Foreign Bodies, Bezoars, and Caustic Ingestions

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CHAPTER 25 Foreign Bodies, Bezoars, and Caustic Ingestions

Gastrointestinal foreign bodies (GIFBs) are comprised of food bolus impactions and intentionally and unintentionally ingested or inserted foreign objects. Bezoars are ingested materials (food or other materials) that accumulate in a normal or abnormal stomach. Caustic ingestions present following intentional or unintentional ingestion of acid or alkaline materials, which may result in acute and/or chronic injury to the esophagus and stomach. These topics are discussed in detail in this chapter.

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

Thus, because of their frequent occurrence and potential for negative consequences, it is important to understand which patients are at risk for GIFBs, know how to diagnose and treat GIFBs, and deal with their complications.

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

Figure 25-2. Endoscopic image of bratwurst with sauerkraut impacted in the esophagus while the patient was tailgating at a football game.

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

Once a GIFB passes through the esophagus, the vast majority will pass through the entire GI tract without further difficulty or complication. Exceptions are sharp, long, and large objects. Sharp or pointed objects may have a perforation rate as high as 35%. Large objects (larger than 2.5 cm [1 inch] in diameter) may not be able to pass through the pylorus. Long objects (longer than 5 cm [2 inches]) such as pens, pencils, and eating utensils, may not negotiate around the duodenal sweep.

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

Inserted rectal objects are often tenaciously retained because of anal sphincter spasm and edema, making spontaneous passage of the object difficult. The angulation and valves of Houston may also impede passage of objects through the rectum.

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.

Past medical history is useful to identify previous foreign body ingestion, because these repeat offenders are likely to ingest multiple and more complex foreign objects. A history of dysphagia in a person with a food impaction or esophageal foreign body suggests a high likelihood of underlying esophageal pathology.

Physical examination does little to secure the diagnosis or location of a retained foreign body. However, physical examination is crucial to identify already developed complications related to foreign body ingestion. Assessment of the patient’s airway, ventilatory status, and risk for aspiration are crucial prior to initiating therapy to remove a GIFB. A neck and chest examination looking for crepitus, erythema, and swelling can suggest a proximal perforation. An abdominal examination should be performed to evaluate for signs of perforation or obstruction.

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 trachea ⁵³ 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

Figure 25-4. Radiograph of the chest demonstrating pneumomediastinum and bilateral pneumothoraces in a patient who developed esophageal perforation secondary to food impaction left untreated for longer than 24 hours.

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 modalities ⁵⁹ and may aid in detecting complications of foreign body ingestion, such as perforation or abscess, prior to the use of endoscopy.⁶⁰

Endoscopy

Diagnostic endoscopy provides the most precise means to diagnose suspected foreign bodies or food impactions. This ensures an almost 100% diagnostic accuracy for objects within the reach of the endoscope, including nonradiopaque objects and objects obscured by overlying bony structures that are not visualized by radiography.

Endoscopy also allows the most accurate diagnosis of the underlying pathology, such as esophageal strictures, which may have led to a food impaction or impacted esophageal foreign body. Endoscopy also allows visualization of mucosal defects, abrasions, or ulcerations that may have resulted from the foreign body. Diagnostic endoscopy is also linked to the most efficacious therapy for GIFBs, the use of therapeutic endoscopy to remove or treat the object.

Diagnostic upper endoscopy for foreign bodies is contraindicated when there are clinical or radiographic signs of perforation. Once an ingested foreign object has passed the ligament of Treitz, endoscopy is generally not indicated, because these objects will typically pass unimpeded with notable exceptions (see later). Similarly, most small (less than 2.5-cm) blunt objects in an adult patient’s stomach do not require endoscopic retrieval because most will pass without complication.

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 endoscope^85,⁸⁶ (see later).

Table 25-1 Equipment for Treatment and Removal of Gastrointestinal Foreign Bodies and Food Impactions

ENDOSCOPES	OVERTUBES	ACCESSORY EQUIPMENT
Flexible endoscope Rigid endoscope Laryngoscope

Standard esophageal overtube

45- to 60-cm foreign body overtube

Transparent vacuum cap

Latex protector hood

Kelly or McGill forceps

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

Food impactions that cannot be gently pushed into the stomach must be dislodged and withdrawn. Retrograde removal can be achieved with various retrieval devices, including snares, baskets, and forceps. Initial manual disruption of the food bolus into smaller pieces typically makes removal easier. An oroesophageal overtube is useful in such cases because it protects the airway and allows multiple exchanges of the endoscope during retrieval. A dedicated food bolus retrieval net can be useful for removing large pieces of food without the use of an overtube because the food can be satisfactorily secured within the net, thus reducing the risk of aspiration of the ingestate.⁹⁰

Transparent plastic hoods or caps, such as those used to perform variceal band ligation and endoscopic mucosal resection, have been used successfully for the removal of large, tightly impacted meat boluses. With the cap secured to the tip of the endoscope, the device can be used to suction the food into the vacuum chamber and to withdraw the bolus per os.^91,⁹²

More than 75% of patients with food impactions have associated esophageal pathology.^5,²⁵ In addition, approximately half of patients with food bolus impactions have abnormal 24-hour pH studies and/or esophageal manometry. If an esophageal stricture or Schatzki’s ring is present after the food bolus is cleared, it can be safely and effectively dilated concurrently if circumstances allow. More often, mucosal abrasions or erythema exists from the food dwelling in the esophagus for an extended period and dilation is delayed for 2 to 4 weeks, during which patients should be prescribed proton pump inhibitor therapy. When multiple esophageal rings are present, biopsies should be obtained to evaluate for eosinophilic esophagitis.

Sharp and Pointed Objects

Sharp and pointed objects may cause a perforation in up to 15% to 35% of patients and account for one third of all perforations from GI foreign bodies.⁹³ Sharp and pointed objects, particularly toothpicks and animal bones, are the most likely ingested foreign objects to cause a perforation that necessitates surgical management.⁹⁴ Patients with psychiatric illness and incarcerated patients are more likely to ingest more complex and multiple sharp and pointed objects, such as razor blades (Fig. 25-5), pins, needles, and writing and eating utensils (Fig. 25-6).

Figure 25-5. A, A razor blade (in the stomach) ingested by a prisoner. B, Removal of the razor blade with a grasping forceps and overtube.

Figure 25-6. Endoscopic image of a long spoon and nail that became impacted in the duodenal sweep after being swallowed by a psychiatric patient.

Sharp and pointed objects retained in the esophagus are considered a medical emergency and should be removed within 6 to 12 hours. Moreover, any sharp and pointed object within the reach of the endoscope should be removed as well if this can be safely done (Fig. 25-7). When removing sharp and pointed objects, the foreign body should be grasped and oriented so that the pointed end trails on withdrawal to reduce the risk of perforation and mucosal laceration.⁹⁵

Figure 25-7. Endoscopic images of shards of broken glass in the prepyloric antrum.

(Courtesy of Dr. Jamie Anderson and Dr. Tushar Dharia, Dallas, Tex.)

For sharp and pointed objects, retrieval is best achieved with a grasping forceps, polypectomy snare, or biliary stone retrieval basket.⁸⁷ All these devices can secure the object; orient the device used as described earlier. Retrieval nets tend to shear in the removal of sharp objects and may compromise visualization.

Use of an overtube should be considered to protect the esophagus and oropharynx. Long pointed objects can be grasped and directed into the overtube; the entire assembly, including the sharp and pointed object, endoscope, and overtube are then removed in unison.

An alternative to an overtube for the extraction of sharp and pointed objects is a retractable latex hood that can be affixed to the tip of the endoscope (Fig. 25-8). When the endoscope is pulled back through the lower esophageal sphincter, the hood flips over the grasped object and protects the mucosa during withdrawal.^85,⁹⁶

Figure 25-8. A, A latex protector hood with the hood pulled back. This position enables full visualization and allows the endoscopist to grasp a sharp object easily. B, As the protector hood is pulled back through the lower esophageal sphincter, the hood flips forward, protecting the gastrointestinal mucosa from the sharp object.

Although associated with an increased risk of perforation, most sharp or pointed objects beyond reach of the endoscope will pass unimpeded and be eliminated through the GI tract without complication. Because of the increased risk of perforation, sharp and pointed objects should be followed by serial daily radiographs to ensure progression. If a sharp or pointed object fails to progress over three days, operative intervention should be considered.

Long Objects

Ingested objects longer than 5 cm (2 inches), and especially those longer than 10 cm (4 inches), have difficulty passing through the pylorus and duodenal sweep and can get hung up, causing obstruction or perforation at these locations (see Fig. 25-7). The most commonly ingested long objects are pens, pencils, toothbrushes, and eating utensils. Grasping forceps and polypectomy snares are the most commonly used devices to secure and remove long objects. Long objects should be grasped at one end and oriented longitudinally to permit removal. For extraction of long objects, use of the 60 cm overtube endoscope assembly, as described earlier, should be considered.

Blunt Objects: Coins, Disc Batteries, Magnets, and Bread Tabs

Small blunt objects, such as pieces of toys and coins, are the most commonly ingested objects by children. Disc (button) battery and magnet ingestions are uncommon but pose unique potential dangers. Blunt objects in the esophagus should be removed promptly. Impacted coins can result in pressure necrosis of the esophageal wall, resulting in perforation and fistula. A coin of any size can become lodged in the esophagus of children but ingested coins, in particular dimes and pennies measuring 17 and 18 mm, will usually pass through the adult esophagus.

Polyp or dedicated retrieval nets allow capture and secure removal.⁸⁷ Grasping forceps and biliary stone retrieval baskets are also effective. Standard biopsy forceps and snares are not recommended because they fail to secure coins reliably during extraction. If it is difficult to capture a blunt object in the esophagus, it is safe to push the object into the stomach, where there is more room to negotiate.

Once a small blunt object enters the stomach, conservative outpatient management is appropriate for most patients.⁹⁷ Exceptions to this include patients with surgically altered digestive tract anatomy and those who have ingested large blunt objects. In adults, the pylorus will allow passage of most blunt objects up to 25 mm in diameter, which includes all coins except half-dollars (30 mm) and silver dollars (38 mm). Otherwise, once in the stomach, a regular diet is appropriate, with radiographic monitoring every one to two weeks to confirm progression or elimination. If after three to four weeks a blunt object has not passed, endoscopic removal should be performed.⁹⁸

Disc batteries are now contained in many small toys and electronic devices that are accessible to young children. Disc battery ingestion is of particular concern because batteries contain an alkaline solution, which can cause rapid liquefaction necrosis in the esophagus. Disc battery ingestion occurs most commonly in younger children but as few as 10% will become symptomatic.⁹⁹ Therefore, any clinical suspicion of a disc battery in the esophagus should prompt emergent endoscopy. Grasping forceps and snares are generally ineffective for disc battery removal, but use of a retrieval net permits successful removal in almost 100% of cases.¹⁰⁰ Once in the stomach or small intestine, disc batteries rarely cause clinical problems and can be observed radiographically, with 85% passing through the GI tract within 72 hours.¹⁰¹

Small, brightly colored, coupling magnets have become popular as children’s toys. Ingested magnets within the reach of the endoscope should also be removed on an urgent basis. Although a single magnet will rarely be a cause of symptoms, concern exists if multiple magnets are ingested or if magnets were ingested with other metal objects. This can result in magnetic attraction and coupling between interposed loops of bowel with subsequent pressure necrosis, fistula formation, and bowel perforation.^102,¹⁰³ Removal should be performed urgently when the magnets are more likely to be within reach of a standard endoscope; this can be achieved with grasping forceps, retrieval net, or basket. Magnetic attraction to metallic retrieval devices may ease the task of removal.

Bread tabs or bread bag clips are another otherwise seemingly innocuous blunt object that when ingested (usually unknowingly) have been associated with a high risk for gastrointestinal tract complications.¹⁰⁴ Bread bag clips, introduced in the 1950s, are ubiquitous in developed societies. Bleeding, bowel obstruction, and perforation have all been described. The small bowel is the most common site of impaction, where the arms of the clip tenaciously grasp the mucosa. Esophageal and large bowel injury have also been described. Management is problematic in that ingestion is typically not detected until complications arise. Bread bag clips are radiolucent and, as such, are not detected by conventional radiography. When recognized at endoscopy, an attempt at removal is justified, using a gasping forceps; however, operative intervention is commonly required.

Narcotic Packets

Ingested packets of illicit narcotics in the GI tract present in two general groups, termed body stuffers and body packers. Body stuffers are drug users or traffickers who quickly ingest small amounts of drugs, but in poorly wrapped or contained packages that are prone to leakage. Body packers are the mules used by drug smugglers who ingest large quantities of carefully prepared packages intended to withstand GI transit.^105,¹⁰⁶ These patients may present with intestinal obstruction because of the packages or symptoms related to the drug ingested. The latter may result in serious toxicity and death in 5% of these mules.¹⁰⁷

Suspected patients are typically uncooperative and accompanied by law enforcement agents. Diagnosis is initiated with plain film radiology or CT scan, with multiple round or tube-shaped packets seen. Endoscopic removal is contraindicated because of the high risk of package perforation with resultant drug overdose.¹ Observation on a clear liquid diet is recommended. Operative intervention is indicated when bowel obstruction or drug leakage is suspected.

Colorectal Foreign Bodies

Ingested objects uncommonly become lodged in the colorectum. More commonly, colorectal foreign bodies were inserted into the rectum intentionally or unintentionally. Radiographs should be obtained prior to attempting removal of colorectal foreign bodies for better visualization of the location, orientation, and configuration of the object (Fig. 25-9). To avoid health care provider injury, attempts at manual removal or digital rectal examination should be deferred until the presence of a sharp or pointed object has been excluded.

Figure 25-9. A self-introduced rectal foreign body is apparent in a 73-year-old man presenting with lower abdominal pain.

(Courtesy of Dr. William Beaujohn, Plano, Tex.)

Manual digital extraction may be successful for the removal of small, blunt, palpable objects in the distal rectum. Conscious sedation may be adequate for manual removal in some patients, but examination and extraction under general anesthesia may be required in others to allow greater anal sphincter relaxation and successful object extraction.

Nonpalpable and sharp or pointed objects should be removed under direct visualization with the use of a rigid proctoscope or flexible sigmoidoscope.¹⁰⁸ Standard retrieval devices can be used as described earlier for the upper digestive tract. A latex hood or overtube can be particularly useful in removing long, sharp, pointed objects to protect the rectal mucosa from laceration and to overcome the tendency of the anal sphincter to contract on attempted removal of objects. Although conscious sedation will often facilitate removal, general anesthesia can allow maximum dilation of the anal sphincter to help remove larger and more complex objects.¹⁰⁹

Operative intervention is indicated for any suspected complications secondary to a rectal or colon foreign body, including perforation, abscess, and obstruction. Complications are more common when the object is proximal to the rectum.¹¹⁰

PROCEDURE-RELATED COMPLICATIONS

Although the reported complication rate associated with endoscopic removal of gastrointestinal foreign bodies and food impactions is low (0% to 1.8%), it is thought to be much higher in practice.^5,^9,^23,^24,^58,⁷⁸ Perforation is the most feared complication, although aspiration and sedation-related cardiopulmonary complications may also occur (see Chapter 40). Factors that increase the risk for complications include removal of sharp and pointed objects, an uncooperative patient, multiple and/or deliberate ingestion, and extended duration of time from food impaction or foreign body ingestion.¹²

BEZOARS

Bezoars are collections of indigestible material that accumulate in the gastrointestinal tract, most frequently in the stomach. The three most common types of bezoars encountered are phytobezoars, composed of vegetable matter; trichobezoars, made up of hair or hair-like fibers; and medication bezoars (pharmacobezoars) (Fig. 25-10; Table 25-2).

Figure 25-10. Endoscopic image of a pharmacobezoar in a patient with a history of a pancreaticoduodenectomy who had obstructive symptoms. The pills were removed with an endoscopic net, with subsequent relief of the patient’s symptoms.

Table 25-2 Oral Pharmacologic Agents Associated with Medication Bezoar Formation

Nonabsorbable antacids

Bulk laxatives

Cardiovascular medications

Nifedipine

Verapamil

Procainamide

Vitamins and minerals

Vitamin B₁₂

Enteral feeding formulations

Theophylline

Sodium polystyrene sulfonate (Kayexalate) resin

EPIDEMIOLOGY

Phytobezoars are the most common type of bezoar. Offending fruits and vegetables include celery, pumpkin, prunes, raisins, leeks, beets, and persimmon.⁵ All these foods contain large amounts of insoluble and indigestible fibers, such as cellulose, hemicellulose, lignin, and fruit tannin.¹¹¹ A phytobezoar develops when large quantities are ingested and accumulate.

Trichobezoars occur most commonly in young women and children from ingestion of large amounts of hair, carpet fiber, or clothing fiber. Trichobezoars are more often associated with psychiatric disorders, mental retardation, or pica.¹¹²

Medication bezoars occur with fiber-containing medications, resin-water products, or extended-release medications designed to resist digestion.¹¹³ Medication bezoars can result in decreased pharmacologic efficacy when the active agent is trapped in the bezoar and cannot be absorbed or, alternatively, increased toxicity when the contents of a large gastric medication bezoar are released all at once into the small intestine.

The vast majority of patients with bezoars (other than trichobezoars) have a predisposing factor that decreases emptying of gastric contents. Prior gastric surgery is evident in as many as 70% to 94% of patients with bezoars. Retained gastric contents may be observed in up to 65% to 80% of patients who have undergone a vagotomy with pyloroplasty.⁵² Bezoar formation after surgery results from delayed gastric emptying, decreased gastric accommodation, and reduced acid-peptic activity.¹¹⁴ Gastroparesis is commonly seen in patients with gastric bezoars. Patients with diabetes or end-stage renal disease, and patients on mechanical ventilation, are all at greater risk for bezoar formulation.¹¹⁵

CLINICAL FEATURES

Patients with gastric bezoars may be asymptomatic, but most (80%) have vague symptoms of epigastric discomfort.¹¹⁵ Associated anorexia, nausea, vomiting, weight loss, and early satiety may also be present. Bezoars can cause gastric ulceration secondary to pressure necrosis. Bezoar-induced gastric ulcers can cause bleeding and gastric outlet obstruction.¹¹⁶

Bezoars may also accumulate in the small bowel and usually present with mechanical obstruction. Rapunzel syndrome is a term used to describe trichobezoars located primarily in the stomach that extend past the pylorus and into the duodenum, causing bowel obstruction or even jaundice or pancreatitis because of obstruction at the level of the ampulla of Vater.^117,¹¹⁸

DIAGNOSIS

The history is helpful in the diagnosis of bezoar, with a focus on the amount and types of food or medications consumed. A history of previous bezoar, gastric surgery, or gastric dysmotility should be considered. Physical examination usually assists little in the diagnosis, although occasionally a palpable abdominal mass may be appreciated. Halitosis may be present because of the putrefying materials of the bezoar residing in the stomach. Baldness and a patchy hair pattern may be present in patients who suffer from trichotillomania; they are consistently ingesting their own hair.

A plain abdominal radiograph may demonstrate the outline of the bezoar. On contrast radiography, a gastric bezoar classically presents as filling defects within the stomach.¹¹¹ Plain films and contrast studies will detect only 25% of bezoars detected at upper endoscopy, however. Therefore, gastric bezoars are definitively diagnosed with upper endoscopy. On upper endoscopy, phytobezoars are a dark brown, green, or black mass of amorphous vegetable material in the stomach. Trichobezoars tend to have a hard, blackened, and almost concrete appearance. Medication bezoars will be seen as whole pills or pill fragments in the midst of the material (see Fig. 25-10).

TREATMENT

Smaller bezoars may be treated with conservative medical management; usually, this consists of a liquid diet for a short period of time and a prokinetic agent to promote gastric emptying.¹¹¹ Chemical dissolution, most commonly with cellulase, has been reported successful in up to 85% of patients with small bezoars.¹¹⁶ Cellulase can be taken as a tablet or instilled into the stomach as a liquid via an endoscope or nasogastric tube. Nasogastric lavage may aid in the physical dissolution of small bezoars.

For larger bezoars and bezoars resistant to medical therapy, endoscopic therapy may be effective. The endoscope is used to fragment the bezoar into smaller pieces. Fragmentation can be performed with the endoscope itself, with accessory devices such as forceps or snares, or with the instillation of saline or water flushes through the endoscope. The fragments of the bezoar can be pushed into the small bowel or removed by mouth. If most of the bezoar is to be removed, an overtube is recommended to facilitate frequent passes of the endoscope and to protect the airway. Mechanical disruption and endoscopic removal will be successful in 85% to 90% of gastric bezoars. Resistant gastric bezoars may be treated with mechanical lithotripsy, electrohydraulic lithotripsy, Nd:YAG laser, or a needle-knife sphincterotome.¹¹⁹^–¹²¹

Operative intervention may be needed if endoscopic therapy fails or if there is a complication related to the bezoar, such as a perforation, obstruction, or bleeding. Trichobezoars typically require surgery more often than phytobezoars. Gastric bezoars are usually removed via a small gastrostomy.^116,¹¹⁸ Small bowel bezoars are removed via an enterotomy or can be transmurally milked to the cecum, where they rarely cause a problem in the larger diameter colon. When operative intervention is contemplated, care must be made to exclude multiple bezoars in more than one location.

Preventing bezoar recurrence is as important as active treatment. If the underlying causes of bezoar formation are not corrected, recurrence is likely. Avoidance of high-fiber and other nondigestible foods should be followed. A starting dose of the enzymatic dissolution medication, cellulase, can be taken prophylactically by patients who have frequently recurring bezoars. Probiotics may be useful for patients with underlying motility disorders. In particularly refractory patients with recurring gastric bezoars, repeated periodic endoscopy with physical disruption of food material may prevent larger and clinically significant bezoar formation.

CAUSTIC INGESTIONS

EPIDEMIOLOGY

Approximately 5000 caustic ingestions are reported annually in the United States.¹²² Most caustic ingestions occur as accidental ingestions by children younger than 6 years.¹²³ Caustic ingestions in adults occur as suicide attempts, in patients with mental health problems, and in the intoxicated person as a result of alcohol or recreational drug ingestion. Adults may tend to have more serious injuries because of ingesting larger amounts of caustic substances as compared with children, who will spit out or throw up the caustic agent that was swallowed.

Broadly, two types of caustic agents are most commonly ingested, alkali agents or acidic agents. Alkali agents are most commonly household cleaners, including drain, toilet bowl, and oven cleaners. Lye ingestion is an alkali ingestion that contains sodium or potassium hydroxide. Alkali solutions are often odorless and tasteless, which can result in large amounts being swallowed accidentally. Finally, as noted, disc batteries may also cause alkali-induced damage.

Acid ingestion usually comes from swallowing toilet bowl cleaner, swimming pool cleaner, or battery acid. Acid ingestion often causes immediate pain, which results in the agent being rapidly expelled. Household bleach may contain both acid and alkali products, but rarely causes severe injury because of their diluted concentration.

PATHOPHYSIOLOGY

Alkali

Alkaline ingestion causes a liquefactive necrosis that very rapidly extends through the mucosa, submucosa, muscularis of the esophagus, and stomach.¹²⁴ Vascular thrombosis occurs following the necrosis. The initial alkali injury can be transmural and can result in perforation, mediastinitis, and peritonitis.¹²⁵ External sloughing and ulceration occur a few days after ingestion. Finally, extensive granulation tissue, fibroblastic activity, and collagen deposition occur over weeks, leading to chronic stricture formation (Fig. 25-11). With alkali ingestion, the esophagus is affected the most, with some limitation of damage in the stomach because of neutralization by acid; a minority of patients have damage in the small intestine as well.¹²⁶ The degree of injury is also dependent on the agent ingested, its quantity, and how long the GI tract was exposed to the agent.¹²⁷

Figure 25-11. Barium esophagogram showing a stricture in the upper esophagus, with narrowing of the midesophagus, several weeks after a caustic ingestion.

(Courtesy of Dr. Robert N. Berk, University of California, San Diego, Calif.)

Acid

Acidic agents cause a coagulative necrosis, with thromboses of mucosal blood vessels and a more limited superficial necrosis. Acidic agents are more apt to damage the stomach, particularly the antrum, more than the esophagus (Fig. 25-12). Furthermore, acidic agents tend to be ingested in a smaller quantity because of their offensive taste and immediate pain. Thus, acidic ingestions are associated with less overall damage compared with alkali agents.

Figure 25-12. Caustic injury to the esophagus and stomach by acid. A, After the ingestion of acid, the squamous mucosa of the esophagus has sloughed in a linear pattern. The esophageal mucosa is edematous and has a bluish discoloration. B, The gastric mucosa in this patient is hemorrhagic and edematous.

(From Wilcox MC: Atlas of Clinical Gastrointestinal Endoscopy. Philadelphia: WB Saunders; 1995. p 85.)

CLINICAL FEATURES

Patients may present with oropharyngeal pain, epigastric pain, chest pain, dysphagia, or odynophagia. Oropharyngeal involvement can cause sialorrhea and drooling. Hoarseness, stridor, and dyspnea suggest injury to the epiglottis, larynx, and upper airway. Persistent chest or back pain may suggest esophageal perforation and mediastinitis, whereas severe abdominal pain can be related to gastric perforation and peritonitis. Of importance is that early signs and symptoms do not always correlate with the amount of caustic injury and likelihood for late complications.¹²⁸ On physical examination, patients may have evidence of burns to the oral cavity with edema, ulceration, and exudate, but as many as 20% to 45% of patients will have normal physical examinations.¹²⁹

DIAGNOSIS

Radiologic images such as chest x-ray and abdominal films will not aid in the direct diagnosis or grading of severity of injury, but will indicate the presence of perforation by showing a pneumomediastinum, pneumothorax, or pneumoperitoneum. CT of the neck, chest, and/or abdomen should be considered when a high degree of suspicion remains for perforation, despite negative plain films. If perforation is present, surgery rather than endoscopy should be performed emergently (Fig. 25-13).

Figure 25-13. Algorithm for the approach to acute caustic injury. For the definitions of endoscopic grades of injury, see Table 25-3. EGD, esophagogastroduodenoscopy.

Given the fact that symptoms and the physical examination may not match the degree of injury after a caustic ingestion, an upper endoscopy examination should be performed in the first 24 to 48 hours after ingestion in patients without perforation.¹³⁰ An upper endoscopy allows diagnosis of injury to the GI tract, permits grading of the degree of injury, establishes a prognosis, and can guide therapy (see Fig. 25-13). It is important to note that up to 40% to 80% of patients with a reported caustic ingestion will have no evidence of injury on endoscopic examination.¹³¹

The degree of injury seen on endoscopic examination can be graded and provides prognostic information (Table 25-3). Grades I and IIA burns, which correspond to first- and second-degree burns, will usually heal without sequelae.¹²⁶ However, strictures will develop in 70% to 100% of patients with grade IIB injury, which causes circumferential ulceration, and grade III injury, with associated necrosis.¹³² Grade IV injury, with perforation, carries a mortality rate of up to 65% and requires urgent surgery.

Table 25-3 Endoscopic Grade of Caustic Injury

GRADE	ENDOSCOPIC FINDINGS
I	Edema and erythema
IIA	Hemorrhage, erosions, blisters, ulcers with exudate
IIB	Circumferential ulceration
III	Multiple deep ulcers with brown, black, or gray discoloration
IV	Perforation

TREATMENT

Initial management should address the ABCs of resuscitative management: airway, breathing, and circulation. Regional poison control should be contacted at 1-800-222-1222. Once initially stabilized, management is based on the clinical status of the patient and grade of injury seen on endoscopy. Asymptomatic patients who have a normal endoscopic examination or only grade I or IIA injury can be started on oral intake in the first 24 to 48 hours and usually discharged within that same time frame.

Clinically ill patients with hypotension, respiratory distress, and grade IIB (circumferential ulceration) or III necrosis on endoscopy should be admitted to an intensive care unit and managed with intravenous fluid resuscitation and close monitoring for evidence of perforation. Laryngoscopy should be performed in patients with respiratory distress. A patient with an edematous necrotic laryngopharynx should not undergo endotracheal intubation and will need a tracheotomy to maintain an airway.

Emergency surgery is required with esophagectomy or gastrectomy for perforation. Colonic interposition is sometimes required. Operator and institutional experience affects mortality and morbidity of emergent esophagogastrectomy and is best undertaken at referral centers when circumstances allow.¹³³

The need for and timing of operative intervention in patients with severe ulceration or necrosis without clear evidence of perforation remains controversial. Comparative analyses are difficult in this patient population. Some authorities have suggested that early operative exploration decreases mortality,¹³⁴ but others cite lower mortality rates and complete healing in patients with nonoperative supportive care.¹²⁷ As such, management must be considered on an individualized basis.

Inducing emesis or placing a nasogastric tube to clear or dilute the GI tract of the caustic agent is contraindicated because it may re-expose the esophagus, oropharynx, and airway to the caustic agent. Induced retching and vomiting may increase the risk of perforation. The use of neutralizing agents is not recommended because they have not been shown to be efficacious, may lead to increased thermal injury, and may also promote retching and emesis.¹³⁵ In addition, the routine use of glucocorticoids¹²⁴ and systemic antibiotics¹²² is not recommended.

LATE COMPLICATIONS

Up to one third of caustic ingestion patients will develop esophageal stricture after initial recovery (see Fig. 25-11). Stricture formation presents most commonly at two months after injury but can occur at any time from two weeks to many years after the initial injury.¹²⁶ Stricture formation occurs more commonly following more severe (grade IIB or III) injuries (see Table 25-3). The primary treatment of esophageal strictures secondary to caustic ingestion is frequent dilation. Endoscopic management of caustic strictures must be deliberate, with gradual and incremental progressive dilation to 15 mm or until symptom relief is obtained.¹³⁶ The perforation rate is 0.5% for endoscopic dilation of chronic caustic strictures and as many as 10% to 50% of patients will eventually require operative intervention. Esophageal resection with an esophagogastric anastomosis, esophagojejunostomy, or colonic interposition may be considered.¹³⁷ Case reports have described successful treatment with the use of temporary esophageal stents soon after caustic ingestion, but there is insufficient evidence to support recommendations for routine prophylactic stenting or for prophylactic early endoscopic dilation to prevent caustic-related strictures.¹³⁵

Antral and pyloric strictures may also occur after caustic injury (Fig. 25-14). Antral and pyloric stenoses will usually develop one to six weeks after caustic ingestion, but can also occur years later.¹²² The risk of antral stenosis is also related to the degree of injury. Endoscopic dilation with the addition of acid suppression is successful in many patients, but many others will require antrectomy.