We have some fun things to talk about now. I'm going to give a talk here on ingested foreign bodies. Hopefully, I have some nice pictures here to show you. I have no disclosures for this talk. We're going to talk about why is this important for us to understand? What's the epidemiology and importance in the evaluation when we're evaluating somebody for an ingested foreign body? What are the keys to management? When does imaging play a role? We'll review some of the different types of swallowed objects and what our approach should be to managing these. Ingested foreign bodies account for over 100,000 cases per year in the U.S. The vast majority of these are in children and are accidental ingestions. The rate in children has been increasing. You can see data there that particularly in children that are less than six years of age, the rate rose nearly 100% between 1995 and 2015, accounting for a 4% annual increase in the rate of swallowed foreign objects. It's also important to note that the vast majority of ingested foreign bodies will pass on their own spontaneously. Only 10% to 20% will actually require an endoscopic intervention, and less than 1% will require an operation. The mortality rate is exceedingly low. Particularly because the majority of these patients are children or pediatric, there is a notable recurrence rate of approximately 10% to 20%. In pediatrics, what are the most commonly swallowed foreign objects? The majority of those are coins. Nearly two-thirds of all swallowed objects for the pediatric populations are coins, and two-thirds of those are pennies. Others are small toy parts, jewelry, batteries. Batteries are an important consideration considering the increase in use of button batteries for various household electronics that kids may be able to get their hands on. That has corresponded to a significant increase in the frequency of foreign body ingestions of button batteries specifically. Other considerations are things like magnets and safety pins and other small objects and toys. Where do these usually get caught in children? Particularly, the vast majority are at the upper esophageal sphincter, so the thoracic sphincter. The vast majority are at the upper esophageal sphincter, so the thoracic inlet, whereas fewer will pass into the deeper levels of the esophagus. When they are caught in the esophagus, it's at those physiologic narrowings, the UES, the aortic arch, and the mid-esophagus, or the lower esophageal sphincter. In adults, the most common presentation is with food impaction or meat impaction. There's usually some underlying esophageal pathology that's contributed to that food impaction. This can vary from structural things such as a stricture or a ring to neuromuscular disease like achalasia. Tumor is a consideration as well, but in up to 50% of patients who are presenting with an acute esophageal food impaction have underlying eosinophilic esophagitis. Other predisposing factors may include previous GI tract surgery or congenital malformations. True foreign body ingestion is rare in adults, and even those, 95% of those foreign body ingestions are related to food, primarily with chicken bone, fish bone, or toothpicks, as opposed to the pediatric population. Other contributing factors in adults, particularly those with psychiatric disorders, developmental delay, intoxication, or intentional ingestion in patients who are incarcerated and individuals who are incarcerated, drug trafficking, and the role of body packing. We'll touch on that later in the talk. And then sometimes we'll get older adults who are dentureless may have swallowed their dentures themselves or have difficulty chewing and swallowing. So the initial evaluation for a patient presenting with a foreign body ingestion or a food impaction, you want to take a clear history. What was the foreign body that was ingested? Understanding the size and the shape of that foreign body because that's going to influence your decision making about timing of endoscopy potentially. When did that ingestion occur and are there any symptoms that have developed as a result of that ingestion? Are there esophageal symptoms suggesting esophageal obstruction? Are there other symptoms such as respiratory symptoms? Do you have to be concerned about aspiration? Do you have to be concerned about more of an oropharyngeal foreign body? Should we be thinking about getting our ENT colleagues involved? Are there any systemic symptoms or other GI symptoms? Is there abdominal pain? Is there a fever? Are there things to make you think that there may be a complication related to the ingestion? Physical exam findings also you want to think about the oropharyngeal and neck exam. Look for changes such as neck swelling or asymmetry, tenderness, crepitus as we learned about in esophageal perforation talk earlier, but also a chest and abdominal exam particularly when you're concerned about respiratory complications or other systemic complications like perforation. What are some of the symptoms that patients may describe? They'll describe dysphagia. They may be in those patients who aren't able to give that clear history. They may just be refusing to eat. They may endorse symptoms of regurgitation or vomiting. They're not able to tolerate their secretions. They may be drooling and some just experience what we call globus sensation or a sensation that something is stuck there, a foreign body sensation as we call it. Other possibilities of blood staining on the saliva should obviously raise your risk, raise your concern about risk of complication. Odynophagia or pain with swallowing and then chest pain and sore throat, important symptoms to pay attention to. More systemic symptoms may include fever, abdominal pain, distension. Patients who are at risk of more of a delayed presentation or chronic symptoms may present with weight loss. And then those cardiopulmonary type symptoms, is there a component of choking, wheezing, cough? Are they maintaining their oxygenation and breathing? Imaging plays an important role particularly in the pediatric population as coins are the most common swallowed foreign body. You would want to potentially get x-rays, plain films of the neck and chest. You want to get two views, so AP and lateral. That helps to assess those flat objects such as coins to really differentiate are they in the esophagus or are they in the trachea because they'll take different orientations depending on which area they're in. It also allows you to confirm the size, location, shape of the object as most of these objects will be visible on plain film. It also allows you to assess for other complications such as free air, mediastinal air, or peritoneal air, and also examine for other potential objects that may not have been reported in the history. Does this patient have a pattern? Has this child, for instance, swallowed other objects previously that we're not aware of? Keep in mind that some objects will not be seen, so some small bones will not be visible. Plastic, glass, thin metal objects may not be visible on x-ray. Food impaction is not going to show up on a plain film either. Sometimes you might want to consider a CT scan, especially when you're concerned about the risk of perforation. If you have a suspicion that there's been a perforation or other complication from the foreign body ingestion, if the foreign body ingestion was a sharp or pointed object, or if you're suspecting multiple ingestions, intentional ingestion, could they be packets of drugs and how that might influence our decision making. You want to try to avoid contrast, avoid barium exams. One, because the risk of aspiration, you don't want that barium to become aspirated. That will increase the risk of pulmonary complications, but barium also will interfere with the eventual need for endoscopic visualization. Avoiding the oral contrast is important. How do we go about managing these? First and foremost, again, we want to address the airway. We want to think about, is that patient able to tolerate their secretions? Are they able to swallow or are they at a higher risk of aspiration? If they're not, if they're not able to tolerate their secretions, if you do consider them to be at a high aspiration risk, whether that be because of their inability to tolerate their secretions or because of what we've identified as multiple swallowed objects or objects that we anticipate will be difficult to remove, should we be considering those patients for endotracheal intubation before we embark on endoscopic approach? If you suspect that the foreign body is in the proximal esophagus, that may make the extraction more difficult, particularly with the approach with the endoscopy and keeping a stable scope, so that endotracheal intubation would be helpful in some of those situations as well. We have multiple devices that can be used to achieve foreign body removal, and it's important for the endoscopist to know what the options are in their armamentarium. You see here a variety of different objects we can use. This is the overtube. So the overtube is particularly useful in extracting certain kinds of objects. It basically has two lumens within it and allows one to distend the esophagus and insert the scope within it to facilitate removal. There are shorter and longer versions. The shorter version is an esophageal overtube. The longer version is intended for removal of gastric foreign objects, so that will allow traversal of the gastroesophageal junction. Other retrieval devices, there's hoods and caps, foreign body extractors that can be inserted on the tip of the scope to facilitate removal as well. And there's a variety of caps that are available on the market, various different shapes and sizes, but any of these could be potentially useful in the approach. So when we're dealing with food impactions, primarily in our adult populations, these patients will frequently have underlying esophageal pathology. If it's a complete obstruction, then that is truly an emergency. The recommendation is truly it's an emergency endoscopy. If patients are comfortable, if they are able to tolerate their secretions, even though there is a persistent food impaction, you may be able to wait a few hours, but you definitely don't want to delay it beyond 24 hours when they're comfortable. These patients may need actual extraction of the food impaction, but a lot of times you're able to advance the food directly into the stomach by applying gentle pressure to the center of the food bolus. You do want to try to examine the esophagus distal to the food bolus if you can, manipulate the scope around to ensure there's not a very narrow stricture beyond it. And so long as there's not, that will allow you to generally, most often safely, advance the bolus directly into the stomach. But if you're not able to achieve that, there are various devices we can utilize to achieve piecemeal extraction. Sometimes even just breaking it up into small pieces will allow you to then advance it further into the stomach. And there's also benefits to using caps in these situations where the cap will allow you to then apply better suction, maybe to the center of that bolus, and remove it on block. Again, you want to be careful if you're going to try to do that about the aspiration risk and consider using the overtube or general endotracheal intubation before embarking on that. Other things that have been tried to facilitate retrieval or removal or passage of the food bolus, glucagon and nitroglycerin solutions have been suggested. These are relatively safe. You can certainly try them, but they shouldn't necessarily delay your plan for endoscopy. We've had variable success with these, not very convincing, at least in personal practice, that they do much for our patients other than give us some time to get everything set up and get ready to go for the endoscopy. But we do have the rare patient where it is effective. They are relatively safe and low risk, so worth the consideration. Depending on how long that food has been impacted and how severe the impaction is, you may want to consider endoscopic dilation in the same setting and consider biopsies for eosinophilic esophagitis, considering the high frequency with which these patients might have underlying EOE. And it's important to know that you should avoid proteolytic enzymes because these have significant risks of complications and you do not want to consider those in the acute setting for this indication. So we'll get into some of the different types of objects that you might encounter or patients may have accidentally or intentionally swallowed. Short blood objects can again be, are objects like you see here. If these are in the esophagus, they can be manipulated generally into the stomach where it's a little bit easier to remove them. If they have already passed into the stomach, then they may actually pass on their own without needing an endoscopic intervention. This is where it's important to know the size and the shape as well. So those that are greater than two centimeters in size are unlikely to pass the pylorus or unlikely to pass through the IC valve. And so those are patients where you may be able to delay the endoscopy until the following morning, but you still want to retrieve them because of that lower likelihood of them passing spontaneously. In those that are able to pass spontaneously, you'll typically want to try to follow those by x-ray until you're sure that they have passed. Short blunt objects like this, you may be able to monitor with weekly x-rays. Patients would not necessarily need to alter their diet. In those patients where they're not developing any symptoms, but they are failing to pass by x-ray, whether they're in the duodenum, you may not want to wait longer than a week. In the stomach, you may be able to wait three or four weeks even, but if they don't pass by that point, an endoscopy is indicated. If they do pass into the mid or distal small bowel, so beyond the duodenum, but they fail to progress from that area, unfortunately that's likely gonna need a surgical removal. You may be able to consider deep enteroscopy if that's available as an alternative for retrieval. And this is something that we see, for instance, in some cases where we have a retained video capsule endoscopy, we may pursue deep enteroscopy to retrieve that. Long objects, so these have other considerations as well. Long objects may include things like toothbrushes, spoons, or forks. Those that are longer than five or six centimeters in length are unlikely to pass through the duodenal sweep, and even if they do, they're likely to impact at the ileocecal valve. So these are, again, if they're already in the stomach, these are ones that you may be able to wait until the next day, but they're unlikely to pass through into the small bowel or beyond. If they are in the stomach, there may be benefit to using the longer overtube so that you can traverse the gastroesophageal junction, which may facilitate your removal. You may be able to withdraw it into the tip of the overtube or just against the overtube and withdraw everything all at once together. If the long object, if that toothbrush or spoon or fork has already passed into the small bowel, that's an indication to follow it by x-ray and consider surgical removal if it fails to progress. These are some examples of retrieved long objects, mostly blunt, but there are some sharp objects there. These are some examples of razor blades that have been retrieved from the esophagus or the stomach, upper GI tract in various patients. And again, with sharp objects, you want to consider using those protective hoods or the overtube to help reduce the risk of trauma to the upper GI tract with removal. So sharp pointed objects carry a high risk of perforation that can be as high as 15 to 35%. These may include things like razor blades, but also chicken or fish bones, straightened paperclips, toothpicks, et cetera. And many of those, keep in mind, are not going to be visible on x-ray. So even if we do that plain film looking for them and we don't see it, it doesn't mean it's not there. And so even if that x-ray is negative, you still want to be considering those patients for endoscopy. If it is in the esophagus, the patient is complaining of symptoms that make you concerned that it's an esophageal retained foreign body, then you do want to consider that to be an emergent indication for removal. And again, various tools that we can use for retrieval. When you're retrieving these, it is helpful to try to orient the sharp end trailing so that you reduce any trauma as you're pulling it forward up the esophagus. And again, consider the protective hood or the overtube. Here's an example of a sharp object that was retrieved from a pediatric patient. And in the bottom right, you see the protective hood that was used on the scope to reduce that risk of trauma to the upper GI tract with removal. Sharp pointed objects that have reached the stomach may actually pass on their own. But again, because that nature of the shape, and there is still a risk of perforation as high as 35%. Typically, these will occur where these sharp objects are most likely to get lodged. So at the ileocecal junction or the rectosigmoid junction, if they do reach that portion of the colon. If they've passed into the small bowel and remain asymptomatic, but again, sharp pointed object, these are ones that you might want to consider keeping that patient in hospital for daily x-rays or at least getting them very frequent x-rays as an outpatient. And again, consider surgery if they fail to progress after several days. If they develop symptoms, of course, you need to have your surgical colleagues consider removal. So coins are the most common presentation in young children, very common. They can be asymptomatic. And if they are asymptomatic, you can generally observe children. I know that sounds scary as a parent, but if they're not showing any symptoms, observe them for 24 hours or up to 24 hours. And 20 to 30% of these will actually pass spontaneously. If the time of the ingestion is unknown or if they exhibit any symptoms, then you want to approach this as a more urgent endoscopy. Or if you've followed them and they fail to pass beyond 24 hours, then endoscopic retrieval is indicated. Batteries are a very important consideration. These are more common in, obviously, the pediatric population. Again, button batteries are the ones that are the most concerning. One, because they are so widely available, but also because of the risks associated with button batteries. If they are in the esophagus, it's considered a medical emergency, basically because there is a conduction of electricity from both poles of the button battery and that can lead to necrosis and ulceration and perforation within hours of exposure. There's also a risk of leakage of caustic material from it and pressure necrosis from the battery being isolated in one location for an extended period of time. You want to, again, consider the use of an overtube or endotracheal intubation to protect the airway during retrieval. And if it is in the esophagus, again, sometimes passing these objects into the stomach may actually facilitate your ability to successfully remove them. If they've already passed into the stomach, most will pass without a complication. It's really in the esophagus where those are these emergencies. Again, you want to consider keeping these patients for close monitoring, frequent x-rays, maybe every three days or so. Remember that if they do fail to progress, there is a higher risk of that liquefactive necrosis and pressure ulceration. Again, as we mentioned with other objects, the size is important. So larger size button batteries, or larger size batteries are unlikely to pass through the pylorus. And so that would be an important consideration for when to consider endoscopy. And the cylindrical batteries, if they stay in the stomach longer than 24 hours, should be considered for removal. There's no real benefit to using emetics or cathartics to help pass the foreign objects. In those that have passed through the duodenum already, then 85% of those, the vast majority of those will pass through the GI tract within 72 hours. Magnets are important because magnets can be associated, or have been associated with severe complications, including 10% life-threatening morbidity. This is particularly, especially when there's multiple magnets that have been swallowed because there's direct pressure necrosis that can develop if they're in different parts of the GI tract. Those magnets can attract each other despite the intervening GI mucosa, and lead to perforation and fistula formation, can also lead to complications related to that peritonitis and obstruction. If they're single magnets, then theoretically you may be able to allow those to pass with monitoring. You should consider endoscopic removal, of course, if it is in an accessible location, but otherwise follow with x-rays, and make sure you're avoiding any metallic exposure to the patient. But those with multiple magnets, these are the most dangerous presentations as those are the ones that you really want to promptly remove and retrieve. If patients are asymptomatic, you can follow them with serial x-rays much more frequently though, because of that higher risk of complications and higher risk of perforation. Even when these do pass into the small bowel or colon, consider them for endoscopic intervention, endoscopic retrieval. This is one where you may want to use those laxatives to get things moving quickly and out into either into a retrievable area or through the GI tract completely, but don't use emetics because of the aspiration risk. And then we have miscellaneous objects. So toys these days come with various different parts to them and different compartments, different components to them. Fidget spinners may have lights, motors. They may have batteries. They may have different pieces that you have to consider each of those component potentially as they may come apart and you have to treat each of those as distinct objects. There are super absorbent objects. So these are objects that are going to rapidly absorb fluid and rapidly expand in whatever space they're in. So if one of these has been swallowed, you want to consider removal of that immediately before they have a chance to expand to a size where size or consistency where they won't be retrievable endoscopically. If we know that there's been a high lead content exposure, again, remove those as quickly as possible. There may be a benefit to using PPIs to reduce acid, gastric acid in reducing the risk of lead poisoning or lead exposure. And here we touched on this earlier, body packing. So body packing is an important consideration. These are basically patients who are swallowing multiple packets of some drug, whether it's cocaine, heroin, or other drugs, they're swallowing them to traffic them. And these can be seen by x-ray or CT scan. But you really want to understand that there's a very high risk of significant morbidity, mortality if one of these packets ruptures or leaks. And so the general recommendation is that you should not consider these for endoscopic retrieval. Has it been done? Yes, but it carries a very high risk, particularly if you're not careful and if one of the packets does rupture. So these are patients that we will always involve our surgical colleagues, especially for failure to progress or any suspicion or concern for rupture. There's also anesthesia risks when you're concerned about rupture, depending on the drug that's been trafficked. So all of these recommendations are outlined in the ASG Standards of Practice Committee publication from 2011. And here's a nice summary from that article. That's the end of my talk. Hope those were some interesting presentations.

foreign bodies

ingestion management

children

endoscopy

button batteries

ASG guidelines