluses and foreign bodies become lodged, including the upper esophageal sphincter, level of the aortic arch, level of the main stem bronchus, and gastroesophageal junction. These areas are all luminal narrowings of 23 mm or less.38 However, food impactions and foreign bodies more commonly lodge in the esophagus at areas of pathology, including rings, webs, or strictures. Multiple esophageal rings associated with eosinophilic esophagitis (see Chapter 27) contribute to esophageal food impaction at an increasing prevalence in young adults.26,39,40 Similarly, esophageal motor abnormalities (see Chapter 42) such as diffuse esophageal spasm, achalasia, or segmental variation in peristalsis may lead to food or foreign body impaction in the esophagus.41–44 Foreign body and food impaction in the esophagus generally have the highest incidence of overall adverse events, with the complication rate being directly proportional to how long the object is lodged in the esophagus. Serious complications of esophageal foreign bodies include perforation, abscess, mediastinitis, pneumothorax, fistula formation, and cardiac tamponade.45,46
Objects may become obstructed in the small intestine at the ligament of Treitz or at the ileocecal valve. Adhesions, postinflammatory strictures, and surgical anastomoses within the small intestine may also be sites where foreign bodies lodge and become obstructed. However, most objects, even sharp ones, rarely cause damage once in the small intestine and colon because the bowel naturally protects itself through peristalsis and axial flow; these tend to keep the foreign body concentrated in the center of fecal residue, with the blunt end leading and the sharp end trailing.47,48
HISTORY AND PHYSICAL EXAMINATION
The history from children or noncommunicative adults is often unreliable. Most gastric and up to 20% to 30% of esophageal foreign bodies in children are asymptomatic.49 Most of these present after having been witnessed or suspected by a parent, caregiver, or older sibling. However, in up to 40% of cases, there is no history of a witnessed ingestion.50 Thus, symptoms are often subtle in children, presenting as drooling, not wanting to eat, and failure to thrive.
For communicative adults, history of the timing and type of ingestion is usually reliable. Patients are able to relate exactly what they ingested, when they ingested it, and symptoms of pain or/and obstruction. Patients with esophageal food bolus impactions are symptomatic, with complete or intermittent obstruction. They are unable to drink liquids or retain their own oral secretions. Sialorrhea is common. Ingestion of an unappreciated small, sharp, object, including obscured fish or animal bones, may cause odynophagia or a persistent foreign body sensation because of mucosal laceration. The type of symptoms can aid in determining whether an esophageal foreign object is still present. If the patient presents with dysphagia, odynophagia, or dysphonia, there is an 80% likelihood that a foreign body is present, causing at least partial obstruction. Symptoms of drooling and inability to handle secretions are indicative of a near-total obstruction of the esophagus. If the symptoms are restricted to retrosternal chest pain or pharyngeal discomfort, less than 50% of patients will still have a foreign body present.51 Patient localization of where an ingested foreign object is lodged is not accurate, with only a 30% to 40% correct localization in the esophagus and essentially a 0% accuracy for foreign bodies in the stomach.49,52 Once the object reaches the stomach, small intestine, or colon, the patient will not report symptoms unless a complication occurs, such as obstruction, perforation, or bleeding.
Patients with rectal foreign bodies are frequently asymptomatic,31 but obtaining an accurate history from the patient may be difficult because of the embarrassment associated with its insertion. Presentation is often after the patient or another person has made multiple attempts to remove the object.36 Symptoms may include anorectal pain, bleeding, and pruritus, with a small number of patients presenting with more serious complications, including obstruction, perforation, and peritonitis.
DIAGNOSIS
Diagnostic Imaging
Plain films of the chest and abdomen are recommended for patients presenting with suspected foreign body ingestion to determine the presence, type, number, and location of foreign objects present. Both anteroposterior and lateral films are needed, because lateral films will aid in determining if a foreign body is in the esophagus or the trachea53 and may detail foreign bodies obscured by the overlying spine in an anteroposterior film. Biplanar neck films are recommended if there is a suspected object or complication in the hypopharynx or cervical esophagus. Plain films are also useful in identifying complications such as free air, aspirations, or subcutaneous emphysema (Fig. 25-4).54
Unfortunately, radiography is unable to diagnose nonradiopaque objects such as plastic, glass, or wood and may miss small bones or metal objects. The false-negative rate for plain film investigation of foreign bodies is as high as 47%, with false-positive rates up to 20%. Thus, if there is continued clinical suspicion or symptoms, the individual should undergo further clinical investigation.55
Use of plain films in children is more controversial because of the inability of the child to give a history and the radiation associated with the x-rays. Some have suggested mouth to anus screening films to detect the presence of foreign bodies in children. To limit radiation, hand-held metal detectors have been used, with a sensitivity higher than 95% for the detection and localization of metallic foreign bodies.56
Barium studies are generally not recommended for the evaluation of GIFBs. Aspiration of hypertonic contrast agents in patients with complete or near-complete esophageal obstruction may lead to aspiration pneumonitis.57 Furthermore, barium may delay or impair the performance of a therapeutic endoscopic intervention by interfering with endoscopic visualization.58 Also, even if a barium study is considered normal, an endoscopy is still recommended if symptoms persist or the suspicion of a foreign body is high.36
Imaging such as computed tomography (CT) or magnetic resonance imaging (MRI) rarely is needed for the diagnosis of GIFBs. However, CT has been found to detect foreign bodies missed by other modalities59 and may aid in detecting complications of foreign body ingestion, such as perforation or abscess, prior to the use of endoscopy.60
TREATMENT
Nonendoscopic Methods
Treatment of gastrointestinal foreign bodies should always be planned with the knowledge that 80% to 90 % of GIFBs will spontaneously pass through the GI tract without complication.5,8 This has led some investigators to suggest that all foreign bodies can be managed with conservative observation.61,62 Although conservative management is effective in most cases of GIFB, it is more appropriate to perform selective endoscopy for treatment based on the location, size, and type of foreign body ingested.20,63
A number of medical therapies have been considered as primary treatment of esophageal foreign bodies and food impactions. The smooth muscle relaxant glucagon is the most widely used and studied drug for the treatment of esophageal food and foreign object impactions. Glucagon, given in doses of 0.5 to 2.0 mg, can produce relaxation of the lower esophageal sphincter by as much as 60%, with the potential to permit passage of the impacted food or foreign body.64,65 Success with glucagon ranges from 12% to 58% in treating food impactions.66–68 Glucagon may cause nausea, vomiting, and abdominal distention. In addition, glucagon has little effect when a fixed obstruction is present, preventing passage of the foreign body. Nifedipine and nitroglycerin are not recommended because of hypotension-related side effects.
The use of gas-forming agents such as carbonated beverages or preparations consisting of sodium bicarbonate and citric acid have been described for treating esophageal impactions. These agents are purported to release carbon dioxide gas to distend the lumen and act as a piston to push the object from the esophagus into the stomach.69 However, the effectiveness of this method is doubtful, and perforations have been reported associated with the use of gas-forming objects.70 Similarly, the meat tenderizer papain is not recommended for the treatment of esophageal meat impactions because of lack of efficacy and risk of complications, including perforation and mediastinitis.71,72
Radiologic methods have been described for the treatment of esophageal foreign bodies. Under fluoroscopic guidance, Foley catheters, suction catheters, wire baskets, and magnets have been used to retract objects.73 The most commonly described device is the Foley catheter; the balloon tip of the catheter is passed distal to the object, inflated, and then the object is withdrawn into the oropharynx. Success of Foley catheter extraction of esophageal foreign bodies under fluoroscopy has been described as more than 90%. However, all radiographic methods suffer from lack of control of the object, particularly at the level of the upper esophageal sphincter and hypopharynx. Complications may include nosebleeds, laryngospasm, aspiration, perforation, and even death.74 Radiographic methods are generally recommended only if flexible endoscopy is not available.
Endoscopic Methods
Flexible endoscopy has become the treatment of choice for gastrointestinal food impactions and foreign bodies because it is safe and highly efficacious. Multiple large series have reported the success rate for endoscopic treatment of GIFBs to be more than 95%, with complication rates of less than 5%.5,58,63,75–78 The risk for complications is increased when sharp or multiple objects are ingested and when the ingestion is intentional as opposed to accidental.
Because most GIFBs pass spontaneously without causing symptoms, it is important to understand the indications and timing for endoscopic intervention. Generally, all foreign bodies lodged in the esophagus require urgent intervention. The risk for an adverse outcome from an esophageal foreign body or food impaction is directly related to how long the object or food dwells in the esophagus.79 Ideally, no object should be left in the esophagus longer than 24 hours.
Once in the stomach, most ingested objects will pass spontaneously and the risk of complications is much lower, thus making observation acceptable. There are notable exceptions, as follows. Sharp and pointed objects are associated with perforation rates as high as 15% to 35%.79 Objects longer than 5 cm and round objects wider than 2 cm also may not be passed and should be removed from the stomach with an endoscope at presentation or if they have not progressed in three to five days. If a more complex or sharp object has progressed beyond the stomach and cannot be retrieved, periodic radiographs should be obtained to document progression through the GI tract.80 The patient should then be followed for any symptoms suggestive of obstruction or perforation, such as fever, tachycardia, abdominal pain, or distention.
The type of sedation selected to facilitate endoscopy for the management of food impactions and ingested foreign objects should be individualized. Although conscious sedation is adequate for the treatment of most food impactions and simple foreign bodies in the adult population, anesthesia assistance may be required for uncooperative patients or patients who have swallowed multiple complex objects (see Chapter 40).
For management of impactions and ingestions below the level of the laryngopharynx, flexible endoscopy is preferred.81 Rigid esophagoscopy and flexible nasoendoscopes can be used, but provide no additional benefit and are often available to only a few endoscopists.82,83 Laryngoscopes with the aid of a Kelly or McGill forceps can be useful for proximal foreign bodies and small sharp objects in the hypopharynx.
Availability of and familiarity with multiple endoscopic retrieval devices for the removal of foreign bodies and food impactions is critical (Table 25-1). An endoscopy suite and/or travel cart should be equipped with at least a grasping forceps, polypectomy snare, Dormia basket, and retrieval net.84 Overtubes of 45 and 60 cm in length should be available to the endoscopist. An overtube allows protection of the airway, multiple exchanges of the endoscope, and mucosal protection from sharp objects. The longer 60-cm overtube enables retrieval of sharp and complex objects from the stomach, bypassing the lower esophageal sphincter. An alternative adjunct for extraction of sharp objects is a latex protection hood, which fits onto the tip of the endoscope85,86 (see later).
Table 25-1 Equipment for Treatment and Removal of Gastrointestinal Foreign Bodies and Food Impactions
| ENDOSCOPES | OVERTUBES | ACCESSORY EQUIPMENT |
|---|---|---|
When planning for extraction of complex, sharp, or pointed ingested objects, and when opportunity permits, it may be valuable to go through an ex vivo dry run on a similar object when considering retrieval devices and extraction technique.5 Success and speed of retrieval of the foreign body have been shown to be directly related to endoscopist experience.87 When personnel or facilities are not available to accomplish relief endoscopically, consideration should be given to transferring the patient to another center.
SPECIFIC FOREIGN BODIES
Food Impaction
Food impaction is the most common ingested foreign body in the United States.27 The most common foods to cause impactions in the United States are meat products, including beef, hot dogs, and chicken. Fish bone impactions are more common in coastal areas and Asian countries. Imbibing alcohol while eating large cuts of meat may increase the risk for food impactions and has led to the terms backyard barbecue syndrome and steakhouse syndrome.
Given that food boluses may pass spontaneously, the need for endoscopic intervention is based on the persistence of symptoms. Patients with signs of complete or near-complete obstruction with drooling or excessive salivation should undergo urgent upper GI endoscopy. Endoscopic intervention should be achieved at the latest within 24 hours of onset of symptoms and more ideally within the first 6 to 12 hours. An increased risk for complications is thought to be proportional to the duration of esophageal food impaction.1,17,88
The primary method to treat food impaction is the push method, with success rates well over 90% and with minimal complications.24 Before the food impaction is pushed into the stomach, an attempt to steer the endoscope around the food into the stomach should be made. Generally, if the endoscope can be passed around the food impaction into the stomach, the food impaction can be safely pushed into the stomach without difficulty. This also allows assessment of any obstructive esophageal pathology beyond the food impaction. Even if the endoscope cannot steer around the food impaction, gentle pushing pressure can be safely attempted. Larger boluses of impacted meat can be broken apart with the endoscope or an accessory prior to pushing the smaller pieces into the stomach safely.
Eosinophilic esophagitis has increasingly been associated with esophageal food impactions (see Chapter 27). Reports indicate that food impaction in patients with eosinophilic esophagitis can be treated effectively and safely with the push method.39 However, care should be taken to minimize inducing mucosal tears.89
