Gastrointestinal Foreign Bodies 

Updated: Jan 04, 2018
Author: David W Munter, MD, MBA; Chief Editor: Steven C Dronen, MD, FAAEM 

Overview

Background

Patients with foreign bodies in the gastrointestinal (GI) tract commonly present to the emergency department (ED). Foreign bodies in the upper GI tract are usually swallowed, purposefully or accidentally. The presentation is usually straightforward but on occasion can be extremely subtle. A foreign body in the GI tract is shown in the radiograph below.

A screw in the stomach; peristaltic action will ca 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 gastrointestinal (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 80% chance of passage.[1] 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.

Occasionally objects such as bones or toothpicks may pass all the way to the rectum, where they become entrapped, causing a foreign body sensation and, potentially, a perforation.

Swallowed magnets from toys and household items have become a serious health hazard in children. Buckey-ball magnets are small round magnets in the shape of ball-bearings that are especially strong and are used to make toys of various shapes. If these small magnets are ingested, especially at various times, they can adhere across layers of bowel and lead to pressure necrosis, fistula, volvulus, perforation, infection, or obstruction.

Etiology

Children

The most common causes of gastrointestinal (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.

Adults

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.

Epidemiology

United States data

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

One study suggested approximately 1,671 ingested magnet injuries annually. This was expected to decrease as sales of these small toy magnets have been banned by the Consumer Protection Agency because of safety concerns.[2]

International data

In a retrospective study (2002-2015) that evaluated the effectiveness of a mandatory product recall on the frequency of multiple mini-magnet ingestion at a large tertiary Canadian pediatric hospital, investigators noted a significant reduction for all magnet ingestions and multiple magnet ingestions in the 2 years after the recall (2014-2015) compared to the 2 years before the recall (2011-2012).[3]

In another retrospective study (1995-2013) of pediatric esophageal foreign bodies (age ≤12 years) in King Khalid University Hospital, Riyadh, Saudi Arabia, investigators identified 70 children, of whom 53 presented within 24 hours of ingestion and 13 had underlying predisposing factors, with a coin being the most common foreign object.[4]

Race-, sex-, and age-related demographics

No differences in race or nationality have been noted.

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.

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 age group.[7, 8, 9] 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. Nonfood-type items are common in young and elderly patients.[9]

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).[7, 8, 10, 11, 12]   Except for geriatric patients (>65 years), the tonsils appear to be the most common anatomic site of foreign body impaction, and the stomach and esophagus are also common locations in children younger than 10 years and those older than 65 years.[9]

 

Prognosis

Morbidity/mortality

An estimated 1500 deaths occur annually from foreign bodies in the upper gastrointestinal (GI) tract.[10]

Complications

Complications of GI foreign bodies include the following:

  • Potential complications of oropharyngeal foreign bodies include esophageal or pharyngeal abrasions, lacerations, and punctures, with associated abscesses (eg, retropharyngeal abscess), perforations, and soft-tissue infections.

  • Esophageal foreign bodies can also cause mucosal scratches or abrasions, punctures, and perforations[13] , with resultant injuries or infections to surrounding structures, including abscesses, pneumomediastinum or mediastinitis[14] ; pericarditis/tamponade, pneumothorax, pneumomediastinum, tracheoesophageal fistula, or even vascular injuries to the aorta (aortoesophageal fistulas)[15] ; or pulmonary vasculature.[16]  Additionally, button batteries can rapidly create esophageal necrosis.[17]  Esophageal strictures may also occur.

  • Complications from foreign bodies in the stomach and small intestine typically involve perforation and associated infection, including peritonitis and sepsis. In general, peforation occurs in less than 1% of cases.[18]  Small-bowel obstruction may also occur

  • Swallowed toy magnets that adhere across layers of bowel can cause pressure necrosis, fistula, volvulus, perforation, infection, or obstruction.

 

Presentation

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.[11, 19] 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.[20] 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[21] ; or pulmonary symptoms, such as repetitive pneumonias from aspiration.[22] 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 Examination

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 upper esophageal sphincter.

Complete obstructions can cause drooling and the inability to swallow.

Delayed presentations may be accompanied by signs of infection, including peritonitis.

 

DDx

Diagnostic Considerations

Other conditions to consider in the differential diagnosis of patients with suspected gastrointestinal foreign bodies include the following:

  • Dysphagia

  • Esophageal carcinoma

  • Esophageal stricture

  • Failure to thrive

  • Intestinal perforation

  • Odynophagia

  • Peritonitis

  • Pneumomediastinum

Important considerations

The following are important things to consider in patients with gastrointestinal foreign bodies:

  • 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.[17] 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.

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. PMID: 18435994.

Munter DW, Esophageal foreign bodies. In: Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 5th ed. Philadelphia, PA: Saunders; 2010:715-33.

Differential Diagnoses

 

Workup

Approach Considerations

Most patients with gastrointestinal (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 complete blood cell count may be indicated, and patients who require preoperative studies.

In general, radiography and computed tomography (CT) scanning are the main imaging modalities used to evaluate GI foreign bodies.[23] However, ultrasonography may be useful in detecting ingested drug packets[24] ; endoscopic ultrasonography can help identify foreign bodies of the colon and rectum.[18] CT scanning is more accurate if the patient is stable. In the case of an unstable patient, bedside ultrasonography (or portable radiography) may be the only imaging option.

 

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 computed tomography (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 (examples of a lodged coin are shown in the radiographs below).

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

Button batteries can usually be differentiated from coins on plain films.[25] However, if any question exists as to whether the object is a button battery, urgent intervention is indicated because of the rapidity of esophageal necrosis that can be seen in button battery ingestion.[17]

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.[26]

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.

Computed Tomography Scanning

In one study, computed tomography (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.[27, 28]

CT scanning is the modality of choice for the diagnosis of perforation of gastrointestinal (GI) tract by ingested bone fragments, toothpicks, and dentures. Ultrasound is of limited value in depicting a foreign body, but can often reveal secondary signs of perforation.[29]

CT scanning is 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. This should be performed with IV contrast if the patient does not have any contraindications to the use of contrast material such as allergy or renal insufficiency.

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.[30]

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, computed tomography (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. Thus, it is indicated for multiple (>1) small magnets in the esophagus or stomach and may be indicated for single magnets, owing to their potential complications.

This procedure 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.[31]

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, 32, 33]  Advantages of the endoscopic approach to managing ingested foreign bodies and food impaction include high success rates, lower incidence of minor complications, decreased need for surgery, and shortened hospitalizations.[34]

If endoscopy is not successful for removing magnetic foreign bodies, timely surgical intervention may help avoid serious complications such as gastrointestinal perforation and intestinal obstruction, as well as local bowel wall tissue ischemia necrosis and perforation and fistula-related complications.[35]

Delayed flexible endoscopy in patients, especially elderly patients, with sharp esophageal foreign body impactions results in worse endoscopic outcomes.[36] Therapeutic results with the use of general anesthesia versus topical pharyngeal anesthesia does not appear improve the success rate or reduce the complication rate.[36]

 

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).[37]

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. Patients who are drooling may be more comfortable holding a suction catheter and using it as needed

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.[38, 39] Button battery ingestion continues to be a problem in the United States, with increasing frequency, most commonly in children with an average age of around 4 years.[17, 40]

The presence of a button battery in the esophagus is a medical emergency because necrosis of the esophageal wall may occur within 2 hours.[41] These batteries range from 7-25 mm and are radiopaque. On radiographs, they appear as round densities, similar to an ingested coin, but some demonstrate a "double-contour" configuration.

It is important to distinguish between a coin and a battery because button batteries must be expeditiously removed.

Batteries consist of 2 metal plates joined by a plastic seal. Internally, they contain an electrolyte solution (usually concentrated sodium or potassium hydroxide) and a heavy metal, such as mecuric oxide, silver oxide, zinc, or lithium. If ingested, these batteries often lodge in the esophagus and cause injury by electrical current, electrolyte leakage, or pressure necrosis. If they break in the GI tract, they can cause heavy metal poisoning.

Button batteries lodged in the esophagus must be removed immediately. Removal options include endoscopy, Foley catheter removal, esophageal bougienage, or Magill forceps removal.

Intact button batteries in the stomach are safe and 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 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 ca 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.

Nonopaque foreign bodies

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

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

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.[42]

NOTE: the use of meat tenderizer is contraindicated in patients with food boluses at the LES, as meat tenderizer may cause necrosis of the esophagus.

Body packers

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. Normally, topical oral anesthesia is used, as is mild sedation on occasion. The success rate for this procedure has been reported as 85-100%, although most pediatric centers that commonly perform the procedure report higher success rates. 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 well-lubricated 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%.[43, 44, 45]

Magill forceps removal of esophageal foreign bodies

In children, the most common accidentally ingested foreign body is a coin, and the most common location for the coin to be lodged is the cricopharyngeus muscle. When this is the case, the patient is a candidate for Magill forceps removal. The procedure requires sedation, and airway equipment must be available. Centers that are using this technique report a success rate of 95-100%.[12, 46, 47] and are using direct visualization with a laryngoscope or video assisted system.

The procedure is rapidly performed, usually in less than a minute, and complications are typically minor bleeding or vomiting. The procedure seems ideally suited for the stable child with a coin at the cricopharyngeus muscle in a facility that is well equipped, staffed, and experienced in managing procedural sedation and airways in children. The patient is sedated, the laryngoscope or video-assisted laryngoscope inserted, and the upper esophagus and foreign body visualized and removed with the Magill forceps. The patient recovers from sedation in the normal fashion.

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%,[48] which may not be any better than spontaneous passage with no interventions (or placebo), especially with coin ingestions in children.[49] The benefit seen from glucagon alone is negligible; the benefit from gas-producing agents appears to be the major contributing factor in the combination of the two.[50]

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, thus this should be avoided.

This procedure does not work in patients with structural abnormalities.

Cost

Cost is always a consideration when selecting a procedure. In one study, endoscopy averaged $2700; Foley catheter removal, $660; and bougienage, $614.[51] In another study, the average cost of endoscopy was $6087, whereas that of bougienage was $1884.[52]

Negative workup

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

Five generally broadly accepted approaches to management of esophageal coins in children are as follows: endoscopic removal, Foley catheter removal, bougienage, Magill forcep removal if in the upper esophagus, 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.[53]

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.[54] After ascertaining location of the coin at the LES, the child is discharged with follow-up arranged in 24 hours for repeat radiography.[55, 56]

Each of the 5 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, although no evidence to date has demonstrated any danger from these coins.

Magnets

If one magnet is ingested, the risk is lower, but because even single magnets have some risk, endoscopic removal should be considered if the magnet is accessible. Single magnets passed beyond the stomach can generally be managed conservatively, but serial outpatient radiographs should be obtained to confirm that the magnet is progressing through the GI tract. Theoretically, the patient should be kept away from any magnetic or metallic material (including buckles or metal buttons) until the magnet has passed.

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. If there are more than one ingested magnets in the esophagus or stomach, emergent endoscopic removal is indicated to prevent passage into the intestines. If radiographs show the magnets are past the pylorus, they may be already adherent to each other, or in a worst case, separate, and become adherent across loops of bowel wall. In this case, necrosis, perforation, and peritonitis may occur.

Management depends upon on the symptoms and progression.[57, 58, 59] Asymptomatic patients who have swallowed multiple magnets should be admitted and monitored closely with serial radiographs and physical examination every 4-6 hours. Whole bowel irrigation is a consideration. Alternatively, magnets can be removed by enteroscopy or colonoscopy if accessible. In a report of 2 cases of a button battery and an open safety pin injestion that impacted in the terminal ileum after migration from the stomach, colonoscopic retrieval was successful in both cases.[1]  Symptomatic patients or any patient with multiple magnets that do not progress on serial radiographs should have a surgical consult for possible operative removal of the magnets.

In 2011 the U.S. Consumer Safety Product Commission issued an alert describing the safety risks from swallowed magnets (http://www.cpsc.gov/cpscpub/prerel/prhtml12/12037.html).

Press-through packaging (bubble packaging for medications)

Increasingly reported, especially in elderly patients or in those with dementia, the entire package is swallowed accidently. The sharp edges cause entrapment in the esophagus. These should be treated as sharp foreign bodies and endoscopically removed.[60, 61]

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.[62]

Medical Care

Patients in an unstable condition, including those with drooling, stridor, inability to handle secretions, and/or 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 emergency department (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.

Body packers

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.

Long-Term Monitoring

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.

 

Medication

Medication Summary

Smooth-muscle relaxation agents may be used to relax the lower esophageal sphincter, thereby allowing the passage of foreign bodies lodged in this location. However, there is not convincing evidence in the literature that the use of such agents changes clinical outcomes.[48, 49]

Gastrointestinal agents

Class Summary

These agents may improve peristaltic activity in the GI tract.

Glucagon (GlucaGen)

Mechanism of action unknown.

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

Neutralizes acidity and relieves functional gastric bloating.

 

Questions & Answers

Overview

What are gastrointestinal (GI) foreign bodies?

What is the pathophysiology of injuries caused by gastrointestinal (GI) foreign bodies?

What are the most common causes of gastrointestinal (GI) foreign body ingestion in children?

What are the most common causes of gastrointestinal (GI) foreign body ingestion in adults?

What is the prevalence of foreign body ingestion in the US?

What is the global prevalence of foreign body ingestion?

Which patient groups are at highest risk for foreign body ingestion?

What are the mortality rates associated with gastrointestinal (GI) foreign body ingestion?

What are the possible complications of gastrointestinal (GI) foreign bodies?

Presentation

Which clinical history findings are characteristic of gastrointestinal (GI) foreign bodies in the oropharynx?

Which clinical history findings are characteristic of gastrointestinal (GI) foreign bodies in the esophagus?

Which clinical history findings are characteristic of gastrointestinal (GI) foreign bodies in the stomach or small intestine?

What is included in the physical exam for evaluation of gastrointestinal (GI) foreign bodies?

DDX

Which conditions should be included in the differential diagnoses of suspected gastrointestinal (GI) foreign bodies?

What are important considerations in the workup of gastrointestinal (GI) foreign bodies?

What are the differential diagnoses for Gastrointestinal Foreign Bodies?

Workup

What is the role of lab testing in the workup of gastrointestinal (GI) foreign bodies?

What is the role of imaging studies in the evaluation of gastrointestinal (GI) foreign bodies?

What is the role of radiography in the workup of gastrointestinal (GI) foreign bodies?

What is the role of barium swallow in the workup of gastrointestinal (GI) foreign bodies?

What is the role of CT scanning in the workup of gastrointestinal (GI) foreign bodies?

What is the role of metal detectors in the workup of gastrointestinal (GI) foreign bodies?

What is the role of endoscopy in the emergent management of gastrointestinal (GI) foreign bodies?

Treatment

What is included in prehospital care for gastrointestinal (GI) foreign bodies?

What is the approach to treatment of suspected gastrointestinal (GI) foreign body in the ED?

How are patients in unstable condition with gastrointestinal (GI) foreign bodies treated in ED?

How are patients in stable condition with gastrointestinal (GI) foreign bodies treated in ED?

How are radiographically localize radiopaque objects in the gastrointestinal (GI) tract treated?

How are non-opaque foreign bodies in the gastrointestinal (GI) tract treated?

How are button batteries in the gastrointestinal (GI) tract treated?

How are smooth foreign bodies in the gastrointestinal (GI) tract treated?

How are body packed drugs in the gastrointestinal (GI) tract managed?

What is the role of Foley catheter removal in the treatment of gastrointestinal (GI) foreign bodies?

What is the role of bougienage in the treatment of gastrointestinal (GI) foreign bodies?

What is the role of Magill forceps in the treatment of gastrointestinal (GI) foreign bodies?

What is the role of lower esophageal sphincter relaxation in the treatment of gastrointestinal (GI) foreign bodies?

What is the average cost for treatment of gastrointestinal (GI) foreign bodies?

How should gastrointestinal (GI) foreign bodies with a negative workup be managed?

How are coins in the esophagus treated?

How are magnets in the gastrointestinal (GI) tract treated?

What is the treatment for ingested bubble packaging for medications?

What is the ED care for razor blades in the gastrointestinal (GI) tract?

When are patients with gastrointestinal (GI) foreign bodies considered to be in an unstable condition?

When is referral to an ENT indicated for the treatment of gastrointestinal (GI) foreign bodies?

When is referral to a gastroenterologist indicated for the treatment of gastrointestinal (GI) foreign bodies?

What is the medical care for body packed drugs in the gastrointestinal (GI) tract?

What is included in the long-term monitoring for patients following gastrointestinal (GI) foreign body removal?

Medications

What is the role of medications in the treatment of gastrointestinal (GI) foreign bodies?

Which medications in the drug class Gastrointestinal agents are used in the treatment of Gastrointestinal Foreign Bodies?