eMedicine Specialties > Emergency Medicine > Gastrointestinal

Foreign Bodies, Gastrointestinal

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

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 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.

Differential Diagnoses

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 cricopharyngeus muscle.

Coin lodged at the level of the aortic crossover.

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

Treatment

Prehospital Care

The patient should be transported in a comfortable position. Patients with airway compromise may need acute airway management. Patients unable to tolerate secretions are often most comfortable in the sitting position. A suction catheter should be provided to assist in handling secretions.

Emergency Department Care

The treatment of patients with suspected radiopaque foreign bodies is usually straightforward because these can be easily localized on plain radiographs.

For nonradiopaque foreign objects, plain radiographs are not helpful. Studies such as barium swallows or CT scanning may help to confirm or localize a foreign body, but often they only delay definitive care.

In cases involving suspected oropharyngeal foreign bodies, which usually present with a foreign body sensation, the evaluation and treatment is complicated by the fact that the physical examination is usually unhelpful; only a minority (26% in one study) of patients have any pathology at all as seen on endoscopy, and imaging studies are either unhelpful (plain radiography or barium swallow) or expensive (CT scanning).²¹

Because of the broad range of presentations of GI foreign bodies, a tiered approach is appropriate.

• Patients in an unstable condition
  • Patients with airway compromise; drooling; inability to tolerate fluids; or evidence of sepsis, perforation, or active bleeding are considered to be in an unstable condition.
  • Treatment includes airway management as indicated, followed by urgent endoscopy (see Procedures).
  • Patients who have ingested button batteries are considered to be in an unstable condition. The presence of a button battery in the esophagus is a medical emergency because necrosis of the esophageal wall may occur within hours. These button batteries must be expeditiously removed. Button batteries in the stomach can be allowed to pass but must be monitored radiographically to observe for disruption of the battery. Follow-up radiographs are needed in 24-48 hours. If the battery is still in the stomach, endoscopic removal is indicated.
  • Patients who are drooling may be more comfortable holding a suction catheter and using it as needed.
• Patients in a stable condition
  • For patients complaining of an oropharyngeal foreign body sensation, perform direct and indirect oropharyngeal examination or fiberoptic nasopharyngoscopy, if available; ENT consultation may be required to assist in removing any visualized foreign bodies.
  • Radiographically localize radiopaque objects. If the foreign body is sharp, elongated (>5 cm in esophagus, >6 cm in stomach or small intestine), or multiple in number, refer for endoscopy. Sharp objects, such as pins, razor blades, toothpicks, and chicken bones, should be removed endoscopically on an urgent basis because up to 35% of these sharp objects perforate the bowel wall if not removed. Most smaller, sharp foreign bodies, such as straight pins, transit the GI tract without difficulty, as the peristaltic action carries the blunt end first (see Media file 4); however, many authorities recommend endoscopic removal for these as well. If the foreign body is smooth or blunt, consider the following modalities (endoscopy is discussed in Procedures; the other 3 techniques are discussed in detail below):
    • Endoscopy (see Procedures)
    • Foley catheter removal
    • Bougienage
    • Sphincter relaxation if lodged at LES
  • For patients whose history strongly suggests an ingestion of a nonopaque foreign body such as a plastic object, toothpick, or aluminum soda can tab, consider CT scanning and refer for endoscopy. When the history is less clear about the definitive swallowing of a nonradiopaque foreign body, obtain CT scanning and refer for endoscopy if the foreign body is localized in the oropharynx or esophagus.
  • Button batteries in the stomach can be allowed to pass but must be followed radiographically to observe for disruption of the battery. Follow-up radiographs are needed in 24-48 hours. If the battery is still in the stomach, endoscopic removal is indicated.
  • Smooth foreign bodies, such as coins or marbles, almost always transit the GI tract without any difficulties. Coins lodged in the distal esophagus of healthy children spontaneously pass into the stomach in up to 60-80% of cases, usually within several hours of presentation.²²
  • Note that the use of meat tenderizer is contraindicated in patients with food boluses at the LES, as meat tenderizer may cause necrosis of the esophagus.
  • People who body pack, those who ingest carefully wrapped packets of drugs, such as heroin or cocaine, should be admitted for observation. Whole-bowel irrigation is frequently used to aid passage. Endoscopy is generally avoided because instrumentation of the packets may result in rupture.
• Foley catheter removal
  • Foley catheter removal is another widely used technique for the removal of single, smooth, blunt, radiopaque foreign bodies.
  • Foley catheter removal is contraindicated in patients with foreign bodies that have been present for more than 72 hours, those with a history of esophageal disease or surgery, those who are experiencing respiratory distress, and those who are uncooperative.
  • This procedure is performed under fluoroscopy with immediate availability of emergency airway equipment and personnel capable of emergency airway management.
  • In this procedure, the patient is placed in a head-down position, and a #12-#16 Foley catheter is passed orally past the foreign object under fluoroscopic guidance. The balloon is inflated, and the catheter is pulled out with the foreign body. The success rate for this procedure has been reported as 85-100%. Complications, including epistaxis, dislodgment of the foreign body into the nose, laryngospasm, hypoxia, and aspiration, have been reported at rates of 0-2%.
  • Foley catheter removal should be attempted only by those familiar with its use. Until ED personnel become comfortable with this procedure, it should be performed under controlled conditions with immediate backup available for complications.
• Bougienage
  • Smooth esophageal foreign bodies, such as coins, lodged at the LES in children have been advanced successfully into the stomach by using bougienage.
  • Indications for this procedure are a smooth foreign body, lodged less than 24 hours, with no underlying esophageal disease or respiratory distress.
  • Dilator size is selected according to the patient's age; the dilator is advanced gently through the mouth and esophagus to the stomach with the child in a sitting position, essentially in the same manner as is used in passing a nasogastric tube. Often, topical anesthesia is used for the oropharynx.
  • A repeat radiograph is used to confirm passage into the stomach.
  • Published success rates for this procedure are 83-100%, and complication rates in limited studies are 0%.^23,24,25
• Relaxation of the lower esophageal sphincter
  • Foreign bodies lodged at the LES can be managed by relaxation of the LES, although in some studies, success rates associated with this technique are no greater than those associated with watchful waiting.
  • Typically, glucagon is used, with or without a gas-forming compound. The patient is administered 1-2 mg of glucagon intravenously (0.02-0.03 mg/kg in children, not to exceed 0.5 mg) followed by ingestion of E-Z Gas mixed with 240 mL of water. The use of carbonated beverages if E-Z Gas is not available in the ED has been reported.
  • The published success rates for this procedure range from 12-50%,²⁶ which may not be any better than spontaneous passage with no interventions, especially with coin ingestions in children.²⁷
  • Nitrates, such as sublingual nitroglycerin and nifedipine, have been used less widely; a risk involved with this procedure is creating significant hypotension in the patient.
  • This procedure does not work in patients with structural abnormalities.
• Cost is always a consideration when selecting a procedure. In one study, endoscopy averaged $2700; Foley catheter removal, $660; and bougienage, $614.²⁸ In another study, the average cost of endoscopy was $6087, whereas that of bougienage was $1884.²⁹
• If the workup is negative for a foreign object, discharge the patient with analgesics as needed and refer for follow-up in 24 hours. If the patient is still symptomatic at recheck, refer for endoscopy.
• Esophageal coins: Four generally broadly accepted approaches to management of esophageal coins in children are as follows: endoscopic removal, Foley catheter removal, bougienage, and "watchful waiting," which is based on the fact that up to 80% of coins at the LES will pass spontaneously within 24-48 hours with no interventions.³⁰ The watchful waiting approach is used only in patients with single coins, who are able to handle secretions with no difficulties, and who have no pain or distress, and no stridor or drooling.³¹ After ascertaining location of the coin at the LES, the child is discharged with follow-up arranged in 24 hours for repeat radiography.^32,33 Each of the 4 modalities is relatively site or regionally accepted based on training and experience of local practitioners.
• Magnets: If one magnet is ingested, the patient may be treated as any other patient with an ingested foreign body. However, if 2 or more magnets are ingested, there is a risk that the magnets may be in different loops of bowel and become attached via magnetic attraction. In this case, necrosis, perforation, and peritonitis may occur. Patients who have ingested 2 or more magnets warrant surgical consultation.^34,35,36
• Press-through packaging (bubble packaging for medications): Increasingly reported, especially in elderly patients or in those with dementia, the entire package is swallowed. The sharp edges cause entrapment in the esophagus. These should be treated as sharp foreign bodies and endoscopically removed.^37,38
• Razor blades: These are normally swallowed by prisoners or psychiatric patients. Often, the sharp edge is taped to avoid injury. Remove the razor blade if in the esophagus or stomach. They can usually be safely observed if past the pylorus.³⁹

Medication

Smooth-muscle relaxation agents may be used to relax the LES, thereby allowing the passage of foreign bodies lodged in this location.

Gastrointestinal agents

These agents may improve peristaltic activity in the GI tract.

Glucagon (GlucaGen)

Mechanism of action unknown.

Dosing

Adult

1-2 mg IV, repeat in 10-20 min prn

Pediatric

0.02-0.03 mg/kg IV; not to exceed 0.5 mg

Interactions

May enhance effects of anticoagulants (although onset may be delayed); monitor prothrombin activity and for signs of bleeding in patients receiving anticoagulants; adjust dose accordingly

Contraindications

Documented hypersensitivity; pheochromocytoma; Zollinger-Ellison syndrome

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Monitor blood glucose levels in patients with hypoglycemia until they are asymptomatic; glucagon is effective in treating hypoglycemia only if sufficient liver glycogen is present; because liver glycogen availability is necessary to treat patients with hypoglycemia, glucagon has virtually no effects on patients in states of starvation, adrenal insufficiency, or chronic hypoglycemia

Sodium bicarbonate, citric acid, and simethicone (E-Z Gas)

Neutralizes acidity and relieves functional gastric bloating.

Dosing

Adult

1 packet mixed with 240 mL of water administered PO

Pediatric

<2 years: Not recommended
>2 years: One-half adult dose

Interactions

None reported

Contraindications

Documented hypersensitivity; mixed stricture; esophageal diverticulum; proximal obstruction; sharp foreign body

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Use only with foreign bodies at LES and in conjunction with a muscle-relaxing agent

Follow-up

Further Inpatient Care

• Patients in an unstable condition including drooling, stridor, inability to handle secretions, signs of perforation or bleeding:
  • Manage airway and refer for urgent endoscopy.
  • Patients with button batteries in the esophagus are considered to be in an unstable condition.
• Patients in a stable condition
  • Oropharyngeal foreign bodies: If ED evaluation is negative for a foreign body, discharge with follow-up, generally with an ear, nose, and throat (ENT) specialist in 24 hours. If ED evaluation is positive for a foreign body that cannot be removed under direct visualization, refer to an ENT specialist for endoscopy.
  • Esophageal foreign bodies: In cases that involve sharp, elongated, or multiple foreign bodies, refer the patient to a gastroenterologist for urgent removal. For patients with entrapped smooth foreign bodies, if treatment in the ED does not result in removal or passage into the stomach, refer to a gastroenterologist for endoscopy. In children with coins at the LES, watchful waiting may be used if the patient is stable, with follow-up and repeat radiography in 12-24 hours; if the coin has not advanced to the stomach by that time, refer for endoscopy.
  • Stomach or small intestine foreign bodies: Patients with smooth, blunt objects that are less than 2 cm in width or 6 cm in length should be discharged to home. Serial radiographs are generally not needed. Instruct patient to return if fever, vomiting, or abdominal pain occurs. Those with sharp or large foreign bodies in the stomach should be referred to a gastroenterologist for endoscopic removal. Serial radiographs are indicated for sharp or large foreign bodies in the duodenum or small intestine. In most cases, refer to a surgeon or gastroenterologist in 24 hours for follow-up examinations, radiographs, and intervention.
  • People who body pack should be admitted to a monitored setting and are typically treated with whole-bowel irrigation or observation alone. If they develop signs of drug toxicity, this indicates rupture of one of the drug-containing packages and mandates resuscitative measures and surgical consultation for possible surgical removal.

Further Outpatient Care

• For adults with resolved esophageal foreign bodies, referral to a gastroenterologist in 24-72 hours is mandatory because a large percentage of these patients have underlying structural abnormalities, including malignancies, and follow-up endoscopy is needed.
• In children with resolved esophageal foreign bodies, no follow-up is needed.

Complications

• Oropharyngeal foreign bodies - Esophageal or pharyngeal scratches, abrasions, lacerations, or perforations; retropharyngeal abscess; soft-tissue infection or abscess
• Esophageal foreign bodies - Mucosal scratches or abrasions; esophageal necrosis; retropharyngeal abscess; esophageal stricture; esophageal perforation leading to paraesophageal abscess, mediastinitis, pericarditis/tamponade, pneumothorax, pneumomediastinum, tracheoesophageal fistula, and vascular injuries, including aortoesophageal fistulas
• Stomach and small intestine foreign bodies -Small-bowel obstruction; perforation with intra-abdominal infection, peritonitis, and sepsis

Miscellaneous

Medicolegal Pitfalls

• Toothpicks, when ingested, have a high risk of complications, and persons with this foreign body should be treated with early endoscopy.
• Patients with button batteries in the esophagus are at a high risk for esophageal necrosis. Urgent removal is mandatory.
• Aluminum soda can tabs are not visualized on plain radiographs and are frequently entrapped in the esophagus. Early endoscopy is indicated if the ingestion is definitive; if unclear, localization of the soda can tab can be visualized via CT scanning.
• Foley catheter removal of esophageal foreign bodies should be performed only in carefully selected patients and only by those who are experienced in its use who have emergency airway equipment immediately available.
• Children with esophageal foreign bodies may present with minimal or no symptoms. Evaluate all children who may have swallowed an object.
• Children with chronic esophageal foreign bodies may present with vague symptoms such as irritability, poor feeding, or pulmonary symptoms. Maintain a high index of suspicion for an esophageal foreign body.

Multimedia

Media file 1: Coin (quarter) lodged at the level of the cricopharyngeus muscle.

Media file 2: Coin lodged at the level of the aortic crossover.

Media file 3: Coin lodged at the lower esophageal sphincter.

Media file 4: 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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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

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.

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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