body management. Okay, hello everyone and thank you all for being here. My name is Danny. I'm an interventional endoscopist at UCLA. I'm very honored to be here with this excellent group of faculty and fellows and I'd like to thank Catherine for inviting me to join. Today I will be talking about management of foreign bodies and food impactions. I have no disclosures related to this topic. Food impactions and foreign bodies are one of those true emergencies you see as gastroenterologists. The others of course being acute cholangitis, bowel obstruction, and of course GI bleeding. And when you approach patients with food impaction or foreign body ingestions, there are five questions you have to think about right away. The first question is when do you do endoscopy if endoscopy is indicated? In other words, do you really wake your attending up from sleep at 11 p.m. and you know risk that they will hate you for the rest of the week? The answer is yes. Always wake the attending up at night for food impactions and foreign bodies. The other question is where is the foreign body? And that's what you figure out with history taken and what the foreign body is also through some examination and history taken. And then you want to discuss what to use for taking it out and how to protect the airways. So let's talk about those things. Foreign bodies can really be anything from food into glass into some weird stuff you'll see throughout your fellowship. So you know taking good history is extremely important and this is a very serious problem because 1500 people die annually from foreign body ingestions. As a matter of fact, 80% of patients with foreign bodies are kids between six months and three years. And some other population includes psychiatric patients, alcoholism, and prisoners usually present with foreign body ingestions. Although 80% of those foreign bodies will pass without a problem, up to 20% will need an intervention which is usually endoscopy and rarely surgery. Otherwise complications can happen which include perforation, mediastinitis, fistula formation, abscess formation, bowel obstruction, and others. The esophagus is the most common site for foreign bodies and as well as food impactions. For kids it's a little bit different. It's usually something related to toys or something they're playing with. And how do patients present? It's very important to remember that 40% of kids don't recall the history of foreign body ingestion and the parents don't even recall that. So just keep that in mind just because they don't remember that and kids specifically it can also happen. For adults it's pretty easy. Most of the times the patient will tell you what happened and 90% of the time they present with dysphagia. Sometimes they present with neck pain, tenderness, adenophagia, or sometimes abdominal pain. History is very important but examination is also as important especially when you're dealing with these kind of patients and it's pretty straightforward. So you look at a few things. So you look for a subcutaneous emphysema which happens if the patient has esophageal perforation. If the patient has acute abdomen you want to think about abdominal perforation somewhere. Small bowel obstruction can happen as well. So those are the signs that you look for when you're examining a patient with foreign body ingestion. You don't need to get tons of imaging. Basically a simple plain x-ray is what you need most of the times except for a few, you know, exceptions that we will talk about. And if you need to get imaging usually a CT scan is what helps you. You don't really want to get a PO contrast study because contrast can stick in the esophagus or the stomach and it will make it harder for you to see. And you want to avoid gastrographin if you're suspecting esophageal obstruction. So if you have a patient with food impaction don't get gastrographin study, don't get PO contrast. You don't really need an x-ray but you can get an x-ray or if you're suspecting perforation definitely get a CT scan and usually that will do. Now, you know, I mean there are some areas where foreign bodies can get stuck and it's pretty straightforward. Usually, you know, the lower esophagus things can get stuck there, pylorus. C-sweep is harder for the foreign bodies to go through and IC valve of course. So you all know this but mainly keep those areas in mind specifically for objects that are bigger than two centimeters diameter by five centimeter long. Those have hard time navigating the pylorus. And we know that from like esophageal stents when we sometime place esophageal stents usually for benign lesion, benign esophageal strictures, they can migrate into the stomach and if they are that long or that big, most of them are, will stay in the stomach. So you have to remove them from the stomach because it's very hard for the object to go through the pylorus and then they can get stuck at the IC valve or the duodenal sweep. So the main question is what is the indication for endoscopic removal of foreign body? And really anything in the esophagus should be removed. So foreign bodies in the esophagus including foot impaction, most of the times you need to remove those within 12 hours. So it's kind of urgent consult, sometimes it's emergent, so you have to do it as soon as possible. And if you don't do that patients can have complications including airway problems, perforation, aortic or pulmonary fistulas, and can lead to further issues. The other indications for emergent endoscopy is sharp objects. So if you have something sharp like a pen or needle or other things, if you have something forward pointing, meaning that something sharp and also going forward pointing down, that is something that you really need to get out of the patient as soon as possible. And also it's very important to keep those areas in mind where the foreign body is. And one important question is to ask all patients that you see with foreign bodies and mainly for foot impaction is can the patient handle their saliva? So Firas knows this, he was on call first weekend with foot impaction I believe. So if a patient does not handle their saliva you should call, you should do emergent endoscopy. Sometimes ER will tell you that, ER docs or attendings, sometimes they don't. But you have to test it, you have to talk to the patient and really see if they're spitting everything out. That really tells you that there is a full obstruction, you really have to go down there. And the longer the patient waits to come to the ER, the worse the problem. And then the worse the smell when you go down the esophagus and look at whatever they had. So just keep all those factors in mind, the timing, the handling of secretions and saliva, and what kind of object it is. And then you will make your decision based on that. And whenever you do endoscopy, you have to think about airway protection. So anesthesia is always there to help. And most of the times we do those endoscopic procedures under MAC anesthesia, basically monitored anesthesia care, with propofol. I think modernization is very uncommon to do for this kind of interventions. But you can consider if the patient is very healthy and you're in some situation. But most of the time is you would do it under anesthesia with propofol. Sometimes you need to do a general anesthesia. I will say the majority of those cases can be done without general anesthesia. But if you're really concerned, the patient is mentally ill, if the patient is not cooperative, that might be a reason to do it with general anesthesia. It's just they put the ET tube and then they remove it at the end of the procedure. So what tools can we use for foreign body removal? There are really a lot of things you can use. And you will pick your favorite ones. And you start with some stuff and then go a little bit more. You can use forceps. But it's pretty small. You can use a rat tooth forceps, which is a little bit bigger. And it will grasp more things. One of my favorites is that tripod thing. You can actually grab things easier with it and try to get them out. And then you can use a snare if you need to. You can use a retrieval net like a Roth net or some other net. Basket, if you're comfortable with ERCP tools. We use baskets for stone retrievals. So you can use that as well. It's very helpful. And there are some other tools like the hood and the overtube. Overtube is very important. We'll talk about it in a second. But basically, when you have a patient with food impaction, if you want to focus on that, how do you take care of it? There are two maneuvers. You can either push it towards the stomach or you can pull it back, right? I mean, it's either ways. But pushing it towards the stomach, you have to be very careful. I would advise against it if you are not able to see what's distilled to the food impaction. So if you're able to get your scope around a little bit and make sure there is no stricture, no ulcer, no bone going through the mucosa, if you make sure that you're not going to cause trouble by pushing it to the stomach, you can do that. And it takes some practice. When you push it, you have to be very gentle when you do it and really have that tactile sensation, know that you're not going through the wall. But if you're able to go around it, you can probably push it to the stomach. It'll be easy, and then you're done. If you cannot do that, I would recommend or I would generally recommend starting by trying to pulling the object out using all those tools that we talked about. And you have to do it step by step. Make sure you talk to your assistant very well. So if I'm grabbing that piece of whatever that is and pulling it out, make sure your assistant is closing all the time all the way when you're pulling it out. Make sure you pull it out very carefully from the upper esophageal sphincter area. If you need jaw thrust, you can ask the anesthesiologist or somebody to give you that. Don't drop it right in the oral area. So you have to be careful for all those things, and you have to keep repeating it till you make some progress. Some will be very easy. Some will take you an hour to get done. And then you can also use some extra tools to help you in addition to that. And one of the tools we use is the overtube, which is basically a plastic tube that you kind of deploy around the scope, and then you remove the scope and leave it in place. It comes in two sizes, 25 centimeter and 50 centimeter esophageal or gastric size, and it helps to protect the mucosa basically, especially if you have foreign bodies that are sharp. So if you want to get something out and it's pretty sharp and you're worried that you're going to have problems with the esophagus getting stuck or you cannot have the axis of the foreign body aligning with the lumen, this device will help you very much. It's very easy to place. It's really not that complicated, and then you can get things throughout it, and it will protect the esophageal and the airways, mucosa as well. Some patient populations that you need to recognize as being high risk for food impactions and stuff like that are patients with EOE. And EOE is relatively new disease, 20, 30 years ago, did not know much about it. But basically those patients present sometimes the first time with food impactions. So it's the very first time they're seeing a doctor. And they tell you usually a history of difficulty swallowing for months or years, and they will tell you that this happened before, but it was not a problem. They just passed it, but this time it's stuck there. So keep that in mind. And when you do the endoscopy, you will see some typical signs of EOE, like when you see the rings or strictures or other things. So keep that in mind, especially for young patients presenting with dysphagia. And again, advancing pointed objects will cause trouble because they will puncture. And sharp objects like all of those razors, pens, pins, nails, they will cause trouble. So those are the objects that you really need to remove once again, just a reminder. And don't leave them in the esophagus or the stomach. Now, when do you consider waiting a little bit or removing them? So in general, sharp objects in the stomach and esophagus need to be removed. If they pass the stomach, you might be able to, first of all, you need to make sure there's no perforation, no obstruction. So physical exam and taking a really good look at the patient. If there is none, sometimes they just pass through. What you would do is you would usually communicate with your attending and your team and have a surgical consult on board. And you will follow the patient with them and get serial x-rays. In three days, if this object does not pass, then they will need a surgical resection. Again, it depends on what it is. Sometimes you can do like a single balloon or a double balloon to remove it depending on what it is or where it is. But most of the times, if it does not, if it passes the stomach and stays there for three days, you might need a surgical removal and that will help. Some other special consideration is patients who swallow or ingest batteries, specifically batteries because they can cause a lot of injury. In the esophagus or the stomach, definitely remove them, especially in the esophagus because they can cause trouble. And you can use different tools for that. I would recommend using Overture for those kind of things. And if they pass the stomach, if it's only like few, you can observe the patient with x-rays. If it's so many and we've seen like some crazy cases, the patient will likely need a surgical removal. Yep. So I can watch that video a little bit. So you can suction, you can use a snare, you can use any tools that you can get. And you can see the overtube going around there and patient ingested. I'm not sure why the color is quite different. Yeah. So that's that. So this is an example when the batteries are in the esophagus, they can cause fistula, especially if left in place for a long time. I think this is a fistula for me. I think this is an object that kind of caused the tracheoesophageal fistula, I believe. The other objects that you need to know about and also carefully remove them as soon as possible, magnets, especially if multiple ones, because they can kind of gather and create fistula as well. And you don't want that. Yeah. So it's important to keep in mind the guidelines that we have for foreign bodies ingestion and food impaction. I think those are very, very helpful guidelines. Try to keep them very available for you and your phone or something, because you might need to go back to them frequently. So in summary, foreign bodies and food impactions are true emergencies that you will see as fellows and gastroenterologists. They tend to be really fun cases. So when you see those cases, you will enjoy them because it's a lot of fun to get them out and the patient will feel better. And you use different tools and skills. So it's really fun. But they are serious. So make sure you recognize the complications that can happen. Make sure you follow the patient very carefully and recognize that patients with EOE are special consideration and also follow up with those patients in clinic to take biopsies. Also recognize that sharp objects, pointed objects need emergent endoscopy. And apart from that, as a general advice, you're all endoscopists. So for all endoscopists, you have to know all the tools you have available for you in your room. So whenever time comes in the middle of the night, you know exactly what's available and you know how to use it. That's it. All right. Thank you.

foreign bodies

food impactions

management

endoscopy

emergency