eMedicine Specialties > Emergency Medicine > Gastrointestinal

Foreign Bodies, Gastrointestinal: Differential Diagnoses & Workup

Author: David W Munter, MD, MBA, Assistant Clinical Professor of Emergency Medicine, Eastern Virginia Medical School; Medical Director, Emergency Medical Department, Sentara Obici Hospital; Partner, Emergency Physicians of Tidewater, LPC; President of the DESA Consulting Group
Contributor Information and Disclosures

Updated: Nov 3, 2009

Differential Diagnoses

Disk Battery Ingestion
Obstruction, Small Bowel
Esophageal Perforation, Rupture and Tears
Pediatrics, Foreign Body Ingestion
Foreign Bodies, Rectum
Pediatrics, Gastrointestinal Bleeding
Foreign Bodies, Trachea
Retropharyngeal Abscess
Mediastinitis

Other Problems to Be Considered

Dysphagia
Esophageal carcinoma
Esophageal stricture
Failure to thrive
Intestinal perforation
Odynophagia
Peritonitis
Pneumomediastinum

Workup

Laboratory Studies

  • Most patients with GI foreign bodies do not require any laboratory studies. Exceptions are patients who present with signs and symptoms consistent with infection or complications, in which case a CBC may be indicated, and patients who require preoperative studies.

Imaging Studies

  • Radiography
    • Plain radiographs are indicated for every patient with a known or suspected radiopaque foreign body in the oropharynx, esophagus, stomach, or small intestine. Plain radiographs are also mandated for children in whom any ingestion of a radiopaque foreign body is suspected. Keep in mind, however, that in cases of nonradiopaque foreign bodies, imaging studies rarely have any influence on management, except in delaying endoscopy or CT scanning.
    • In small children, a mouth-to-anus radiograph can be obtained. In older children and adults, posteroanterior (PA) and lateral chest radiographs provide better localization.
    • Radiopaque objects are easily seen and localized on the radiograph.
    • Plain radiographs typically have been used in patients who have swallowed bones, although the yield is low, with only 20-50% of endoscopically proven bones visible on plain radiographs. Xeroradiography does not increase this yield.
    • Coins are usually seen in a coronal alignment on anteroposterior (AP), or frontal, radiographs (see Media files 1-3).


Coin (quarter) lodged at the level of the cricoph...

Coin (quarter) lodged at the level of the cricopharyngeus muscle.

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Coin (quarter) lodged at the level of the cricoph...

Coin (quarter) lodged at the level of the cricopharyngeus muscle.



Coin lodged at the level of the aortic crossover.

Coin lodged at the level of the aortic crossover.

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Coin lodged at the level of the aortic crossover.

Coin lodged at the level of the aortic crossover.



Coin lodged at the lower esophageal sphincter.

Coin lodged at the lower esophageal sphincter.

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Coin lodged at the lower esophageal sphincter.

Coin lodged at the lower esophageal sphincter.

    • Button batteries can usually be differentiated from coins on plain films.12
    • If the foreign body is in the trachea, it presents in a sagittal orientation because the tracheal rings are incomplete in the posterior aspect.
    • In adults with food impactions, a plain radiograph may be indicated to search for imbedded bony fragments if techniques, such as LES-relaxing agents or bougienage, are being considered. If endoscopy is used to treat the patient, plain radiographs are not indicated.
    • Drug packets typically have a characteristic appearance on plain films.13
  • Barium or Gastrografin swallow
    • Barium swallow may be indicated in cases of ingestion of nonopaque foreign bodies, such as toothpicks or aluminum soda can tabs, although CT scanning is a much better imaging modality and should be used as the first choice when available.
    • A barium or Gastrografin swallow, without cotton balls, can sometimes outline the foreign body, but, again, the yield is very low.
    • Barium swallow can be used for food impactions; however, most authorities believe that it adds nothing to the evaluation and delays definitive treatment.
    • Contrast studies are not useful in detecting foreign bodies in the stomach or small intestine.
    • Barium is contraindicated in cases in which esophageal perforation is suspected. Gastrografin may be used if a study is needed.
  • CT scanning
    • In one study, CT scanning was superior to plain radiographs for localization and identification of foreign bodies in 83-100% of cases. CT scanning is highly reliable in localizing foreign bodies in the esophagus.14,15
    • CT scanning is now considered the imaging modality of choice to locate nonradiopaque foreign objects in the oropharynx or esophagus. However, the application is probably unwarranted in every case of acute bone dysphagia, as only a minority (17-25%) of patients who sense a foreign body after eating chicken or fish has a bone present.
    • CT scanning is also the imaging modality of choice in cases of suspected perforation or abscess.
  • Metal detectors: Handheld metal detectors have been shown to be accurate in determining if a coin has been swallowed and may be a useful noninvasive screening tool in children with a suspected coin ingestion. However, the specificity of localization is poor, especially in differentiating LES impaction from coins in the stomach.16
  • Ultrasound: This may be useful in detecting ingested drug packets.17

Procedures

  • Endoscopy
    • Emergent endoscopy is indicated for patients whose airway is compromised or who show signs of complications.
    • Urgent endoscopy is indicated for patients who have swallowed aluminum soda can tabs or toothpicks, since these objects are not visible on plain radiographs and both have a relatively high incidence of complications. If the history is clear, proceed to endoscopy; if unclear, CT scanning may be used to confirm the presence of the foreign body before endoscopy.
    • Endoscopy is absolutely indicated for foreign bodies that are sharp, nonradiopaque, or elongated; for multiple foreign bodies; or for possible esophageal injuries.
    • Endoscopy is the most commonly used technique for active management of impacted esophageal foreign bodies. Endoscopy has been traditionally used for the visualization of the esophagus and the removal of foreign bodies.18
    • Endoscopy is indicated for patients with foreign bodies in the stomach or proximal duodenum if the foreign bodies are larger than 2 cm in diameter or longer than 5-7 cm or for oddly shaped foreign bodies such as open safety pins.
    • Endoscopy is safe and effective but relatively expensive.5,19,20

More on Foreign Bodies, Gastrointestinal

Overview: Foreign Bodies, Gastrointestinal
Differential Diagnoses & Workup: Foreign Bodies, Gastrointestinal
Treatment & Medication: Foreign Bodies, Gastrointestinal
Follow-up: Foreign Bodies, Gastrointestinal
Multimedia: Foreign Bodies, Gastrointestinal
References
Further Reading
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References

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Further Reading

Digoy GP: Diagnosis and management of upper aerodigestive tract foreign bodies. Otolaryngol Clin North Am. 2008 Jun; 41(3):485-96, vii-viii.

Munter DW, Heffner AC: Esophageal foreign bodies. Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine, 4th Ed. Saunders: Philadelphia, PA;  2004: 775-793.

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Keywords

gastrointestinal foreign bodies, GI foreign bodies, swallowed object, esophageal foreign bodies, swallowed foreign bodies, oropharyngeal foreign bodies, chalasia, button battery ingestion, foreign body sensation, dysphagia, small intestine foreign bodies, swallowed coin, swallowed toothpick, impacted esophageal foreign bodies, radiopaque foreign objects

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Contributor Information and Disclosures

Author

David W Munter, MD, MBA, Assistant Clinical Professor of Emergency Medicine, Eastern Virginia Medical School; Medical Director, Emergency Medical Department, Sentara Obici Hospital; Partner, Emergency Physicians of Tidewater, LPC; President of the DESA Consulting Group
David W Munter, MD, MBA is a member of the following medical societies: American College of Emergency Physicians, American College of Physician Executives, Medical Society of Virginia, and Norfolk Academy of Medicine
Disclosure: Nothing to disclose.

Medical Editor

Jerry Balentine, DO, Professor of Emergency Medicine, New York College of Osteopathic Medicine; Executive Vice President, Chief Medical Officer, Attending Physician in Department of Emergency Medicine, St. Barnabas Hospital
Jerry Balentine, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American College of Physician Executives, American Osteopathic Association, and New York Academy of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eugene Hardin, MD, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier Medical Center
Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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