eMedicine Specialties > Emergency Medicine > Gastrointestinal

Foreign Bodies, Gastrointestinal

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

Introduction

Background

Patients with foreign bodies in the gastrointestinal (GI) tract commonly present to the ED. Foreign bodies in the upper GI tract are usually swallowed, purposefully or accidentally. The presentation is usually straightforward but may be extremely subtle. 
 

A screw in the stomach; peristaltic action will c...

A screw in the stomach; peristaltic action will carry the screw through the GI tract with the blunt end (head) leading and the sharp end trailing.

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A screw in the stomach; peristaltic action will c...

A screw in the stomach; peristaltic action will carry the screw through the GI tract with the blunt end (head) leading and the sharp end trailing.


Most of the literature covering GI foreign bodies is anecdotal, with the exception of some recent studies on esophageal foreign body removal techniques.

Pathophysiology

Foreign bodies may involve the entire upper GI tract. The oropharynx is well innervated, and patients can typically localize oropharyngeal foreign bodies. Scratches or abrasions to the mucosal surface of the oropharynx can create a foreign body sensation. Chronic foreign bodies or perforations can cause infections in surrounding soft tissues of the throat and neck.

The esophagus is a tubular structure approximately 20-25 cm in length. Patients can usually localize foreign bodies in the upper esophagus but localize them poorly in the lower two thirds of the structure. The esophagus has 3 areas of narrowing where foreign bodies are most likely to become entrapped: the upper esophageal sphincter (UES), which consists of the cricopharyngeus muscle; the crossover of the aorta; and the lower esophageal sphincter (LES). Structural abnormalities of the esophagus, including strictures, webs, diverticula, and malignancies, increase the risk of foreign body entrapment, as do motor disturbances such as scleroderma, diffuse esophageal spasm, or achalasia.

After reaching the stomach, a foreign body has greater than a 90% chance of passage. Coins reaching the stomach are very likely to pass into the small bowel. Objects larger than 2 cm in diameter are less likely to pass the pylorus, and objects longer than 6 cm may become entrapped at either the pylorus or the duodenal sweep. Objects reaching the small bowel occasionally are impeded by the ileocecal valve. Rarely, a foreign body may become entrapped in a Meckel diverticulum.

Frequency

United States

The incidence of foreign body ingestions in children and adults is unknown. Data are largely anecdotal.

Mortality/Morbidity

An estimated 1500 deaths occur annually from foreign bodies in the upper GI tract.1

  • Potential complications of oropharyngeal foreign bodies include abrasions, lacerations, and punctures, with associated abscesses, perforations, and soft-tissue infections.
  • Esophageal foreign bodies can also cause abrasions, punctures, and perforations, with resultant injuries or infections to surrounding structures, including abscesses, pneumomediastinum or mediastinitis;2 pneumothorax, pericarditis or tamponade, fistulas, or even vascular injuries to the aorta;3 or pulmonary vasculature.4 Additionally, button batteries can rapidly create esophageal necrosis.
  • Complications from foreign bodies in the stomach and small intestine typically involve perforation and associated infection, including peritonitis.

Race

No differences in race or nationality have been noted.

Sex

In children with swallowed foreign bodies, the incidence in males and females is equal.5,6 In adults, the incidence of accidentally swallowed foreign bodies is slightly higher in men than in women, and the incidence of intentionally swallowed foreign bodies is much higher in men than in women.

Age

Patients with foreign bodies in the upper GI tract usually fall into 1 of 3 categories: (1) children, (2) psychiatric patients and prisoners, and (3) edentulous patients.

  • Children account for 75-80% of patients with foreign bodies in the upper GI tract, with a preponderance at age 18-48 months.
  • The objects involved also differ by group. Children typically ingest objects they pick up and place in their mouths, such as coins, buttons, marbles, crayons, and similar items.6 In contrast, adults are more prone to ingest food boluses, chicken or fish bones, fruit pits, dentures, or toothpicks.7 Prisoners and psychiatric patients may present with bizarre objects, as well as multiple objects.
  • The site of entrapment of esophageal foreign bodies also differs with age groups, with about 75% of children having entrapment at the upper esophageal sphincter (UES) and about 70% of adults having entrapment at the lower esophageal sphincter (LES).6,7,1

Clinical

History

  • Oropharyngeal foreign bodies
    • Patients with oropharyngeal foreign bodies normally present with a foreign body sensation, especially after eating chicken or fish, although a variety of other objects, including toothpicks, may be involved.
    • They may have variable degrees of discomfort, from minor to more severe.
    • Patients may complain of inability to swallow or handle secretions.
    • Rarely, patients may have airway compromise, typically in delayed presentations with subsequent infection or perforation.
    • Patients can usually localize the foreign body sensation in the oropharynx.
  • Esophageal foreign bodies
    • Adults with esophageal foreign bodies usually present acutely, with a history of ingestion. A foreign body sensation or vague discomfort in the epigastrium suggests that the foreign body is entrapped at the LES.
    • Dysphagia is the norm in adults. If the obstruction is complete, an inability to handle secretions is common. The classic adult presentation is the person with dentures who has had some alcohol and is eating meat. Incomplete chewing leads to an impaction at the LES. Adults should be asked about the use of dentures, alcohol intake, and circumstances surrounding the ingestion.
    • In children with esophageal foreign bodies, the history may be less clear.8 As many as 35% of children with esophageal foreign bodies are asymptomatic; the history is given by a parent who has seen the child with an object in his or her mouth and suspects the child might have swallowed it. Such reports must be taken seriously and investigated.9 Gagging, vomiting, and neck or throat pain are common presentations. Children with chronic esophageal foreign bodies may also present with poor feeding; irritability; failure to thrive; fever; stridor;10 or pulmonary symptoms, such as repetitive pneumonias from aspiration.11 Large esophageal foreign bodies at the UES can cause tracheal impingement in children, with resultant stridor or respiratory compromise.
  • Stomach/small intestine foreign bodies
    • Patients with foreign bodies in the stomach or small intestine may present with a history of swallowing an object, which has passed through the esophagus.
    • Patients may present with vague symptoms such as fever, abdominal pain, or vomiting.

Physical

  • The physical examination typically is not helpful, but the oropharynx, neck, chest, lungs, heart, and abdomen should be carefully examined.
  • Occasionally, a foreign body in the oropharynx can be visualized and removed. In cooperative patients, indirect laryngoscopy or fiberoptic nasopharyngoscopy provides better information than a direct examination.
  • In children, tracheal compression and stridor suggest a large foreign body at the UES.
  • Complete obstructions can cause drooling and the inability to swallow.
  • Delayed presentations may be accompanied by signs of infection, including peritonitis.

Causes

The most common causes of GI foreign bodies are food boluses and accidental swallowing of other objects.

  • Young children often put any object they find into their mouths and may accidentally swallow them.
  • Although less common, older children also put smooth objects, such as coins or marbles, in their mouths and swallow them. However, the larger diameter esophagus in this age group results in fewer entrapped foreign bodies compared to young children.
  • Children who are abused may present with GI foreign bodies after being forced to swallow objects; however, this is rare.
  • The most common cause of GI foreign bodies in adults involves food that does not pass through the esophagus because of underlying mechanical problems.
  • In adults, accidental swallowing often involves toothpicks and dentures.
  • Psychiatric patients may swallow a wide variety of objects, including multiple objects, large objects, and bizarre items.
  • Prisoners may swallow objects either to hide them from authorities or to seek medical care. In the case of razor blades, they often tape the sharp edge to avoid injury.
  • Drug smugglers may swallow multiple condoms (usually double wrapped) filled with cocaine or heroin. This is called "body packing," as opposed to "stuffing," which occurs when the patient attempts to elude arrest by swallowing packets of drugs in their possession.

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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