These webinars feature expert physicians in their field and I'm very excited for today's presentation. The American Society for gastrointestinal endoscopy appreciates your participation in tonight's event, entitled foreign body impactions. My name is Reddy Yakova, and I will be the facilitator for this presentation. Before we get started, just a few housekeeping items. We want to make this session interactive so feel free to ask questions at any time by clicking the Q&A feature on the bottom of your screen. Once you click on that feature, you can type in your question and hit return to submit the message. Please note that this presentation is being recorded and will be posted within two business days on GILeap, ASG's online learning platform. You will have ongoing access to the recording in GILeap as part of your registration. And now it's my pleasure to hand over the presentation to our two GI fellow moderators who will help with the incoming question. Dr. Malav Parikh and Dr. James Connolly. I will now hand the presentation over to them. Thank you, Reddy. Good evening, everyone. It is my pleasure to introduce the moderator for tonight, Dr. Praveen Chahal, who's a world-renowned advanced endoscopist and also the program director of advanced endoscopy fellowship at Cleveland Clinic. I'll be introducing the panelists for tonight, Dr. Simons Linares, who is the former editor-in-chief of the ACG Case Reports Journal and currently again at Cleveland Clinic, who is an advanced endoscopist and a bariatric endoscopist. And I'll be introducing panelists to Dr. Sunil Amin, who is the director of endoscopy at Jackson Memorial Hospital and the Lenner Foundation Medical Center. Thank you. And my name is James Connolly. I'm one of the third-year fellows at Boston Medical Center. And I have the privilege today of introducing Dr. Swati Pawa, an associate professor at Wake Forest, and a fellow of the ASG, as well as Dr. Aswit Asambang, the director of global health programs at Mass General Hospital and also a fellow of the ASG. So now I'm going to give it over to Dr. Simons Linares to kick off our night. Thank you. Thank you, everyone. Thank you, ASG, to the organizers and to everyone joining today. So I'm going to start with a quick case. It's a really important topic for trainees, for everyone, really. So endoscopic management of foreign bodies. So we're going to start with a quick case. So we have a 32-year-old lady with a past medical history of bipolar disease, depression, anxiety, who presents to the ER after an ingestion of a foreign body. So you're the GI fellow, and you're a PAGE consultant. You're a very good historian. However, a patient is not a good source of information, so you have no information, basically, of what she ingested. The ER has done this x-ray. So this is what you see. And this is the only information you have so far. There's really no history prior. So as you can see, there is an arrow there. There is a really opaque kind of linear object there. And there's other findings as well, you know, some clips here, some other scope clip as well, but those are not relevant right now for the case. Roberto, let me interrupt you at this point. And this question is open for the other esteemed panelists here also. So does every foreign body ingester need an x-ray? What are your thoughts? Can you share who you think would benefit from x-ray and where it's unhelpful? Yeah, no, that's an excellent question. I think, you know, not every foreign body needs an x-ray, especially, you know, if you want to, someone who is not handling secretions, if you're suspecting, you know, a perforation, for example, sometimes you want to see if there is air under the diaphragm. Your physical exam is very important, but not all objects will show up, right? So right here, you're seeing a radio peak. Actually, we don't even know if this is the whole object, right? So in this case, it's helpful to identify where it is. You know, it looks like it's in the esophagus still, but we don't know how big is this, what is it, and especially without a history. So now I would like to hear from my co-panelists, what do they think? Swati, do you want to share? So just to add to your question, so does every impaction need imaging? Not really. You know, but like, and I'm going to mispronounce your name a couple of times. Roberto. Roberto is easy. Now I get it. So that's why I hesitated. But you're right. The physical, the history is key. The physical exam is key, especially if you're thinking this could be a poor pericarpitis or if the patient had any history of what they ate. But answering Praveen's question, if they ate fish bone or chicken bone or plastic or glass, that will not show up on an x-ray and will not be helpful, so it can be avoided. And especially impactions shouldn't be delayed just because you need a contrast study or some kind of an x-ray study, especially contrast study, because the risk of aspiration is high and you don't want them aspirating gastrographin, which is toxic to the lung. So I just wanted to add those few points when you're thinking about imaging. Yeah, I think those are great points that you shared, especially in this case, like Roberto shared, this patient was a poor historian, so we really don't know if the patient swallowed a plastic or a metal or whatnot. So it probably was helpful in this case, but redundant where you know what the patient swallowed, if it's really opaque or not. So yes, Roberto, please continue with your case. Awesome. Well, thank you, everyone. So yeah, in this case, you know, you're like, what is this? It depends on the angle. This is, you know, whatever angle this is taken in terms of the foreign body orientation is also, you don't know, but at least there is a radiopaque object in the esophagus, partially in the esophagus at least. So I just wanted to throw this in there. I mean, we're not going to go over these guidelines, but this exists from ASG. It's a very nice document. So, you know, I put the name of this guideline for the fellows out there to always refer to this. It's very helpful. So you're in the middle of the night, and then you're like, you remember this webinar, and you go and Google these guidelines, and you're like, let me check here. And, you know, there is a sharp pointed object in the esophagus. And, you know, like, yeah, that x-rays kind of look like sharp, kind of linear, right? So this is something that you should take care of, you know, sooner rather than later. And they have this nice table. Like I said, it's very helpful if you're doubting yourself, but basically anything in the, you know, that has a esophageal obstruction, whether it is like food impactures, not handling secretions, that's, you know, something concerning. Or this bad, there is as well in the esophagus or sharps in the esophagus. Those are really more urgent cases. Now, so what's your plan, really? And I'm not going to, you know, bore you with a ton of, you know, what is the algorithms or really checklist for this. But I just put this slide because there's more cases coming from the other panelists and experts. But always, I think it's very important for you to ask yourself, do we need to protect the airway? You know, do we need to intubate this patient? Most of the time I end up doing that, especially if it's in the esophagus, you know, you want a well-controlled environment, protect the airway. I don't think I've removed anything, honestly, without mechanical intubation. I think it's wise to do that. But then also check your, you know, remember, this is endoscopy, you don't forget about other, you know, parameters for endoscopy, you know, platelets, INR, you don't have to really delay, but you know, it's always, you know, good to check regular labs before, you know, putting your scope down. And then also remember, do you need to protect your esophagus? You know, like, do you need an Arbor tube or a hood? And I'm going to show you what I mean by those tools, you probably know some of them, at least. And also, if your program or your hospital have a toolbox for foreign bodies, we do have that in our institution, I think it's very helpful. You know, you have everything you need there. You, I think that's something very good to have, or at least a checklist. You know, of things that you may need, and you don't want to be in the middle of a case, and you forgot one very important thing that then you're looking for, and you have to, you know, go back to the end unit for that. So you put your scope down, and this is what you see. So this is the esophagus, and this is probably the radiopaque part of the object that you were seeing in the x-ray. And then you go down to the stomach, you kind of take a peek, this is kind of in the lower esophagus, and you see that this was not showing up. In the x-ray, like, you know, Dr. Shahal and other panelists were mentioned, this is plastic, right? So this doesn't really show up. This is in the esophagus. You have to be careful also to, you know, take a good look, make sure there is no, you know, serious tears or something else. In this case, you know, it looks pretty embedded in the stomach. But then what we did was we used a snare, you know, a standard snare to actually take this out of the, you know, esophagus from the proximal end that you saw. We did use an overtube to protect. This was a fairly large, you know, not fairly large, but not a short object like you saw in the x-ray. This was a pen. So, you know, it's kind of large. So you want to protect your, you know, your upper esophageal sphincter, especially when you're coming out. And we did use an overtube to actually remove this to make sure we're protecting the esophagus. There's also, I'm not going to show you many tools, I just wanted to point out these two, which are the hood that you're seeing right here. It's a very, you know, shorter, it's a little wider, that can help you, for example, in the picture here to, you know, protect, you know, the esophagus. From grabbing these sharp objects. In this case, I show you, we prefer an overtube because it was a larger object. You wanted to really protect the upper esophageal sphincter. And that's what I got for this case. I'm going to pause here. And I'm going to ask if you have any questions. Thank you very much. So nice case, Roberto. So another question for you. I think you, thanks for sharing that guidelines from ASGE about when you need to scope the patient. So you mentioned somebody with impacted esophagus who cannot handle secretions. That's a key point. And patients with sharp objects in the esophagus or batteries. That's truly an emergency. So when you define emergency, urgency, elective, what is your criteria for something emergent? And Sunil, please chime in on this question as well. Yeah, no, that's an excellent question. I think, you know, one of the first things that I tried to figure out is many patients won't give you a history. Honestly, in my experience, many patients may have some psychiatric problem and they may be not really a good source of information. But physical exams really becomes, you know, I found once or twice a really tense abdomen than they, you know, they've had perforated or at least they had a contained perp. So that becomes really important for me to determine if, you know, they are stable. And then the second thing is if they're handling the secretions. If you have a complete esophageal obstruction, and as I said, whatever it is, one time I found a big shish kebab, you know, I don't think they chew that. It was completely, you know, obstructing and they could not handle secretions. That was not a sharp object, but the complete obstruction I think is very important to determine if you really want to go right away. And then the second thing is try to really figure out if that object is sharp, you know, if it's, in some cases, an x-ray like I show you will help you guide at least where is this object if it's radiopaque, but many times if it's not radiopaque, then, you know, that becomes a little bit more of an issue, unless you know what exactly they ingested. But basically the esophagus, when they're impacted there, these batteries that can, you know, really necrose or cause really serious damage to your mucosa and they handle secretions like the ASG. Those are things that I use. And then in other cases, in my first slide, I had, you know, a kitchen knife that was in the stomach. So I think that was in the stomach, but, you know, if you see that in the middle of the night and the patient is symptomatic, this patient, I remember very clear, has ingested a kitchen knife blade, really fairly big, and it was lodged in the stomach and she was in pain. She was symptomatic. So that's another thing that where the clinical history becomes important. So that patient, I said, we need to scope this right away because that kitchen knife probably is already poking that stomach. A nice overview, Roberto. What brings you in the middle of the night to the hospital, Sunil? You know, I think Roberto really hit it on the head and I was just going to say for these sorts of patients, I think it really is important that you go ahead into the emergency room and take a look and really see what they're doing. You know, you don't trust the referring physician all the time. It's important to see if they're actually tolerating their secretions and your definition may be different from someone else's. So, you know, certainly I think for most things that we're going to see in general practice and for most of these are most commonly food impactions in adults. And I think that's really what's going to make the decision is whether or not they really are tolerating their secretions. I will say, you know, to bring up this point, you did a great job, Roberto, in terms of the endoscopic management. It's important to remember that advancing objects perforate and trailing objects don't, right? So when you are removing a sharp object like a pen or a knife or anything that may potentially perforate, you always want to have the sharp side away and not advancing. You're pulling it back towards you. And so whether you use a hood or however you want to do it, even if you just use a snare, that's a really important aspect of the management here. Right. So the sharp end is always trailing. Absolutely. So a lot of pearls there. And then what I want to see is bucket sign. You know, if a patient is holding a bucket and spitting in it or drooling, that's serious. They can truly not handle their secretions. So, fantastic. Shall we move on to the next speaker? Are there any questions from panelists? Dr. Connolly, Dr. Parikh? We have two questions before we move on. The first is piggybacking on that last discussion about timing. So do you have a time range for emergent, urgent and non-urgent procedures? You mentioned the things that will bring you in the middle of the night. What about the urgent and non-urgent cases? And the second question after that is, does everybody need routine lock-ins before moving to a foreign body? Do you want to take the first question? Yeah. You're muted. Yeah. So in terms of timing, the way I look at it, it's either I'll come in or I won't come in. So it's not going to be, you know, I'm going to come in two or three hours later. And I think the points are, you know, were highlighted by Roberto in terms of, you know, what you had mentioned, the bucket sign. If someone is not able to swallow their saliva, you're going to come in. And then, you know, depending on physical exam. So even if on history, it sounds like it's something emergent. You know, someone has, you know, swallowed a knife of sorts, but on exam, they have crepitus. On exam, they've got a distended bowel. That's not the time for endoscopy. It sounds like it's emergent, but that's not the time for you, the endoscopist, to be going in. That's probably the time for you to contact the surgeons or the cardiothoracic surgeons. So I think it's either you come in or you don't. And if it's, you know, the bucket sign, like you mentioned, then I'll come in. If it's emergent, but there's no intervention from me, then I won't come in. If the history is such that they swallowed something, you know, a week ago, which we get that sometimes, you know, they swallowed something a couple of days ago. But for whatever reason, this was convenient for them to come in. I think that's an example of when I would sometimes say, why don't we get an x-ray and see what's going on. If they came in for convenience, that's not a reason for you to go in. So it also depends on the history and when they swallowed whatever object they swallowed and what the object was. I think for the audience, if you guys want to look up the guidelines, if you visit the ASGE page and also the ESGE guidelines, they talk about, you know, what they call as emergent, urgent, and elective. Emergent is two to six hours. Within two to six hours, literally, you have the scope down the patient and urgent within 24 hours and elective after 24 hours, within 72 hours. And our panelists have shared excellent examples. So Roberto, would you be able to take the second question, please? Sorry, I had trouble to hear the second question. Can you repeat it, James, please? Sure. Just does everybody need routine labs for foreign body removal? Well, the short answer, well, your definition of routine labs, I mean, I'm guessing it's CBC, INR, probably not. Not everyone needs an INR, you know, but you have to also take into account, you know, if someone is on obviously Coumadin, you know, you want to check that before. But I don't think that everyone needs like a hard stop for routine labs. You know, many of these patients, honestly, in my experience, are very young, very healthy from the, you know, physical standpoint. And many times if there is no, you know, INR or recent CBC that they've had one, you know, in the past, I wouldn't, you know, they're not having bleeding, you know, it's, it really depends. I mean, if someone is, nothing is urgent and they're there, you, most of the time you will have some labs. Yeah. But not everyone will require every lab possible. Yeah. And I think in practical world, everybody is a divergence, you know, they get the basic panel anyways, they get BMT, CBC, and if they are on anticoagulants or if they have elderly with comorbidities, medication history, they do get basic labs. I mean, that's just the practicality of the presentation. Yeah. A lot of times they get an x-ray too. Absolutely, they do. And glucagon. And glucagon, yeah. And glucagon. Maybe we can pose that question to our next present presenter. And the meat tenderizer. You forgot that. The pepain. And pepain, absolutely. Hi, everybody. Thank you, Praveen, for having me. Thank you to the ASGE for this honor. And I'm following a great presentation here, which has set the ground for, for what's important in the discussion today. So I, some of my initial slides are still slides and here what I'm trying to, trying to depict here is obviously an impacted food bolus that we, and we've discussed impaction right now. This is a older kid who came in, was not being able to keep his saliva down. He has the bucket sign. And this is something that we see in the setting of eosinophilic esophagitis, which is to your right. And we normally see one third to half the cases, as one of our panelists mentioned, of foreign body infections being food boluses. And one third or half, I'm sorry, are related to eosinophilic esophagitis. Because eosinophilic esophagitis can involve all three parts of the esophagus. It can be proximal, mid, and distal. So most of the cases, or at least half of those are seen in the setting of eosinophilic esophagitis. One thing to keep in mind is that the foreign body infection can occur in two areas. One is of anatomic narrowing. So what are the areas that are anatomically narrow? The esophageal sphincter, the pylorus, the ileocecal valve, these are sphincter sites, the aortic arch, and the distal esophagus. These are areas of anatomic narrowing where foreign bodies can lodge and cause infection. And then there are pathological narrowing, which is where you get the strictures, the rings, the webs, the cancer, the eosinophilic esophagitis, the atelasia, and anastomosis. Also bear in mind, when patients complain of symptoms, they mostly come in with dysphagia or dynaphagia, might have chest pain. You obviously want to make sure nothing bad is going on, but normally where they point is not where the foreign body might be. So it's not always indicative of the site. But again, you have to bear in mind whether they're being able to control their secretions. And the inability to tolerate oral secretions does make you move towards an emergent endoscopy within a few hours, like Prabhavi mentioned. So I just threw this in there, something we've been doing a lot. We've been using it a lot with, interestingly, walled-off necrosis as well. But the three ways you can now tackle a food bolus is, you know, you can take all the tools out, be it the rat tubes, the various kinds of forceps, the roughness, the hood. You know, those are all techniques where you can do a piecemeal removal of the bolus. But what's also now being advocated is just the gentle push technique. So you don't have to push too hard, but if you can actually push the food bolus down without much resistance, a gentle pushing or breaking it down and then pushing, that's okay too. So you either push it down gently, you know, you're careful when you're doing it, or you do piecemeal with the various ways that we have. Or you do something with cap-assisted. This is a cap which you use for banding. You take all the bands out, you put the cap in there, and you put it in that food bolus, and then you gently remove it with suctioning. And you can actually sometimes remove it in blocks. So something to keep in mind as you look at various tools that you have to tackle these. And again, the most important thing to keep in mind are the ABCs. You want to make sure that the airway area is protected all the time. So I totally agree with Roberta. I also intubate most of my impactions just because of this classification. So I absolutely want to protect the airway. So this is something we've already laid the background of our ASG guidelines, which were a few, which came out, I think, sometimes earlier in this. And then followed by the ASG guidelines, I think, in 2016. And both of them talk about various kinds of foreign bodies. Are they sharp objects? Are they blunt objects? Are they long objects? And what is the criteria for removal? So in the first slide, you see a toothbrush, which is in the esophagus. This is a long object, more than six centimeters. So again, by the guidelines that we just shared, we would like to remove this. This is not something that's going to pass on its own. If you can get it into the stomach, that's an easy removal for you. If you can't, because there's a stricture there, then you want to tackle it from the esophagus. You obviously want to use over tubes when you are removing these or a hood to protect the esophagus. The second one is I think a telemetry lead maybe, monitoring lead that was ingested again, objects which are more than 2.5 centimeters in diameter. Again, something we don't have to do emergently, but something we need to take out in the next 12 to 24 hours. And then the third one's a lighter that somebody had ingested that you see again, a blunt object out there that probably is not gonna, something that we're gonna have to remove. These are the sharper objects that we talked about. There's a razor blade. And again, these are the ones where I think Dr. Amin mentioned the, you know, you want the sharp end to trail down. Yeah, you don't want it coming towards you. You've got to be very mindful of that. Something that Roberto and probably mentioned again, something with an overtube. This is not something you want to sit on just because yeah, they will pass, but the risk that they are going to cause a problem and the risk of surgery following that is very high, upwards of 35%. So you want to take these out and you want to use overtube to protect the mucosa as you are taking these out. So this is, these are obviously batteries and they talk about the battery sitting in the stomach and then it doesn't show any sign of damage. You can, it's not an emergency and you can come in and you can take it out in the next 12 to 24 hours. But if it's a button battery to the right and if it's lodged in the esophagus, that is an emergency. And I'll show you my next slide. So this is a nine month old boy who actually came to us about four or five months ago or nine month old baby who apparently couldn't give a history, but the parents took him to a local hospital because he obviously was refusing to eat, was having respiratory distress. The ER over there diagnosed him with croup and they thought he just had a cough and then they sent him home with some medication, maybe inhaler, something like that. Obviously the child got worse and within five days presented to the ER with vomiting, drooling, respiratory distress, wheezing, refusing to eat. They did an emergent X-ray which showed a battery which was lodged in the upper esophagus. They went in, retreat the battery and lo and behold, obviously, what you see there is a fistula. That's when he was transferred to our service over here. This came to our pediatric service. He had a big esophageal fistula and I don't have the video to show you, but just because it's all happening in live time, but notice how the fistula size has now decreased. The story ended nicely. The boy has gone home. We were able to put a billory stent in, a covered billory stent to seal the leak and we did this every four weeks and we had our ENT surgeon who actually took a proline suture and tied it at the tip of the stent, the proximal end and got it out of the nose and held it out there for all these four months that we were doing this to hold the stent in place. So just to keep in mind that batteries, first of all, that there are children and there are impaired adults who will not be able to give you a history. So you wanna get all the history you can with a good physical exam and an X-ray if you don't know what they have ingested. Number two, bear in mind that the button batteries, if they're in the esophagus and they're large, they are going to cause damage very quickly because they leak sodium or potassium hydroxide, they cause necrosis, perforation and so airway protection is key. And again, these could be easily removed with a net or a basket if this was not the situation. You wanna avoid forceps or claspers in these kinds of situations because they could puncture the battery. So this is my aha moment. So this is my foreign body moment in fellowship, guys. This is dating back several years, so you know that I've been doing this now for over 11 years or so or more. But I think I was in fellowship with this 47-year-old male who had schizophrenia, but also was being treated for HIV with the retrovirus, showed up with just symptoms of epigastric pain, vomiting, weight loss. And so we did an upper endoscopy and lo and behold, there were, I can actually, I still remember today, there were 275 because they were all removed by surgery, but he had swallowed pennies and coins because he thought that would improve the caliber of his voice. He wanted to be a singer. And so he would swallow these pennies and many of them had zinc in them. And obviously he came in with signs of zinc intoxication and copper deficiency, which came out of it, which was then the basis of our paper. But just extremely a cool case to visit when I came to know that I was giving a similar talk, I had to find my moment. So be mindful of coins at the most moment in children, but also in adults who might have other, in this particular case, psychiatric conditions or things where they do swallow, either to come out of a mental facility or to come out of a hospital, just where you have these kinds of patients who swallow just anything and everything. But again, just remember that coins can be easily removed with forceps, can easily be removed with a retrieval net. If there weren't so many coins, one could even observe them and see if they pass. And if they don't pass, then remove them in 24 hours. So this is not an emergency. This case, however, was, and eventually he did get surgery and all these were removed. So this was a video, and I wanna thank Nikhil for sharing this with me. Nikhil is at Loma Linda, and this was actually a middle-aged patient who was admitted for accidental ingestion of what he thought was a chicken bone. And here we see, again, the same thing, the sharp end kind of trailing downwards. I think there was a Schatzky's ring beyond it. They couldn't really go anywhere with it, but the whole goal was to kind of grasp this and pull it into an overtube and safely take it out without causing any damage to the mucosa or without causing any perforation. Again, the important thing in this case was we didn't really do an X-ray on this one. The patient didn't have any fever, didn't have any crepitus, so that was our relief. And here you see them kind of pulling this once they can grasp it into the overtube. This video is running a little long. We can always go with it, but I think you'll see the overtube in just a bit. And so again, sharper objects, as an emergency, you don't want them sitting around in the soft areas of the stomach. They can cause perforation, so you want to go in and take them out. You want the protection of a hood as well as an overtube. My preference is an overtube, which is something I use regularly for such objects. So Swati, these are all nice clinical polls that you're sharing, starting with the esophagus, and then if the object is more than 2.5 centimeters, it's unlikely to pass the pylorus, so you wouldn't have to eventually go down into the stomach and fish it out. Don't grasp the button batteries with the sharp retrieval tools, like a raptor or grasping forceps. Use rather a rothnet or a snare so we don't puncture them. So a question for you. We see the overtube there. And actually, this is a question for the panelists. And Swati, you mentioned about pushing the food bowlers gently. And if, starting from you, each of you tell us your preference, pushing versus pulling. When are you comfortable pushing the food bowlers down? When do you say, well, I'm not, we are gonna retrieve it piecemeal? So probably my practice has been more, initially started off with retrieving it piecemeal if this was a really big chunk of a bowlers, and then gently kind of prying it down to see if it will go down. But again, very, very gentle and not kind of trying to force it down. Always it's easy if you can go beyond it and see what's really there. But when they're impacted like that, it's very difficult. My more recent practice has been to use the cap and to try to see if I can just suction it out in block and see if that's the way to go. And then, or just kind of, if it's really impacted out there, to at least open it up some before I try to push it down. So yeah, I still do a gentle push, but I'm not, but I do try to take them either with a cap more so in the last year or so, or piecemeal it with the other treatments that we have. Or over to others. And how about you, Sunil, what's your practice? You know, I think the push is so tempting because it can end your procedure in 30 seconds and you can be done. But so much of it really is the feel that you'll develop, it's, you know, for the fellows over several years. And, you know, I can never kind of advocate that to my fellows, especially the first year fellows right away. But I do think that as you develop the skill, you know, understand what's dangerous, what's not, and just any resistance at all, you have to kind of step back and approach it differently. But once you do develop that comfort, I think the push technique is useful definitely. But, you know, certainly as Swati said, you know, use it with caution. And yeah, I think also, I feel like if, depending upon where the food bolus is lodged, right, if it's in the proximal or mid-esophagus, then especially those other settings as Swati was mentioning, you know, you have the anatomical landmarks where the bolus hangs. And especially if it's EOE, you don't know what's distally. So I feel a little bit leery pushing it down from proximal or mid-esophagus, a little bit more comfortable from the GE junction. So a question, we, so, you know, EOE, very common. Do you biopsy in the index procedure? And Roberto, perhaps you can also answer the same question. Do you biopsy? Do you dilate? Should we be biopsying and dilating the same session? Yeah, and that's a great question. So I do biopsy, but I generally do not dilate in the same setting, but I do biopsy. Yeah, Roberto, how about you? Yeah, no, I think this is a great question. It depends, I tend not to, but for example, if it's very, if there is a lot of esophagitis, a lot of, you know, friable mucosa, you know, I usually don't. I do biopsy if I suspect EOE. I tend not to dilate, but if I see that it's, you know, it is, say, it's a Chaska's ring or, you know, something else that I feel comfortable, and to Sunil's point, you know, kind of the feeling you get, the more you see, and that says that, you know, I sometimes I've done that when I feel like, well, this is very recent, this is going to still, someone who is demented is going to get impacted again, and I may not have an opportunity to biopsy or actually to even dilate. I tend not to, that's my practice generally, but if I feel like there is no friable mucosa, or, you know, it's not been there very, for a while, I will sometimes have done that carefully. You know, it's slow, because sometimes those strictures will require also multiple, you know, sessions. I tend not to, that's my short answer, but I've done it very few times, but it depends on the feeling, how it looks and the settings, like EOE, you know, there's a higher risk for perforation for the fellows, and that's also, and to the point also of Dr. Shahal, where is it, you know? Is it, for example, achalasia, foot impactions in achalasia, you know, I tend more to actually see beyond and go, and that sphincter is really tight, and once you pass the scope, you know, things get better, and then you may inject Botox, you may even dilate in that setting, but if it's very up high, EOE, I've had multiple strictures on EOE, there's just no way to, you know, start doing that, yeah, being too aggressive. You know, a lot of times for the EOE patients, the ones that present with impactions, they're either undiagnosed, and so there's a lot of room to use PPI first, or they're just not taking their therapy well, and so they've relapsed because they just have, so I always, you know, after I relieve the foot impaction, I usually always just give them a good PPI trial and don't dilate the first time, but that's just kind of. Yeah, that's a great point you bring up, Sunil. If there is a mucosal damage, mucosal dilatation, trauma, or EOE, that's what the ESG recommends also, do a course of PPI first, and then bring them back for an active dilation, and if you're pushing the foot bolus down, generally, I tend to go right side of it, you know, try to go next to it, and see if you can go beyond, because of the curve, the GE junction takes on the left side. Swati, what's your practice? Do you dilate in the index endoscopy? No, so if I'm suspecting, as all of you mentioned, if I'm suspecting eosinophilic esophagitis, I don't dilate at the index endoscopy. I do biopsy, though. If it is, if it's a Schatzky's ring, I sometimes, and if everything else looks okay, I will go ahead and dilate at the index, but not for eosinophilic esophagitis. You know, in the interest of time, probably we can skip the second video, and move to the other two presenters, just because they won't, they'll get their time if you're okay with that. So, your second video, do you mind telling us what that case was about? No, no, no, it is, it was actually a garlic, it was a whole garlic clove, I think, that got stuck. You can switch it on, we can still keep talking, but there wasn't anything more to it, and I just saw the time, and I realized that there are two other presenters waiting. But this actually isn't the setting of an eosinophilic esophagitis, if you can actually make out the rings and the pores. And again, something, this was retrieved by a Rothnett, I think that was there to it. But yeah, this was a full clove of garlic that got stuck in a patient with EOE. And so, that's what we're trying to do here. Swati, you just shattered my myth that vegetarians don't get the impact, because it's all history. I really liked it, I really liked this video, it was funny, like, unbelievable. I'm just so disappointed now. James, Malav, are there any questions from the audience you would like to ask? Yes, Dr. Chahal, there's a question to follow up on Dr. Pawar's presentation. So they're asking, can we use a distal attachment cap instead of the bander for the cap-assisted technique? By distal attachment cap, what is it, explain to me what, so we're not using the bander, though, we're using the cap, we get rid of the bands. I think they mean to ask the cap we use for like a bleeding case that we put at the tip of the scope instead of the bander that we use for varicose veins. I think you probably could. I have only used the bander. I have used just that cap to get my food boluses out, and more recently, my pancreatic necrosis out, to tell you the truth. But I'm assuming, go ahead, Sunil. The bander is just a little, it's a little longer, and so, compared to the distal attachment, and so sometimes it can be a little more advantageous in the setting, but you can use it. Either or, yeah, yeah. Thank you. Do we have any more questions from the audience? We have one more question, where they're asking for the pediatric case that was shown. How do you decide to proceed? Do you need credentialing, et cetera? I guess, probably you might have to help me on this one. We don't have, if I understand the question correctly, we don't have interventional pediatric gastroenterologists at Wake, and so we do their pediatric work. This was a very reluctant me on a weekend where I was bombarded with, not to take away anything, was bombarded with calls from every department of pediatric surgery to how we could help, and ultimately, when I did mention the covered delivery stand they said, just come and do it. But it was a case I'll never forget, and yeah, yeah. Yeah, I think any interventional case, it is done by advanced endoscopists within our center also. So it just, you bring up a question of credentialing. I think credentialing for endoscopic procedures, it varies so much from center to center. Every center has their own criteria and protocol. So you may want to check the way you practice as to what their requirements are. So shall we move on to the next presentation? If there are no more questions. There are two more questions in the chat if we want to address quickly. Sure, yeah, we can do that. First is, do you offer patients with a suspected impaction a liquid challenge, and if so, how much? And the second question goes back to medical management. Pre-endoscopy, has anybody had any experience using something, well, nitro dissolved in saline? To facilitate passage of a fluid bolus. Great question. So Neil, you want to take the first one? Repeat the first one for me. I heard the part of the sublingual nitrate. I have never actually used that, but what was the first one again? First was just, do you offer patients a water challenge in the emergency room? You know, it just depends on the situation. I mean, if they're not tolerating their secretions, they usually don't, you know, if it's going to pass, it's going to pass, and the water challenge usually isn't going to help that. If anything, it's just a little unsafe, I think. I agree, me too. I mean, if they're not tolerating secretions, you really don't need a challenge. You will see that they can swallow saliva. So it's actually unsafe to give them more to swallow. How about you, Akwi? Yeah, no, I agree with them. I don't do the water challenge. I think there's also the risk of aspiration, especially if you suspect that someone has an impaction and you're planning an endoscopy. I think it might be a little bit unsafe. I don't have experience of using the sublingual nitro. I've not done that. So, yeah, neither do I. I have not used it, but have I tried glucagon? Yes, I have. I think panelists can chime in on that, how effective it is. It is not recommended by the guidelines. I've seen like flip of coin where it works, but if you have a fixed obstruction distally, it's not gonna work. And I think the question was liquid challenge. That's where history is very important, right? When you're talking to the patient, if the patient is telling you they still have that foreign body sensation, I'm not sure how helpful the water challenge is going to be or if they're still drooling. So we can move on to our next presenter, Dr. Osambong. Okay, perfect. So just a brief history. So I just wanted to highlight. So the reason for consult in this case was three points. I usually, when you get that call for consult, I usually like asking specific questions. What is your question? And so their questions were to identify a fistula, place an NJ tube, and then to remove a biliary stent. So the backstory, it's a 51-year-old male with a history of necrotizing pancreatitis about a year ago, which was complicated by gastric varices that required endoscopic coiling. He had a hemorrhage that needed GDA coiling and then gastric outlet obstruction that required surgery. So gastrointestinal ostomy. And then due to the severe episode of pancreatitis, he had associated biliary stricture and he underwent an ERCP and they placed a covered metal stent. So this was a patient seen recently. So the stent is about a year old. He was in the hospital for other things, weakness, nausea, vomiting, but the key thing was those three points for the consult. So knowing that I was gonna do an ERCP, so usually you do a scout film as a baseline and the scout film can give a lot of information. So first of all, there's a question about a biliary stent. So when you do your scout, you'll see if a patient has a stent or not. Other things you can see on a scout film is if a patient has had surgery, you might be able to see him some surgical clips. And it's always important when you get your scout film that you're able to see the dome of the liver. So in this scout film, I see the stent, I'm like, okay, he truly has a stent and then you could see some drains. So going down his esophagus, you just see some plaques, you get into the stomach, just a little bit of erythema and some fluid within the stomach. Once again, just some gastric erythema and you can see he's had the surgical anatomy. So he had a gastrogynectomy, normal appearing small bowel. And this was a tattoo placed by a colleague previously, just to kind of help identify which limb to go into. So then this is the duodenal bowl. And so when I did the procedure, I'd switched over and used an ultra thin scope, which is about a 5.9 millimeter. And with the scope unintentionally ended up entering into the stent, as you can see on fluoroscopy here. And then I answered the questions they had. Question was where I put the square about the fistula and at the top, I'd pointed out to where the ampulla was and then cannulation, put the wire in and initially tried to remove the stent using a balloon, which is what you can see on this fluoroscopic image. And that was unsuccessful. So then in this video, so then the procedure was actually repeated by a colleague of mine. And so now we're just at the ampulla and there's just a lot of edema at the site and it's just a little bit bloody as well. And so very soon you should get a peek of the stent. All right, yeah, so you can see the ampulla and hopefully you could appreciate the stent. And so what she has here is a rat tooth where she basically tried to move the mucosa in the area of the ampulla to try and grasp the metal stent. So you can see a little, hopefully you can appreciate that little silver lining, which is the metal stent. What she's trying to do here is to actually grab that metal component and pull the stent. And it was a little bit challenging mainly because there was just a lot of edema in the area. And you have to keep in mind that the stent has been in there for about a year. And eventually you'll see her get ahold of the stent and start tugging at the stent. And as you're doing that, it's extremely important that you have your fluoroscopy on as well as you're pulling at the stent so you can watch it on fluoroscopy. And so at this point, she has a good hold of the stent and starts tugging at the stent and your screen may suddenly sort of turn pink because of the tissue. And the last thing you want to do at this point is to panic. And so you'd want to slowly look away and keep tugging. And it required a lot of force for her to be able to get the stent out. And so that's when you're seeing this few seconds of sort of pink white tissue. and the stent was mangled and started to sort of come apart, but there was success. And so that's the mangled stent, but it eventually, the stent eventually came out. Next video is, the stent has been removed, and what's important about this, this is a very short video, is that she, you know, she took the pictures of the stent at different stages, meaning trying to show pictures of the entire stent, because you'd want to examine and make sure that you did not leave any piece of it behind. So this is the stent that had been in place for over a year, and the stent was mangled, but it was intact, and that's extremely important, because if you had a piece left behind, then that would serve as a nidus for further infection. So I think in this case, just a few points that I wanted to highlight whenever we think of a biliary stent. So your biliary stent can actually migrate either proximally, meaning up into the liver, or distally, meaning out of the bile duct. So if it goes up into the liver, the things you're worried about is a hepatic or gastric fistula, or even a pleural biliary fistula. If it migrates out, the best thing that can happen is someone would spontaneously pass it. I actually had a conversation with a patient about that today. Or they could have bleeding, they could have wall injury, they can even have perforation, and I think that goes to the point earlier Roberta had mentioned in terms of the importance of examining our patients. And so the risk of migration is 1 to 20 percent. So it's about 1 percent if it's an uncovered stent, 5 percent if it's a plastic stent, and it's about 20 percent if it's a fully covered stent. And keep in mind, this person had a fully covered stent. And so what are some of the things you'd want to think about when you have a patient with a stent? So the first thing is communication with a team. And that's why it showed those points of asking the question, what is the consult question? And making sure you and the team are on the same plan. Then you want to get a very good history. First of all, why was the stent placed before you try and remove it? Was this placed for a benign reason or for a malignant reason? If it's for a malignant reason, you probably do not want to remove that stent. Generally when we place the mental stents for malignancy, they're permanent. And then you want to know when was the stent placed? Was this something that was placed a few days ago, which sometimes happens. If we've done an ERCP, someone bleeds, we put a covered stent, and we'd come back in a few weeks to pull the stent because we'd put it in there for tamponade. Or was this something that was put a year ago? Maybe the patient was lost to follow-up and that's why the stent wasn't removed. And then you want to know what type of stent was placed. Is this a plastic stent or is this a metal stent? Because then that helps you determine what you should be doing in terms of how you'll remove that stent. And then I just had this picture in terms of the retrieval equipment. So these are things you're thinking about after you've obtained that detailed history, how am I going to remove this stent? All right, so the options are you can use an extraction balloon, which is something that I had tried. And each time I try to drag the stent out, it would sort of fold and form like an accordion, and it would not budge. And then the other thing you can always use is a basket, which is what you see in the second image. You can always use a snare, and the snare is probably easier with the plastic than it would be for the metal. And then you can use a rat tooth to try and grab it. Initially, when trying to grab it, one of the challenges I was having is it was grabbing the pulsa. But eventually, when my colleague had performed the procedure, she was able to grab it. It was mangled, but she applied a lot of force and eventually got the stent out. If none of those work, you can always do a cholangioscopy. And with that, you can use the spy bite. So you can use the forceps, or you can use a snare. It's pretty tiny through the spy scope. But those are always alternatives if you're not able to use, whether it's the balloon, the basket, the snare, or the rat tooth. And I think that should be the end in terms of my main point. So I think for this one, the key thing is just looking at a biliary stent as a foreign body, not necessarily impaction, but one that probably should have come out much sooner than a year. Thank you for sharing that presentation, Akhui. So this is foreign body impaction in the bile duct. And I think one point I would like to make is that all of us, we've encountered these cases of embedded stents. Sometimes you can unravel the stent, just like the wires were coming off. So you can unravel the stent. I would be very careful in how much pressure you're exerting, because they have the effects of total evulsion of the bile duct. So you'll be very careful you're not putting a foot on the patient's button. So excellent case. So moving on to our last presenter, Dr. Sunil Amin. Sunil, do you want to take it away? So this will be quick. And I think this will be a good case to tie everything together. This is a case performed by my colleague. And the endoscopy, you'll see, was by one of our first year fellows. I think it has some good teaching points here from an endoscopic perspective. So this is a 20-year-old woman. She presented to our hospital with epigastric pain and dark stools. She told us that 10 days previously, she'd been forced to swallow a GPS tracker and some coins and by someone that was forcibly trying to control her behavior. She didn't have any hematemesis, dysphagia, nausea, no fevers. She had had a prior c-section. Her physical exam was unremarkable. She was tolerating her secretions. She looked healthy and well. And her laps were pretty unremarkable, but she was HCV antibody positive. So of course, the emergency room obtained an abdominal x-ray. And you see these two ellipsoid-shaped metallic foreign bodies measuring about 2.6 centimeters. And that's important because we talked about 2.5 centimeters kind of being the cutoff of the pylorus concerning for injected foreign bodies, possibly even button batteries. So that's another point we were talking about. If this is a button battery, is this in the esophagus or is in the stomach? And is it safe to do this now or do you have to do it right away overnight? Or do you have to do it or can you do it the next morning? Remember that the history we got was that she'd ingested these 10 days previously. So you can probably guess what we did. I'm just advancing the slide here. So a CT was actually done as well and it showed the same thing. These disquieted metallic densities in the gastric lumen, they were able to specifically say this time, measuring 2.1 by 0.6 centimeters. So you can see them nicely right in the antrum of the stomach. So this is the endoscopy. It's about two minutes long. And as I said, it's one of our first-year fellows who did this case very nicely. Just bear with me. We're advancing the scope into the stomach and turning towards the antrum. And in a second, you'll see These two, exactly as the CTU described, these discoid-shaped foreign bodies, you know, obviously you couldn't tell if they were a button battery or what they really were from the preoperative imaging, but here they are and they've been in the stomach for about 10 days. So, you can see a retrieval net is being used here, and it pretty easily the endoscopist is able to, you know, maneuver around both of these at the same time. And so the net's closed here and in a second you'll see the fellow kind of struggling here at the GE junction to get the foreign bodies into the esophagus and eventually what they ended up doing was going back into the stomach, letting go of one of them. Now you just see there's one here. And again, you'll see the attending actually takes over here and the technique that they're using, they're kind of jiggle, jiggle, jiggling here to get through. The fellow wasn't able to do it and this kind of goes back to the feeling of what, developing that feel and what's kind of an acceptable type of pull and what's not. And so the attending kind of jiggle, jiggle, jiggle was able to get it through the GE junction into the esophagus and when it was measured there, it was just about two centimeters. And here's a second one. And I think that's pretty much all of the teaching. This is pretty similar. And when they're measured, as I mentioned, they're just about two centimeters. So they stayed in the stomach. They did not pass through. I think that's it. That's a nice demonstration, Sunil. Thank you. So, you know, panelists, you showed different tools and techniques, foreign body infection in the esophagus, in the stomach, and in the biodegradable use to treat rot net, retrieval net, grasping forceps, snares, and how we can use those techniques to and how we can use this different tools and techniques in different scenarios. One thing, you know, while I was watching your videos, Sunil, it came to my mind that, you know, rot net, it comes in, the retrieval net comes in different sizes, right? So, you know, be mindful of the endoscope that you're using. So if it's 2.5 centimeter, you can pass through the standard upper scope, but if it's four centimeter, you'll need a therapeutic channel scope to pass the larger caliber grasping net. Do we have any questions? Again, thank you for the great presentation. Any questions from the audience? I'll just say this is what was pulled up. I don't know if any of you have seen these tiled devices, but people use them to to keep track of their keys or their phones and Wow. Oh, wow. Yeah. I wouldn't be remiss to mention magnets. For some reason, Sunil, when you were first presenting, I wondered if there was a magnet in there, too. Yeah, me too. Magnets need to need to come out as well. Yeah, come out. Great point. That's something we don't want there. Yeah, yeah. So we touched that foreign body as well. Right. Magnet, right. Single versus multiple. Multiple is truly an emergency. Absolutely. One's also talking about like magnets, batteries. I've encountered this this batteries on x-ray or CTs in the esophagus that actually were Pepto-Bismol tablets, because Bismuth is radio opaque. Yeah. That's a good type of batteries to swallow. But yeah, no. And this was in the setting of someone with dementia. You know, they they found this and they were like, you need to remove this battery. She swallowed it. But they were Pepto-Bismol, thankfully. Any questions from the audience? James, Malav? Hi, Dr. Jhaal. We have one question. There was a image where there were like, you know, multiple foreign bodies. So for the points in the stomach, like what should be done for that? Should be removed. For example, in that case, there were so many of them should be removed slowly one by one or any other intervention should be considered. Swati, I think this was the case that you presented. There were 275 coins. But also, if you want to, if you want to mention narcotics, the packets, I think that was something else that we didn't mention. Whether you want to remove them or not, when people are ingest those, those will be something that you wouldn't want to remove as well. Yeah, the body packers. Yeah, because of the risk. Yep. The risk of the bag, you know, sort of bursting, basically. Yeah, we don't remove them. That's correct. That's a great teaching point. And I think, you know, whether you can remove 275 coins in endoscopy, you know, we have had patients, I think a lot of the big institutions, we have had patients who because of underlying psychiatric illness, they are just repeat foreign body swallowers. And they end up with multiple surgeries. They end up with frozen abdomen. The first case that Roberto showed you, I don't know if you guys spotted, there was over the scope clip sitting there in the stomach with previous perforation. So I think if you have somebody with frozen stomach, if you don't have any options, you probably just sit there and try to do your best. And another teaching point was coins are made up of copper, zinc, and tin. So now we know the chemical composition. Any other questions from the audience? We have one more question. Dr. Roberto showed an image about a knife with a sharp blade. So what should be done in that case? Because sometimes it's tough for that to come out through the tube for it not to damage the stomach or the esophageal mucosa. Yeah, well, that's, you know, we've discussed multiple good principles that will apply to multiple type of foreign bodies. Like, you know, we were mentioning, well, in a knife, specifically, you know, one thing is, you know, one end of the knife is the very sharp end. So, you know, you want to grab the other end and then over to basically you do your best, you know, like Dr. Shahal was mentioning, many of these patients are, you know, have repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive, repetitive,

foreign body impactions

gastrointestinal tract

careful examination

removal approach

retrieval nets

grasping forceps

snares

Ratnet

esophagus

stomach

bile duct