eMedicine Specialties > Emergency Medicine > Gastrointestinal

Foreign Bodies, Gastrointestinal

Author: David W Munter, MD, MBA, Assistant Clinical Professor of Emergency Medicine, Medical Director and Chair, DePaul University Medical Center; Partner, Emergency Physicians of Tidewater, LPC; President of the DESA Consulting Group
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Updated: Jul 19, 2007

Introduction

Background

People with foreign bodies in the gastrointestinal (GI) tract commonly present to the ED for evaluation. Foreign bodies in the upper GI tract are usually swallowed, purposefully or accidentally.

Presentations of patients with GI foreign bodies can range from the patient in extremis to the patient with subtle or chronic findings without a clear history. Most of the literature covering GI foreign bodies is anecdotal, with the exception of some recent studies on esophageal foreign body removal techniques.

Pathophysiology

The entire GI tract can be involved. 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: the upper esophageal sphincter (UES), which consists of the cricopharyngeus muscle; the crossover of the aorta; and the lower esophageal sphincter (LES). These areas are where most esophageal foreign bodies become entrapped. 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.

Once a foreign body has reached the stomach, it has greater than a 90% chance of passage. Once coins reach the stomach, they have virtually a 100% chance of passage. Objects longer than 6 cm may become entrapped by either the pylorus or the duodenal sweep, and objects larger than 2 cm in diameter also may fail to pass the pylorus. When a foreign body has reached the small bowel, the only structural impediment to passage is the ileocecal valve. Rarely, a foreign body may become entrapped in a Meckel diverticulum.

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, pneumothorax, pericarditis or tamponade, fistulas, or even vascular injuries to the aorta or pulmonary vasculature. 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.

Sex

In children with swallowed foreign bodies, the incidence in males and females is equal. 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. In contrast, adults are more prone to ingest food boluses, chicken or fish bones, fruit pits, dentures, or toothpicks. Prisoners and psychiatric patients may present with bizarre objects, including multiple objects.
• The site of entrapment of esophageal foreign bodies also differs with age groups, with about 75% of children having entrapment at the UES and about 70% of adults having entrapment at the LES.

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, such as drooling or an inability to swallow.
  • 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. 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. 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; or pulmonary symptoms, such as repetitive pneumonias from aspiration. 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 typical cause of swallowed GI foreign bodies is accidental.

• Young children often put any object they find into their mouths and may accidentally swallow them.
• Older children also put smooth objects, such as coins or marbles, in their mouths and may swallow them. However, because their esophagi are greater in diameter than those of young children, foreign body lodgment in this location is less common in older 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 involves toothpicks, dentures, and other objects.
• 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.
• People who smuggle drugs 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.

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