Birk M, Bauerfeind P, Deprez PH, et al. Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016 May;48(5):489-96. doi: 10.1055/s-0042-100456. Epub 2016 Feb 10. PMID: 26862844.
Definition, Etiology, PathogenesisTop
Ingestion of foreign bodies into the gastrointestinal (GI) tract is most frequently observed in children. A frequent reason for intervention in adults is food lodgment in the esophagus, which mostly occurs secondary to postinflammatory stricture, eosinophilic esophagitis, or esophageal tumor (cancer). Less common causes include esophageal diverticula (including Zenker diverticulum), Schatzki ring, and postoperative complications (eg, anastomotic stricture in patients after partial esophagectomy or gastrectomy), radiotherapy, as well as central nervous system diseases associated with dysphagia.
Esophageal foreign body is almost always symptomatic (dysphagia, odynophagia, retrosternal pain, sensation of esophageal obstruction, nausea, and vomiting). Respiratory manifestations such as choking, dyspnea, or stridor develop because of salivary aspiration or when the foreign body is pressing against the trachea. Inability to swallow saliva indicates complete obstruction of the esophageal lumen.
Foreign bodies distal to the esophagus are usually asymptomatic and pass spontaneously.
Sharp foreign bodies (poultry or fish bones) may lead to GI perforation, which manifests with fever, tachycardia, signs of peritoneal irritation, subcutaneous emphysema, and edema of the neck.
History should include asking about the time of the incident and type of material ingested.
1. Radiography: Boneless food boluses do not require radiologic assessment. For other foreign bodies perform a neck, chest, and/or abdominal radiograph, preferably in 2 projections (anterior and lateral). Plain radiographs have limited sensitivity (~50% of false-negative results), primarily due to poor absorption of x-rays by a number of foreign bodies, such as wood, plastic, or glass. Barium swallow is to be avoided due to the risk of aspiration and impaired visualization during the subsequent endoscopic procedure.
2. Computed tomography is indicated in patients with suspected severe complications, such as perforation.
3. Endoscopy is the main diagnostic modality for esophageal obstruction and is performed to confirm the presence of the foreign body and as an initial therapeutic procedure. For esophageal lodgment of a food bolus with no identifiable organic cause, biopsy specimens are collected for histologic examination to exclude eosinophilic esophagitis.
In the case of small, blunt, asymptomatic objects (except batteries and magnets) located below the esophagus, monitoring is sufficient (in most cases they pass spontaneously within 4 to 6 days after reaching the stomach). Patients could be discharged and instructed to be aware of perforation or obstruction signs and to observe the stool. If asymptomatic, weekly plain abdominal radiographs are sufficient to assess passage of the foreign body in the GI tract. If the material is still present in the stomach after 3 to 4 weeks, endoscopic intervention is indicated. Pharmacotherapy is of limited use and should not delay endoscopic or surgical treatment. There are limited reports of effective dislodgement of esophageal foreign bodies using glucagon.
Ten to 20% of patients require endoscopic treatment. The time of endoscopic intervention depends on the type and location of the foreign body in the GI tract:
1) Emergency intervention (according to the European Society of Gastrointestinal Endoscopy [ESGE] guidelines, within 2-6 h): Sharp-pointed foreign bodies and batteries in the esophagus, as well as foreign bodies that cause complete esophageal obstruction.
2) Urgent intervention (within 24 h): Small, blunt foreign bodies in the esophagus, as well as magnets, batteries, and sharp-pointed or long objects (>5-6 cm) in the stomach (risk of impaction in duodenal flexures).
3) Elective intervention (within 72 h): Medium-sized foreign bodies in the stomach (>2-2.5 cm in diameter [risk of impaction in the pylorus or ileocecal valve] and <5-6 cm in length).
If endoscopic removal of a sharp-pointed object or battery is unsuccessful, the ESGE guidelines recommend inpatient observation with radiographic imaging performed daily for sharp-pointed objects and every 3 to 4 days for batteries beyond the duodenum. Surgery should be considered if these objects have passed the ligament of Treitz and have not progressed within 3 days after ingestion.
For esophageal impaction of a food bolus, it is enough to gently push the bolus into the stomach with the endoscope. Otherwise treatment involves trapping of the foreign body with appropriate instruments (forceps, snares, retrieval net, Dormia basket) and its extraction from the GI tract. The use of additional accessories, such as overtubes or latex protector hoods fitted over the end of the endoscope, is recommended in order to protect airways and esophageal walls against injury. Where the risk of aspiration is high, endotracheal intubation should be considered prior to endoscopic intervention.
Surgical treatment is needed in ~1% of cases, mainly after unsuccessful endoscopic treatment. Long objects lodged in the duodenum that have failed endoscopic removal need surgical therapy. Indications for emergency surgery include perforation of the GI tract, bleeding that cannot be controlled by endoscopy, and obstruction of the small intestine by the impacted foreign body.