Foreign body ingestion and food bolus obstruction

• Accounts for 4% of emergency endoscopies
• 1% need surgery
• 85% of foreign bodies pass spontaneously – often in 4-6 days if seen in the stomach on imaging, but can take up to 4 weeks
• Can be intentional or non-accidental, and this is on the increase
• If the object measures > 2cm across and/or >5cm long – unlikely to pass into duodenum and will need to be retrieved endoscopically
• There may be a risk of perforation (and typically no gas under the diaphragm in this scenario)

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Assessment

• Assess airway and breathing
• History
  • • Timing – embedded objects scan be more difficult to retrieve
    • What was ingested (could it be a food bolus?), and how many
    • Intentional/accidental
    • Ask about mental health / learning disabilities / neurodevelopmental disorders
• Symptoms
  • • Ability to swallow saliva
    • Neck/chest pain
    • Odynophagia
    • Vomiting
    • Patient’s localisation of object/food bolus is often not very good
• Examine for signs of perforation (crepitus, fever) and obstruction

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Imaging

• X-rays
  • • Consider x-rays of the neck, erect chest, abdomen if radiopaque object ingested or object unknown
    • False negatives common (eg glass, wood)
    • Lateral CxR can help with localisation
    • X-rays useful in most but especially if intentional (multiple objects may be visible, and may not have been mentioned)
• Consider CT scan if possibility of perforation, complications, or fish bone suspected but not visible on x-ray
• Don’t do barium swallow before endoscopy – aspiration can cause pulmonary oedema

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Endoscopy (OGD)

• Generally quite safe and successful in at least 90% of cases. Most need one. Occasionally risks outweigh benefits.
• Sometimes involve ENT as rigid pharyngoscopy may be required
• Consider general anaesthesia – depends on airway safety, type of object, patient cooperation, comorbidities, expected procedure length
• Type of object swallowed determines urgency of scope
• If delay in endoscopy – consider re-imaging
• Methods
  • • Can use rat-tooth forceps, snares, over-tubes or nets to retrieve
    • Sharp objects are retrieved with a plastic cover to avoid damaging oesophagus during the procedure
• Indications of urgent scope (within 6 hours, including overnight)
  • • Magnet or sharp object in the oesophagus is the most urgent
    • Complete obstruction – unable to swallow saliva
    • Button batteries much more dangerous than AA or AAA batteries, especially in the oesophagus
• Endoscopy within 24 hours indicted for
  • • Most food boluses in the oesophagus
    • Blunt foreign objects in the oesophagus
    • Coins in the oesophagus (complications increase if scope delayed > 24 hours)
    • Most objects in the stomach – sharp objects, magnets, batteries, larger/long objects
    • Cylindrical batteries – occasionally left but generally extracted and always if bitten/chewed
• Occasionally elective endoscopy appropriate in several weeks’ time if multiple repeated foreign body ingestion (repeated general anaesthetics carry risk) – ‘batch scoping’
• What else to look for during the scope
  • • Signs of eosinophilic oesophagitis – take a biopsy
    • Peptic strictures – give high dose PPI, can dilate later
    • Schatzki ring – dilate later
    • Cancer
    • Possible motility disorders – consider barium swallow later
    • Fragile dentures!

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Other management strategies

• Can try fizzy liquids for food boluses, but poor evidence, and definitely not in complete obstruction
• 1mg IV Glucagon is no longer recommended – poor evidence and delays the scope
• Can try benzodiazepines, but careful if aspiration risk
• Involve other specialties
  • • MDT for repeated intentional ingestion
    • ENT if the object is high up
    • Psychiatry if non-accidental
    • Speak to surgeons if perforation confirmed

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Specific scenarios

• Body packing for transporting drugs over borders
  • • Get help (gastro/surgeons) if stuck in oesophagus or burst
    • If not, let it pass through
• Eosinophilic oesophagitis
  • • Often behind a lodged food bolus
    • Take biopsy (even if mucosa looks normal) and chase up
    • See oesophageal disorders
• ‘Intentional’ ingestion / self-harm
  • • Often not truly intentional – patients may have constrained options, and maladaptive strategies
    • Can occur in those with psychiatric comorbidity, trauma, autism, substance misuse or in prisoners (10x risk). Often a patient has several of these risks
    • Involve liaison psychiatry