Gastrointestinal Foreign Bodies in Emergency Medicine 

  • Author: David W Munter, MD, MBA; Chief Editor: Steven C Dronen, MD, FAAEM   more...
 
Updated: May 24, 2012
 

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 foreign body in the GI tract is shown in the radiograph below.

A screw in the stomach; peristaltic action will caA 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.

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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.

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Epidemiology

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, 7] 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 75-85% 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.[7] In contrast, adults are more prone to ingest food boluses, chicken or fish bones, fruit pits, dentures, or toothpicks.[8] 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).[8, 1, 7, 9, 10]
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Contributor Information and Disclosures
Author

David W Munter, MD, MBA  Associate Clinical Professor of Emergency Medicine, Eastern Virginia Medical School; Associate Professor of Emergency Medicine, Edward Via Virginia College of Osteopathic Medicine; Partner, Emergency Physicians of Tidewater, PLC; 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.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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.

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  Chair, Department of Emergency Medicine, LeConte 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.

References

  1. Stack LB, Munter DW. Foreign bodies in the gastrointestinal tract. Emerg Med Clin North Am. Aug 1996;14(3):493-521. [Medline].

  2. Ghimire A, Bhattarai M, Kumar M, Wakode PT. Descending necrotizing mediastinitis: a fatal complication of neglected esophageal foreign body. Kathmandu Univ Med J (KUMJ). Jan-Mar 2007;5(1):98-101. [Medline].

  3. Macchi V, Porzionato A, Bardini R, Parenti A, De Caro R. Rupture of ascending aorta secondary to esophageal perforation by fish bone. J Forensic Sci. Sep 2008;53(5):1181-4. [Medline].

  4. Kunishige H, Myojin K, Ishibashi Y, Ishii K, Kawasaki M, Oka J. Perforation of the esophagus by a fish bone leading to an infected pseudoaneurysm of the thoracic aorta. Gen Thorac Cardiovasc Surg. Aug 2008;56(8):427-9. [Medline].

  5. Balci AE, Eren S, Eren MN. Esophageal foreign bodies under cricopharyngeal level in children: an analysis of 1116 cases. Interact Cardiovasc Thorac Surg. Mar 2004;3(1):14-8. [Medline].

  6. Nadir A, Sahin E, Nadir I, Karadayi S, Kaptanoglu M. Esophageal foreign bodies: 177 cases. Dis Esophagus. Jan 2011;24(1):6-9. [Medline].

  7. Hurtado CW, Furuta GT, Kramer RE. Etiology of esophageal food impactions in children. J Pediatr Gastroenterol Nutr. Jan 2011;52(1):43-6. [Medline].

  8. Conway WC, Sugawa C, Ono H, Lucas CE. Upper GI foreign body: an adult urban emergency hospital experience. Surg Endosc. Mar 2007;21(3):455-60. Epub 2006 Nov 28. [Medline].

  9. Chinski A, Foltran F, Gregori D, Ballali S, Passali D, Bellussi L. Foreign Bodies in the Oesophagus: The Experience of the Buenos Aires Paediatric ORL Clinic. Int J Pediatr. 2010;2010:[Medline]. [Full Text].

  10. Baral BK, Joshi RR, Bhattarai BK, Sewal RB. Removal of coin from upper esophageal tract in children with Magill's forceps under propofol sedation. Nepal Med Coll J. Mar 2010;12(1):38-41. [Medline].

  11. Little DC, Shah SR, St Peter SD, Calkins CM, Morrow SE, Murphy JP, et al. Esophageal foreign bodies in the pediatric population: our first 500 cases. J Pediatr Surg. May 2006;41(5):914-8. [Medline].

  12. Louie JP, Alpern ER, Windreich RM. Witnessed and unwitnessed esophageal foreign bodies in children. Pediatr Emerg Care. Sept 2005;21(9):582-5. [Medline].

  13. Kim N, Atkinson N, Manicone P. Esophageal foreign body: a case of a neonate with stridor. Pediatr Emerg Care. Dec 2008;24(12):849-51. [Medline].

  14. Miller RS, Willging JP, Rutter MJ, Rookkapan K. Chronic esophageal foreign bodies in pediatric patients: a retrospective review. Int J Pediatr Otorhinolaryngol. Mar 2004;68(3):265-72. [Medline].

  15. Lee SC, Ebert CS Jr, Fordham L, Rose AS. Plain films in the evaluation of batteries as esophageal foreign bodies. Int J Pediatr Otorhinolaryngol. Oct 2008;72(10):1487-91. [Medline].

  16. Hergan K, Kofler K, Oser W. Drug smuggling by body packing: what radiologists should know about it. Eur Radiol. Apr 2004;14(4):736-42. Epub 2003 Oct 18. [Medline].

  17. Palme CE, Lowinger D, Petersen AJ. Fish bones at the cricopharyngeus: a comparison of plain-film radiology and computed tomography. Laryngoscope. Dec 1999;109(12):1955-8. [Medline].

  18. Eliashar R, Dano I, Dangoor E, Braverman I, Sichel JY. Computed tomography diagnosis of esophageal bone impaction: a prospective study. Ann Otol Rhinol Laryngol. Jul 1999;108(7 Pt 1):708-10. [Medline].

  19. Bassett KE, Schunk JE, Logan L. Localizing ingested coins with a metal detector. Am J Emerg Med. Jul 1999;17(4):338-41. [Medline].

  20. Chung CH, Fung WT. Detection of gastric drug packet by ultrasound scanning. Eur J Emerg Med. Oct 2006;13(5):302-3. [Medline].

  21. Lin HH, Lee SC, Chu HC, Chang WK, Chao YC, Hsieh TY. Emergency endoscopic management of dietary foreign bodies in the esophagus. Am J Emerg Med. Jul 2007;25(6):662-5. [Medline].

  22. Lin CH, Chen AC, Tsai JD, Wei SH, Hsueh KC, Lin WC. Endoscopic removal of foreign bodies in children. Kaohsiung J Med Sci. Sep 2007;23(9):447-52. [Medline].

  23. Pokharel R, Adhikari P, Bhusal CL, Guragain RP. Oesophageal foreign bodies in children. JNMA J Nepal Med Assoc. Oct-Dec 2008;47(172):186-8. [Medline].

  24. Lue AJ, Fang WD, Manolidis S. Use of plain radiography and computed tomography to identify fish bone foreign bodies. Otolaryngol Head Neck Surg. Oct 2000;123(4):435-8. [Medline].

  25. Litovitz T, Whitaker N, Clark L, White NC, Marsolek M. Emerging battery-ingestion hazard: clinical implications. Pediatrics. Jun 2010;125(6):1168-77. [Medline].

  26. Litovitz T, Whitaker N, Clark L. Preventing battery ingestions: an analysis of 8648 cases. Pediatrics. Jun 2010;125(6):1178-83. [Medline].

  27. Sharpe SJ, Rochette LM, Smith GA. Pediatric Battery-Related Emergency Department Visits in the United States,1999-2009. Pediatrics [serial online]. 5/14/2012;doi:10.1542:Accessed 5/14/2012. Available at http://pediatrics.aapublications.org/content/early/2012/05/09/peds.2011-0012.abstract.

  28. Waltzman ML. Management of esophageal coins. Curr Opin Pediatr. Oct 2006;18(5):571-4. [Medline].

  29. Calkins CM, Christians KK, Sell LL. Cost analysis in the management of esophageal coins: endoscopy versus bougienage. J Pediatr Surg. Mar 1999;34(3):412-4. [Medline].

  30. Bonadio WA, Jona JZ, Glicklich M, Cohen R. Esophageal bougienage technique for coin ingestion in children. J Pediatr Surg. Oct 1988;23(10):917-8. [Medline].

  31. Dashan AH, Kevin Donovan G. Bougienage versus endoscopy for esophageal coin removal in children. J Clin Gastroenterol. May-Jun 2007;41(5):454-6. [Medline].

  32. Cetinkursun S, Sayan A, Demirbag S, Surer I, Ozdemir T, Arikan A. Safe removal of upper esophageal coins by using Magill forceps: two centers' experience. Clin Pediatr (Phila). Jan-Feb 2006;45(1):71-3. [Medline].

  33. Bhargava R, Brown L. Esophageal coin removal by emergency physicians: a continuous quality improvement project incorporating rapid sequence intubation. CJEM. Jan 2011;13(1):28-33. [Medline].

  34. Al-Haddad M, Ward EM, Scolapio JS, Ferguson DD, Raimondo M. Glucagon for the relief of esophageal food impaction does it really work?. Dig Dis Sci. Nov 2006;51(11):1930-3. [Medline].

  35. Metha D, Attia M, Cronan K. Glucagon for esophageal coin dislodgement in children: a prospective, double-blind, placebo-controlled study. Acad Emerg Med. Feb 2001;8(2):200-3. [Medline].

  36. Conners GP. A literature-based comparison of three methods of pediatric esophageal coin removal. Pediatr Emerg Care. Apr 1997;13(2):154-7. [Medline].

  37. Arms JL, Mackenberg-Mohn MD, Bowen MV, Chamberlain MC, Skrypek TM, Madhok M, et al. Safety and efficacy of a protocol using bougienage or endoscopy for the management of coins acutely lodged in the esophagus: a large case series. Ann Emerg Med. Apr 2008;51(4):367-72. [Medline].

  38. Conners GP, Chamberlain JM, Ochsenschlager DW. Conservative management of pediatric distal esophageal coins. J Emerg Med. Nov-Dec 1996;14(6):723-6. [Medline].

  39. Soprano JV, Fleisher GR, Mandl KD. The spontaneous passage of esophageal coins in children. Arch Pediatr Adolesc Med. Oct 1999;153(10):1073-6. [Medline].

  40. Conners GP, Chamberlain JM, Ochsenschlager DW. Symptoms and spontaneous passage of esophageal coins. Arch Pediatr Adolesc Med. Jan 1995;149(1):36-9. [Medline].

  41. Weiland ST, Schurr MJ. Conservative treatment of ingested foreign bodies. J Gastrointest Surg. May-Jun 2002;6(3):496-500. [Medline].

  42. Durko A, Czkwianianc E, Bak-Romaniszyn L, Malecka-Panas E. [Accidental ingestion of two magnets--aggresive or prolonged approach?]. Pol Merkur Lekarski. May 2007;22(131):416-8. [Medline].

  43. Baliga SK, Hussain D, Sarfraz SL, Hartung RU. Magnetic attraction: dual complications in a single case. J Coll Physicians Surg Pak. Jul 2008;18(7):440-1. [Medline].

  44. Cortes C, Silva C. [Accidental ingestion of magnets in children. Report of three cases]. Rev Med Chil. Oct 2006;134(10):1315-9. [Medline].

  45. Hou SK, Chern CH, How CK, Wang LM, Huang CI, Lee CH. Press through package mis-swallowing. Int J Clin Pract. Feb 2006;60(2):234-7. [Medline].

  46. Lee KI, Wang CP. Images in emergency medicine. Press-through package mis-swallowing. Ann Emerg Med. Aug 2008;52(2):98, 115. [Medline].

  47. Butterworth JR, Wright K, Boulton RA, Pathmakanthan S, Goh J. Management of swallowed razor blades-retrieve or wait and see?. Gut. Apr 2004;53(4):477, 486. [Medline].

 
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Coin (quarter) lodged at the level of the cricopharyngeus muscle.
Coin lodged at the level of the aortic crossover.
Coin lodged at the lower esophageal sphincter.
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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