And now it's my pleasure to ask Dr. Christie to come back to the podium and to talk about something that I think we all deal with, usually I think around 3 a.m. on a Sunday morning, about how do we manage foreign bodies and food impactions. Thank you, Anne-Marie, and yes, that was going to be part of my introduction. I think we're all very much accustomed to those 2 a.m. calls on Saturday night, or excuse me, Sunday morning, that it's not so fun when you get the call, but as you're driving in and you're thinking about what the fellow or what the nurse or tech told you about that patient and planning what to do, and then once you get in there and do it, and oftentimes we are successful in actually extracting that foreign body, it's extremely gratifying. You know, obviously to the patient, but certainly to us and the entire team. So I'm excited to talk about this today. Here are my disclosures again. So our four major objectives in this talk are to, one, discuss the incidence and risk of food impactions, as well as foreign bodies in the GI tract, number two, to understand the appropriate timing of endoscopic removal, three, to review the strategies and the tools necessary for endoscopic removal, and then lastly, talk about some of the techniques for safe endoscopic extraction of foreign bodies. So when approaching foreign bodies and food impactions, it can be thought of in two major categories. The first category is foreign body ingestion. This typically happens either accidentally in a child or someone who is mentally altered, or in patients who have psychiatric disorders. It's not, it's something that we see in these patients, and then sometimes in patients who are after secondary gain, specifically around people who are incarcerated and they're looking for an exit. Most of these foreign bodies move, pass spontaneously, about 80%, however, impaction, obstruction, and perforation can occur, particularly at areas of angulation. So the upper esophageal sphincter, the aortic arch, the GE junction, the duodenal sweep, also the IC valve, and the anal canal. So usually when we come in, they're sitting somewhere in those areas. As far as esophageal food impactions, usually there's some underlying benign pathology that's precipitating this. Commonly we see distal, we see rings in the distal esophagus, or strictures, or webs. Oftentimes we see it in areas where there's some surgical alterations, such as in fundoplication or anastomosis, and also we see it commonly in patients who have eosinophilic esophagitis. So always think about that underlying pathology as well. As far as the epidemiology, it's hard to really know what the actual epidemiology is in the United States, but it's estimated to be an annual incidence of about 120,000 in this country, with about 16 per 100,000 as far as food impactions specifically. Like I said, most of these foreign body ingestions and food impactions will pass spontaneously, however, 10 to 20% of them will require intervention, and endoscopy is the most common modality for that intervention. About 27% of patients will have some adverse event, and that can come in the form of tears, or even perforation or ulceration. And as I mentioned, we do see it commonly in children, but also commonly in patients in their fourth decade of life or older. So the types of foreign bodies that can be ingested, it ranges, and oftentimes this depends on a patient's age. So children, it's not uncommon, unfortunately, that they will accidentally swallow coins, toys that have magnets in it, crayons, pens, pencils. When you take your eye off the child for a hot second, and I've had some close calls in my lifetime with my kids, but it can happen, unfortunately. Batteries are another common foreign bodies. And then as far as adults, food impaction is actually the most common foreign body ingestion. In Western cultures, it's typically meat. However, on other continents, such as Asia and Africa, actually bones are the most common type of food impactions. And in the elderly, we see that dentures can oftentimes slip out, and the patient may swallow them accidentally. And also sharp objects, specifically in patients who are mentally altered or are out for some secondary gain, such as razors and needles and that kind of thing. And then we also see foreign body ingestion in the form of drug smuggling. So we know that there's this phenomenon of body packing, where people will either swallow a bunch of heroin packets or inject them rectally to try to smuggle them to different regions of the country or the world. So in terms of the actual trends and clinical features of accidental and intentional foreign body ingestions, this group looked at the prevalence in the United States between 2000 and 2017 in adults specifically. And they found that patients who ingested accidentally foreign bodies, they typically were altered in some kind of way. And alcohol was the most common thing that caused them to be altered. And as far as intentional, again, people who tend to be in police custody for secondary gain is a common underlying theme, and also patients who have mental disorders. So I want to share with you about my patient, one of my patients who is a 73-year-old woman who was just, the story that I got was that she was just sitting on her porch in St. Thomas, the Virgin Islands, talking to some friends and family, and she was drinking water and she was playing with the water bottle cap in her mouth and just having a good time, you know, chilling out and all of a sudden she swallowed it. And then 48 hours later, because they couldn't get the bottle cap out of her upper esophagus in the Virgin Islands, they just didn't have the people or the tools to do that. She was flown to Atlanta, 48 hours later she landed in our endoscopy suite. So when we went in with the flexible endoscope, we saw the bottle cap here just sitting right below the UES, and she was already intubated, like I said, because she had to be flown over. So we used rat tooth forceps, graspers, snares, baskets, everything kept slipping off, couldn't get it off. And then after about 90 minutes, we decided, the fellow and I and the whole team, at this point it was a team sport, we put a 9mm balloon just past on the side of that bottle cap and then just slowly withdrew the scope with that balloon inflated outside of it and we were able to pull the bottle cap right above the UES but couldn't get it all the way through. So then my anesthesia colleagues took a McGill forceps and under direct visualization was able to just grab that bottle cap out and you could see it just above the UES on this right panel here. And once we got it out, I mean, it sounded like a football game in that endosuite. We were high-fiving, we were hugging, and this was before COVID, we were hugging and the whole nine, and it was just extremely gratifying. The patient woke up the next day, extubated, saying, you know, what happened here, why am I here? But anyway, it was a good story. So decisions, decisions. So what we want to do when we approach these patients is, when they're sitting in the bed looking at us in the ER, is to ask them, you know, where do you feel it? Do you have pain, do you feel, do you have dysphagia? The location is helpful, but it's not predictive, but it is important to try to elucidate that. Also see if they are drooling, if they can handle their secretions. That's going to impact the timing of when you're going to extract that device or that object. And then also if they have shortness of breath, which may suggest that there was perforation. As far as radiology, oftentimes for true foreign bodies, such as bones or coins, you can actually see radiopaque objects, as seen in this child who has a coin in the upper esophagus. And also in this lower panel here, where you can see a bone that's stuck in the upper esophagus in this patient, it can be helpful. And also CT scan can be helpful to determine if there's a perforation or if that foreign body moved beyond the esophagus where it is exactly in the GI tract. However, if imaging is negative, it should not preclude you from going in to try to extract the foreign body, particularly if the patient is symptomatic. And then certainly we do not encourage using contrasts in these patients, because if a patient is obstructed, they could aspirate. And the gastrographin specifically is very hypertonic, and it could cause pulmonary edema. So no oral contrast studies. So in terms of timing, the type of object that the patient ingested really dictates when you want to go in. So in any situation where a patient is obstructed, you want to go in within six hours. So that's very important. Any disc batteries that are in the esophagus, you want to go in soon, because liquefaction necrosis can occur with these disc batteries and cause perforation and multiple complications. And then certainly any sharp or pointed objects, such as the bones we talked about, or razors, you want to go in and get them quickly, as they can cause perforation. Urgent endoscopy, so that's within 24 hours, is for esophageal food impactions, as long as the patient can handle his or her secretions and aren't too obstructed. And then dull esophageal objects also can be done within 24 hours. Sharp objects that have gotten past the esophagus and now they're in the stomach and duodenum, you still want to go get those out, but it's not as urgent as these will less likely cause perforation. Magnets, certainly if you have two or more, you want to make sure you get those out within 24 hours, because the attractive forces between those two magnets can cause fissilization, perforation, and neuronecrosis. So make sure you want to try to get those out. Coronabodies that are considered non-urgent, or within 24 to 48 hours, are esophageal coins. Oftentimes, they can be observed to see if they pass, and certainly in a patient who is asymptomatic. Objects that are greater than 2.5 centimeters in the stomach, you can wait a little bit there. Most likely, they're not going to be able to get through the pylorus and that duodenal sweep, but you do want to get in within one or two days to remove those. And then, of course, disc and cylindrical batteries beyond the esophagus, without signs of injury, you can wait for up to two days. So in terms of management, so we talked about some of the timing factors. The other important component is your collaboration. Who do you need in the room on your team during that endoscopy? So if you need an airway, someone needs to be intubated, obviously you want your anesthesia colleagues to be there, or if there's an increased risk for aspiration, or you think you may need to intubate that patient. But you also may need ENT or pulmonary in the event that the patient may aspirate the object and need a bronchoscopy. And then oftentimes, the surgery team has to be on board, too, in the event that the object doesn't pass or there's signs of perforation. And preparation and anticipation is really, really important. Oftentimes we're thinking about it, like I said, as we're driving in to approach that patient. What do we need? So you want to really go through that exercise of what scope you're going to need. Even have that conversation on the phone with your fellow or with the nurse or the team that's setting up for you. Flexible endoscopes for upper GI tract objects are usually most beneficial, but in some situations a rigid endoscope is helpful, particularly for objects that are above the UES. Also what tools you're going to need, and we'll go over some of these. We do use pharmacological agents such as effervescent agents, although the data is very limited. There's no really strong studies to support the use of these agents. But we do know anecdotally that they can be effective. So when we get that call and you're saying, did you give him something that's carbonated to try to push that object down into the stomach, you hope it works. Oftentimes it doesn't. But also consider glucagon, and the recommended dose is one milligram IV. If that doesn't work initially, you can wait maybe 20 to 30 minutes and give another dose and see if that will help with the relaxation and peristalsis and get that object to move through. Other pharmacological agents include your anti-muscular, anti-cholinergic agents like hyacinamine, and it anecdotally can be helpful. So in terms of the equipment and tools, we talked about the flexible scope and the rigid scope. Other devices that can be helpful are your baskets, your Rothnets, your retrievers, your forceps, and then also your snare. So you want to make sure you have all of those in the kit ready to go. And of course, over tubes and hoods. So when you approach a esophageal food impaction, typically you want to try to get past that impaction to see what's just beyond it, to see if there's a stricture, how narrow it is, and also assess the angle so you know which direction and which to go. But if it's possible and the stricture is not too narrow, you can gently push in the center of the bolus to get that bolus to move into the stomach. And oftentimes it works. If you cannot do that, then you can maybe snare it down piecemeal and then push the bolus into the esophagus, or you may need an over tube or intubate the patient to slowly extract the food bolus by the mouth. So special considerations in EOE, as I mentioned, it's very common that these patients will have impactions. It's present actually in about 33% of patients with food impactions. So it's important to recognize EOE. Typically it's a young Caucasian male who has a history of dysphagia, as well as eczema or atopy. And in these situations, you want to consider pulling the bolus out as opposed to pushing because of the risk of perforation. And if possible, it's good to biopsy the esophagus at that index endoscopy so you know how to manage that patient going forward. In terms of removal of long objects, that is urgent, as I mentioned. So here's a pencil in the esophagus. It can be very helpful to use sometimes that you may need like a double channel scope to be able to maybe snare that pencil and then use forceps to grab it through and pull it up through an over tube. The perforation risk, like I said, is very high. So you want to try to get those objects out. Here this patient has a spoon in the stomach that you do want to get out pretty urgently. Removing sharp objects, again, remove them emergently, particularly if they're in the esophagus. And if they're in the stomach, sometimes they will pass spontaneously. But if you can get it, you want to get those out. And if you can't get it, then you want to follow up with x-rays to confirm passage. And use a hood or a condom or an over tube to remove that sharp object by pulling the sharp object into the over tube. And the sharp end of that should trail to prevent perforation. This is a very common sharp object in the elderly where you have this medicine packing that gets stuck because older patients sometimes cannot, they have poor vision, so they can't see. Also, they have poor oral sensation and swallowing. So this is something that you may come across. As you see with extraction of that medicine packing, there is a small esophageal tear. These are your hoods and your over tubes. If the device is in the stomach, you want to use a long over tube. So with rectal foreign bodies, again, drug packing is a common reason for a rectal foreign body. And as always, leave the drugs alone, even in terms of impaction. And when you have a patient who has either swallowed heroin packets or injected it rectally, you want to just follow that patient, put them on a clear liquid diet to see if it's able to be passed spontaneously. Because attempted endoscopic removal can cause rupture and death. And if it doesn't pass spontaneously, then the patient may need surgery. This is a report of a patient, and this was published by a group in GIE in 2018, where this patient had actually inserted a test tube into his rectum, and then he couldn't get it out. And you can see the test tube here, and here's a lateral view. And so what this team did, they were actually very creative in that they put a CRE balloon through the scope, and then into the tube, the test tube that was in the rectum, inflated it, and it created a nice seal in the test tube, between the balloon and the test tube. And then they pulled the whole apparatus out of the anus and were able to get that out. So as far as using balloon enteroscopy, the data here is very limited in terms of the effectiveness of balloon enteroscopy for small bowel foreign bodies. But this group, Kim and colleagues, they looked at a series of 34 patients in their center that had extraction using balloon enteroscopy. And they found that half of those patients, they were actually able to get the foreign body out of the small bowel, and most of those were actual capsule endoscopes. And then another 16 of them had to go to surgery, and it was successfully removed. There's this one patient that they described where they did an endoscopy, they did an anti-grade double balloon enteroscopy, and they saw the capsule endoscope large about 60 centimeters from the ileocecal valve. And again, this is under fluoroscopy. So then they dilated this stricture, it was a stenose ulceration from someone who was taking NSAIDs. They dilated it, and then were able to get a basket through the scope, grab the capsule, and then remove it nicely, moving the entire scope with the basket out of the patient. So the key take-home tips I have for you is to, one, plan your strategy and your tools in advance. Take special care to protect the airway, so intubate children and people who have mental illness or who are altered. And collaboration is really important with anesthesia, your surgeons, and maybe even ENT. And also, perform a relook to document for any tears and make sure that there was no perforation. And in the setting of EOE, consider biopsy. If a patient has a stricture, you also consider dilation during that endoscopy. Thank you very much.

foreign bodies

food impactions

gastrointestinal tract

endoscopy

collaboration

esophageal tears