So, we're going to talk somewhat fast about management of foreign bodies and food impactions, okay? This is definitely a call you're going to get. It's a great role for us. We really get to save patients, you know, relieve very significant symptoms. It is an emergency. You kind of have to quickly decide how emergent the procedure is, and hopefully this will give you some guidance to it. So, when you get called by a foreign body, food impaction, et cetera, first question to begin to consider is truly how emergent it is, where is the impaction, if you have a sense or if you can figure that out, what is possibly causing the impaction, and really food or something else, is that something else sharp, is that something else sort of dangerous from a sense that it can leak or create some local effect that will be potentially catastrophic. And then, quite soon afterwards, you want to think about what you're going to do and what your sort of procedural approach to it is. In terms of airway protection, if you're removing something from the, you know, esophagus, stomach, small intestine, whatever, you're pulling it through the oral pharynx, the right answer is always to intubate these patients. There's really no scenario, I think, in my mind when you shouldn't intubate the patient. So this is what you'll encounter a few, maybe not hundred times, but many times during your fellowship. This is a food bolus stuck in the esophagus. And sometimes you'll encounter some more interesting objects. They can be toothbrushes, pens, and many other items that you may not think are swallowable that will turn out to be swallowable. Who does this happen to? So a surprisingly large number of people this happens to, but there are some high-risk groups. Obviously, few of you will see pediatric patients, but older individuals without teeth, certainly younger individuals who'd have either diagnosed or undiagnosed eosinophilic esophagitis, and then certain populations like those who consume a lot of alcohol. For whatever reason, prison patients tend to have this, and then certainly psychiatric patients. It's important to recognize that once it has gotten past your esophagus, and it's not causing dysphagia or any other issues, and you visualize the item on an x-ray in the stomach, the majority of this will pass. And you really have to think about whether is this a type of ingested material or particle that you have to remove for whatever reason, and we'll get into that. And is the size of it or the shape of it, or is it sharp enough that you should think about removing? But most of it will pass, thankfully. So not everything needs to be removed, okay? You want to think about how fast, if you're in the stomach, much easier to remove it from the stomach than in the mid-jejunum. So if you're going to decide we're going to remove it, you might as well remove it fast, okay? Because that's a convenient place to grab these things in the stomach. So this is sort of a list of possible options, but this list is kind of endless, and people are very creative out there, so everything can get stuck, okay? How do they present? So again, dysphagia and difficulty swallowing, inability to tolerate secretions, hypersalivation, those are the things that are big red flags, okay? If you don't have those, and presumably the object has passed, then your attention sort of shifts to what kind of object you're dealing with, okay? So, computers, batteries, anything sharp, needles, etc., and very large or long items that are typically larger than two centimeters are the stuff that are going to either cause a problem or get stuck, okay? So after you've gotten called about the patient, the first thing you probably want to ask is some sort of a radiographic study. The easiest thing for most of these patients is going to be to get a chest X-ray and an abdominal X-ray. At the very least, you should always have that. For patients with any concern for esophageal perforation, either the resident mentions that maybe there's a little bit of crepitus or subcutaneous emphysema or any other signs, it's always the right thing to get a chest CT or a neck CT to look for a little bit better of an anatomy, figure out where things are stuck, and in fact if there is a perforation or not. But you should not be scoping these patients, at least without an X-ray of some sort. Contrast is very, very rarely in this scenario ever helpful. It probably would just make your procedure a little bit more difficult. But if you're thinking about an obstructed esophagus or a food infection, don't use gastrographin. The production of gastrographin can be very bad and will create pulmonary edema. Where do they get stuck? So at the end of the day in the esophagus, they either get stuck above the upper esophageal sphincter or above the lower esophageal sphincter or the G-junction. If it's really high up in the cricopharynx or the upper esophageal sphincter, call your ear, nose, and throat colleagues. It's much better suited to be removed with rigid instruments. Everything else, it really doesn't matter whether it's at the level of the aortic arch or the mainstem bronchus or whatever. Pylorus and IC valve are the next two stopping points, and typically size and shape will determine. So toothbrushes are not going to get through the IC valve, although you can sometimes be surprised what actually does travel through the small intestine. I'm always impressed that we place a fair amount of large esophageal stents. Those can be like 10 centimeters long and 2 centimeters wide, and I have had many patients who have passed them naturally per rectum. So it's impressive what can get through. I don't think toothbrushes will get through, OK? But I'm sure somebody else has an anecdote about that. So this is important to consider, again, because not a food impaction or not an impaction in the esophagus, you identify the item or the object in the stomach. First question to ask, is this big enough or dangerous enough to need to be removed? And if so, quickly do it before it attempts to get through the pylorus. If it's past the pylorus, if it's a reasonably sized object and it's in the mid-small intestine and it's past the pylorus, you're probably going to have to follow it and wait for it to get stuck in the IC valve, OK? For the most part, it's going to be a difficult kind of—it's high bar to do push enteroscopies or balloon-assisted enteroscopies to fish out something from the mid-small intestine, OK? But those patients you have to follow and make sure that it's not actually getting stuck in the IC valve. So what are things that need to be removed? So again, food impactions and esophageal foreign bodies should be removed for sure if they cause airway compromise, if there's a concern for perforation, or they're sticking through the wall or the lumen of the esophagus. If the patient has hypersalivation and is really not able to tolerate their secretions, that tends to be a good enough sign that you should be doing this emergently and that evening or whatever, that next few hours, OK? If they have a sensation and they tell you that it's—you know, and it's a reliable patient and it's clearly food-related, but they're able to swallow, it just feels a little bit uncomfortable, that may not be a patient you have to do at 4 o'clock in the morning. You should probably do first thing in the morning, but they're not in an immediate danger necessarily. So again, sharp objects below the upper esophageal sphincter usually call for ENT. If they're above the upper esophageal sphincter or it's right at the level of the upper esophageal sphincter, OK? If you're removing something that has gone through the wall of the—of whatever part of the GI tract, think about what you're going to do once you remove it. If it's a needle, you're probably not going to do anything. You're going to pull it out and it will close on its own, OK? If it's something larger, I have removed, like, very sharp clam shells or relatively large ones, and when you remove it, there is a defect there. You're going to have to sort of think about how you're going to address that, and you probably have to address that if there's a, you know, more than like a centimeter defect. So again, airway precautions, again, not sure that there is a reasonable path for not intubating these patients, OK? When you're pulling something out, when you're pulling out food particles, there is a chance that they get dislodged as you pull it through the upper esophageal sphincter, then the patient aspirates it, et cetera. It's hard to make a really good case for doing, like, a conscious sedation type of procedure for these patients. So again, resources may be different at some places, and sometimes you may find yourself in a situation that you absolutely have to do this, but in general, I think the good practice would be just to intubate everyone. So know your tools and get ready for all of them to be available. The standard graspers are very helpful to break up things, to pick up, you know, food impactions, et cetera. The snares and the Rothnets and whatnot have the advantage that if you're worried that whatever you're grasping is going to break. So batteries are one that you don't want to grasp because you don't want to release the content of the battery. I'm sure some of you will potentially encounter patients who have swallowed, like, whatever drugs or medications that they're transporting. The most typical one would be cocaine. So if you know that that's what's happening, you obviously don't want to grasp that with a red-toothed forceps. Those are scenarios that you want to use a Rothnet, which is atraumatic and will engulf the object. A Rothnet, if you haven't used it yet, is basically a snare with a net on it that allows it to kind of, like, hold the object inside it, okay? And then very quickly think about what's going to happen on your way out from the esophagus. How can you protect the lining of the esophagus and the upper esophageal sphincter, for example, from something getting stuck or scraping through, okay? So if you've got, like, a clamshell that's about, like, a quarter size or whatever, a couple of centimeters wide, when you pull that thing through, you could easily slice the whole thing on your way out. And at the very least, that will cause a lot of pain. In the worst-case scenario, it will actually tear and perforate. In those cases, a hood is very helpful. It will protect the object that's in front of the endoscope. The other thing that's very helpful is an overtube. So this is something you want to think about. You want to have it available. It's a long plastic tube that you place into the esophagus, okay? And you want to learn, and this you have to do hands-on, how you place it. It's not the most trivial thing, and there are some tools, I mean, tricks to the placement. But it is a very handy thing for two scenarios, when you need to go in and out, bringing things in and out many, many times, and you don't want to, like, intubate every time the esophagus. And the other is that it allows, again, a way to pull something through that's potentially sharp, like a safety pin or whatever, through the plastic tubing without having it come into contact with the lining of the mucosa in the upper esophageal sphincter in the mouth. Okay, so when you encounter, again, your most common scenario, which is this food bolus, so know your patient. Think about, like, you know, what could be below it, okay? Is this a patient that you know has an esophageal cancer, and unfortunately, this is now a full obstruction, okay? So if that's the case, you're not going to jam this thing to try to get it through the obstructed distal esophagus. If this is a patient who has a known stricture, but this is their fifth presentation with a food bolus, and every time they were able to gently push this thing through, that is important information to know. Maybe you can just gently tap on the food bolus with the scope, and it will potentially move, okay? You can also navigate yourself around it a little bit, see if that is possible. If it's possible, it's a good sign. By just getting around it safely under direct visualization, we'll dilate the tract a little bit. You'll be able to push it through, okay? In general, it's much easier to push these things into the stomach and be done than to remove the entire thing, okay? Again, so if you're extracting it, if you're unable to do that, extract it with an overtube. Especially food, especially if your patient is not intubated, an overtube is a must, okay? Because it then protects the airway. Think about the underlying cause. Don't forget the fact that, one, there could be a cancer that's caused the obstruction, and sometimes when these food boluses are removed, the esophagus can look like sort of just really rough, like dog meat kind of thing. If that's what it looks like, maybe that's not the time to biopsy it, or maybe you're concerned that it's oozing, bleeding, whatever. Just think about it and bring the patient back a couple of days later for a repeat endoscopy and biopsy. Same goes for eosinophilic esophagitis. Think about it. If it looked like it, proximally biopsy it. If it didn't, bring the patient back and make sure that this is not someone who has eosinophilic esophagitis, and this will happen many times over and over again. This is what the overtube looks like when it is placed. So it's really just a relatively rigid plastic tube with a softer plastic tube in it. You scope the patient, and then over the scope, you introduce the overtube, okay? So it's first loaded onto the scope, you go down, and then you push into the overtube, then you remove the internal catheter, and now you're left with about a one-and-a-half to two-centimeter-wide plastic tube in the esophagus. Oops, oops, oops, okay. So again, always think about cancer, eosinophilic esophagitis. Those are the two thoughts that come to mind that are important and dangerous. I mean, of course, they can have a stricture, they can have a Schottky's ring, there can be many other causes, but these are the two that you don't want to miss, okay? objects so you can get any kind of sharp thing to get stuck in one part of the GI tract. When you see this, you want to think about how are you going to safely remove it, okay? You're obviously not going to pull it from here and then hope that it doesn't get stuck in the upper esophageal sphincter. This is a perfect scenario for an overtube. Turn it in a way that it folds into your scope or into the overtube, and be sure to safely remove it, okay? So I think this is somewhat repetitive, but again, sharp objects, some of them will usually perforate and the worry is that they will perforate near the IC valve. So this is what I mentioned. This is kind of the position, your ideal position for something sharp, right? You sort of pull it into the scope and let it fold into the scope. If you have an overtube on the scope, which I think this is trying to show that there is, then you pull it gently into the overtube. If it doesn't come through the overtube because it's too big for it, at that point you can just remove the entire thing with the overtube and the scope, okay? So batteries are something you just want to be cognizant about. If you know it's a battery, don't use anything. First of all, it is something that from the esophagus you need to remove, okay? This is a sort of gruesome video that happens at the same time, which is really just sort of showing how to, I think, remove kind of food particles through an overtube. But the thing about batteries, it's really more of a board question more than anything, but if you encounter it, remove it and make sure you don't puncture it, don't crack it. So don't use a grasper for them, okay? The worry is that if they are stuck in a part of your intestine or the esophagus, the leakage can create perforations or fistulizations or potentially catastrophic bleeding if it fistulizes into a vessel, okay? Magnets are another thing that you want to think about. If your patient ingested magnets at different time points or they pass through the intestine at a different rate, they can find each other and they can basically attach and create either a bowel obstruction or a fistula between two bowel tracts, okay? So again, if you have a magnet, you know that the ingested object was a magnet and it's in the stomach, it's in your best interest to hurry up and get that removed, okay? If it's past the stomach and it's somewhere in the small intestine, your best option is probably to very carefully follow it with stepwise and x-rays and be ready to scope the patient and or potentially remove it surgically or call your surgical colleagues. There's good guidelines from the ASG. I think the one thing I would say about this is that this is an opportunity for you to use and be creative with the devices that you use, but when you go into these cases, have them all lined up, okay? Whether it's you or your technician or whoever, make sure that the box contains all of the things that you could possibly use and multiple of them, okay? Because sometimes these cases get a little bit like, one, they can get a little bit long and two, you don't want to be like halfway through it and then somebody says like, okay, let's use a Rothnett and you're like, oh shoot, the Rothnett is upstairs. I'm going to now climb up to the 10th floor, cross over the whatever bridge and bring down a Rothnett. Because you never know what you're going to use. Might as well have everything that comes to mind, okay? But for sure, have an overtube and have a hood available for the endoscope because those are important safety measures. So even if you don't have the best device, those two things you should definitely have available. So recognize urgent indications, really inability to tolerate secretions and certain objects, sharp objects, perforating objects or batteries, okay? And magnets, I suppose. Recognize contraindications to endoscopic retrieval, so already perforated viscous and narcotic packets that may rupture and potentially things that are very, very high up in the oral pharynx. And think about underlying causes. So think about what actually caused the obstruction. And you don't have to think about it that night, but make sure that you reconsider that the next day for the patient. Plan your strategy. Again, have your pallet of everything. Be available with the equipment. And from my perspective, always intubate the patient. All right. That's it. I think that's your last lecture for this packed day. So thank you for coming. Any questions? Yeah. So my question was about, like, specifically for food impactions in the esophagus, do you have any opinion on the use of glucagon prior to endoscopy to see if it'll push it through? There's no harm in it, okay? The patient who is spitting up saliva, okay, you can give them whatever glucagon you want. It's not going to... That's not going to pass. So especially when sometimes people come in quite a while after their aid and there is a sensation, okay, it sometimes is helpful. Like, why not? You know, we give glucagon for, I mean, it's harmless, okay? I don't think I've ever had a scenario when I felt sufficiently reassured after giving glucagon that I said, okay, we don't need to scope this patient. I mean, maybe you will not need to scope the patient as emergently if they do well with the glucagon, but there is no real harm in it. Yeah, it's in the emergency room. I mean, you're not going to be that efficient at getting them to an endoscopy suite. All right, well, enjoy. Have a very nice weekend, and thanks again.

gastrointestinal tract

foreign bodies

food impactions

airway protection

radiographic studies

procedural approaches