Gastrointestinal Foreign Bodies in Emergency Medicine Treatment & Management

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.

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 (as in the radiograph below); however, many authorities recommend endoscopic removal for these as well. 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.
    • 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, and 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.
  • United States pennies are now composed of copper-clad zinc, raising the potential for possible esophageal or gastric ulcerations if impacted. Consider follow-up radiographs in 1-2 days if in the stomach.
• 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]