Gastrointestinal Foreign Bodies 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). ^[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.

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]

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.

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.