All right, everybody. So we're wrapping this up. Thank you, Tom and the course directors and ASG for giving me this opportunity to come here and meet with all of you and catch up with great colleagues and friends. So these are relationships for life. We're meeting here as our first welcome to the GI family. First of all, you are first year fellows. And as you progress in your academic career, these are the faces we're going to run into each other as you progress through your careers, interviews, job search, other courses. So feel free to reach out and stay in touch. I'll be talking about management of foreign bodies and food impactions. These are my disclosures. This is something, has anybody already done any foreign body removal endoscopies here? All right, a couple of hands, not bad. This is a common scenario we're all going to face in any training program you're at. And the goal of this talk is to better understand the tools of the trade. There are different kinds of obstructions, impactions. At Geisinger, we have a psych hospital two blocks down the road, so we have a lot of psych ingestions. There is a prison, so although it's a small village, we still have all the usual troubles as a big city does. So we see all of these pathologies, and being a huge referral center, many times these things are transferred over from some of the other community hospitals that end up at Geisinger. So the point is, no matter what program you're in, you're bound to see this. And if you're prepared for it, you'll know what to do. So the first thing is the timing of endoscopy, right? So to follow along Vivek's talk, you know, is this urgent or emergent? Is this something I need to go in now and fix it, or is this something that I can wait till the morning? Is it something I even need to go see the patient now, or does this look stable where I can lay eyes on it in the morning? So timing of endoscopy is important, and the location is important. Is this something stuck in the throat, in the esophagus, stomach, bowel, colon, where is the obstruction at? Because that will depend on when you do it, what you do with it. The high-risk objects, is this something that's going to cause a perforation? Is this something that's life-threatening to the patient that's going to cause a tear or a bleeding? Is this patient going to aspirate? Is it fully obstructed, and the patient is gurgling and secretions coming out? And then we're doing the procedure, not so much for the object itself, but for the other complications it's going to cause. Choosing the accessories, what scope should I get ready for the attending? What equipment should I have it ready? Location-wise, are we doing this in the emergency room? Do I need to book an OR? So when I trained in my fellowship, we had a bump-out small procedure room in the emergency room. So we used to do these foreign body infections right in the ER. So the emergency room physician would keep these patients under their care, and we would just go to the procedure, and they would get discharged from the emergency room. At Geisinger, the ER is super busy, so they don't have the time or the flexibility to overlook this, so everything bumps to the OR. So now we have to look at OR availability, anesthesia availability. So the logistics of what you're going to do, where you're going to do, and obviously airway protection. Is this something that we can do with conscious sedation, or is this something that needs an endotracheal intubation? Can we get away with an ET tube? What's the patient's ASA class? All those things. So the point is this is kind of a mental checklist that you would go through, and then when you present a plan, you are a much-prepared fellow, where you're calling the attending, saying, this is my assessment, I saw the patient, this is what I think, and then kind of go from there. The other issue becomes, are you dealing with a single food bolus? Are you dealing with an esophagus packed with stuff, right? Sometimes the patient has not had an acute impaction. It's something that's been building over time, where they had a Schatzky or a stricture, and now food is gradually piling up, piling up, and now they feel it only when it's kind of the cups full and overflowing. So need to know what you're going in with, or going in for. The other things are, there are radiopig and radiolucent substances, right? Is it a toothbrush that somebody swallowed, you know, is it a hard, solid object that's flexible or not, and what are the tools that you need for that, what scopes you need for that, and so on. So overall, foreign bodies in the GI tracts account for about 1,500 deaths annually, and that's a lot. The highest age group is the pediatric population. That happens anywhere between three months to six years. So the PEDS population, now we're fortunate we have a PEDS GI group, so when these come in, my pediatric GI colleagues go in and handle that. Some hospitals may not have that, where you are taking care of these kids, so they may call you as an adult GI to take care of foreign body ingestions. Again, even if you have a pediatric GI, they may not be therapeutic people, so they may not be removing foreign objects and foreign bodies where you might have to come in. So know your program, know what resources there are, or is it a pediatric that you don't touch at all, and do you need to transfer it to another specialty center? So these are the logistics you need to figure out. Edentulous adults, so people with bad dentition, they don't have good teeth, so it's not that they're trying, but they just don't have the sensory or the motor function to hold onto this. They're swallowing stuff without even realizing or controlling. They might be swallowing their own oral prosthesis. Many times you'll find dentures that just slip down, and then it's stuck in there as a foreign body. Eosinophilic esophagitis, so this is very important, and we have a slide later on about it. EOE causes narrowing and strictures in the esophagus, and many times you realize that the foreign body impaction is the first presentation of EOE. So the impaction is actually the diagnosis of the patient having an underlying EOE. So look for that, right? Why is there an obstruction? Why does this patient suddenly have a food impaction if they don't have a prior history? Alcoholics, it's the mentation issue. Are they too drunk? Were they out doing crazy things and not realizing? And now they either ate or choked or something, and now you're stuck with that. Prisoners, this is sometimes a get-out-of-jail-free card. So they're in the prison. If they have a foreign body obstruction, they have to be brought to the hospital. And now they're there. They get anesthesia. They get an overnight bed, right? And then they get all this medical care. We've had prisoners who didn't want to go back where we removed the object. In the recovery area, as soon as they woke up, they grabbed something and swallowed it right back down because they didn't want to be discharged back. They've ripped out their IV tubing and just swallowed the IV tubing down the throat. So you have to have one-to-one. People do stuff, right? Because their life is so much more worse back where they're going. So for them, doing that and buying just one extra night, you know, they literally come in and say, can I stay the night? Are you going to discharge me? So they're looking for staying. So sometimes there is secondary issues, psychosocial issues that are going on. And of course, psychiatric patients, you know, they're doing this more of a compulsion as an underlying psychiatric disorder. Outcomes so many, surprisingly, 80 to 90% of ingestions pass spontaneously. We don't have to do anything. They're going to go pass on their own. Endoscopy is only needed in 10 to 20%. So that's our job to triage what is going to pass and what needs to be removed and why. And surgery is even less than that, where it's less than 1% of these patients are actually going to require surgical removals. And that's usually when it's beyond the scope of endoscopy or a complication has already happened. They already have a perforation and they're too sick to undergo an endoscopic removal. So complications, what are the things? As somebody just asked, what are the things we should be looking out for? Perforation. If something is a sharp object and they come in and they have guarding, rigidity, peritoneal signs, fever, you know, something's wrong, bad is going on. Don't jump in with the scope. Because if there's a perf and you go in and blow a bunch of air in it, it's going to make it even worse. So in that case, get a CAT scan, figure out if there is free air, if there is already abscess formation, because you don't know how long that's been stuck in there. And then again, infection-wise, mediastinitis, lung abscesses, fistulas, we had a patient who didn't even realize at some point in the past had eaten the food and a toothpick was in it. And they swallowed or ate the food with the toothpick and the toothpick perforated through the stomach into the liver and caused a liver abscess. And that was just chronically in there, they didn't even realize, and now they came in with pain and there was a huge abscess. So we went in there, we removed the toothpick endoscopically, closed the thing, and then the patient got a PERC train for bringing the abscess. So think of things that could have, may have happened maybe in the past that they're presenting now, but that insult may have happened weeks or months ago. And then aspiration. If the patient's already come in and drooling, are they already decompensated? Have they already aspirated? In which case they need pulmonary involvement, they're in intubation, they need an admission. So yes, we'll take care of the problem, but maybe the consequence or the complication has already happened. In kids, obviously, they're going to have ingestions of what they can get their hands on. Coins, toys, magnets, crayons, pen caps, batteries. So it's usual things that they have access to. So little children obviously, you know, be aware of what are the things you're going to be dealing with. In adults, it's usually food impactions, either meats or bones, usually because of an underlying disease state, like a stricture or EOE or malignancy, Schatzky's, Zankers. So think about these things. In the talk early on yesterday about doing an endoscopy, how you pass a scope down, if there is an impaction, that could be a Zanker. Don't blindly slide in, because now you're going to make it worse. The impaction is because of the Zanker. So or if there's a stricture, don't just try to push things through. Dentures and sharp objects. So sharp objects is a whole different thing, and we'll touch base on some of those things. What is their presenting symptom? Acute dysphagia. They'll come in with difficulty swallowing. That does not determine the location of the object. So if they're saying, oh, it feels like something's stuck right there, they could have a G-junction obstruction. Or like, no, something's stuck right in the throat, the obstruction could be lower on, but they're just kind of pied up, where now food is stuck all the way in the throat, that they're feeling it, but the obstruction could be lower down. So you need to be aware. Neck tenderness. You've got to be careful if they already have a perforation. Pain on swallowing. Dysphagia could be because of impaction, but that usually could indicate that there's already a tear or a spasm in the esophagus that's causing cramps in there. And if they're having hypersalivation or inability to tolerate oral secretions, protect the airway first. You've got to make sure they're not going to make it by giving them sedation. Now they're freely aspirating everything that's in the esophagus. Abdominal pain and regurgitation. Along the same lines, these are all kind of alarm symptoms that you should be looking for. And history. If you do this a number of times, patients will be able to tell you exactly what happened. I was doing this, and this happened. I had a case where around the holidays, a gentleman came in swallowing nails. So he had a bunch of nails that he swallowed. I'm like, why did you do that? He's like, doc, trust me. I don't have a psych issue. I wasn't trying to. He had nails in his mouth, and he was trying to put up Christmas lights. So he went up the ladder, took a bunch of nails, had a hammer, and was putting up one nail at a time, and hiccuped while he was putting the nails up. Next thing he knows, the nails are in his stomach. So many times, you just talk to the patients like, how did that happen? And you would be surprised. You'll be amused every single time, like, wow, interesting. And then again, the timing of the object swallowed, right? You want to know if it happened within the last 12 hours, more than 12 hours ago, and so on. So I actually have an Excel sheet of like the craziest stuff that the patients would tell you, right? I was talking to one of my friends. There was a gentleman with a tennis ball in his rectum. He's like, yeah, it happened to slip while playing tennis. Like, no, it doesn't happen. You don't slip so precisely to get a tennis ball up your rectum and land right on the ball. No, no, no. Come on. What happened here? So, you know, these are like, you can't make this up. So keep a list, and you know, this makes great party conversations, without HIPAA violation, of course. Physical examination, again, is important. Subcutaneous emphysema, you know, is an indication of esophageal perforation. So look for alarm symptoms. You feel crepitus in their chest or in their neck. Got to be careful about drooling, and again, impending airway compromise. And then peritoneal signs to see if there's any below the diaphragm perforation. Radiologic imaging, the easiest thing is an X-ray, right? A cheap and easy thing. Patient comes in, get a flat plate, chest X-ray, KUB. Just figure out what you're dealing with, and you can size it, you know, what is the object of where it's stuck. And it'll also show you air under the diaphragm, so if there's a perforation, you don't need a fancy CT. If they say there's free air, you know that this is a perforation, and then you can plan accordingly for that. Pneumobadystinum, pleural effusions, all along the same lines. Avoid contrast. See, if you're worried if there's a perforation, the last thing to do is a gastrographin or an upper GI. You don't want to do that, because now you're going to make it worse, because first of all, you can't scope them, because you go in there and now it's a pool of liquid there. Now if this patient already is in obstruction, now you're telling them to swallow a glass of liquid, they're going to aspirate even more. So there is absolutely no need to do a gastrographin study, just get a non-contrast CT. That's good enough. It'll give you all the information you need. So either a plane x-ray, or if you're worried about peritoneal signs, then a non-con CT is just fine. Where do they get stuck? So think of all the physiologic sphincters that go down in the GI tract, cricopharyngeus for something like a Zenckers, aortic arch in the mid-esophagus, if they aspirate, left main stem bronchus if it goes down the airway, distal esophagus, if you have a Schatzky G-junction tumor cancer masses, it'll get stuck at the G-junction. And then at the pylorus in the duodenal sweep, that sharp right turn, if you have a rigid object like that toothbrush, that's not making that turn on its own. So things are going to get stuck in the duodenal bulb. Beyond that, also the ligament of Freud's, like D4, when it's making that sharp right turn into the jejunum, that's where things also get stuck. And then finally at the ileocecal valve. That valve is very potent, and things will get there and get stuck. And lastly, the rectum, if it makes all the way to the colon, sometimes you'll be surprised that it's stuck in the rectum and not able to pass the anal sphincters. So again, anatomical landmarks have a visual of things where they could get stuck. Esophagus, pylorus, sweep, ligament of Freud's, ileocecal valve, and then rectum. What are the indications for emergent endoscopic removal? So esophageal foreign bodies should be removed within 12 to 24 hours to prevent complications. Multiple things. Airway compromise, you know, upper things being upper, there could be other complications arise from that. Perforation, worse still, they can cause aortic or pulmonary fissure loss, and now a patient can have catastrophic bleeding if it perforates into one of those major blood vessels. And then foreign bodies leading with the sharp points. If you see something like a safety pin or nail with the point down towards the GI tract, it's only a matter of time until something bad happens. So you've got to get that out, you've got to flip it and get it out. So respiratory distress or compromise is an indication for urgent endoscopy. Pain, unable to handle secretions if they're drowning, please do an urgent endoscopy and get that thing unobstructed. Sharp objects below the upper esophageal sphincter is our job. Any objects above the upper esophageal sphincter call ENT. That's their domain. So they can go in there, they have enough equipment to be able to get those out as well. Always get a PA and lateral to determine the location in the esophagus rather than the trachea. So if you have a coin on an AP view, it might look like in the esophagus, if you get a lateral, it might be in the trachea. So just because it's midline, don't assume it's in the GI tract, because now you can plan better. You can call the pulmonary guys, this patient needs a bronchoscopy, the foreign body is actually in the airway, not in the GI tract. So sometimes an AP and a lateral helps you differentiate where it's actually stuck, if it's above the carina. So if you know that, it could be in the airway versus the esophagus. Airway precautions. So children, mentally ill patients and uncooperative patients start with an endotracheal tube. The last thing you want is you grabbed an object and the patient's thrashing around in the bed, and now you've made a relatively safe condition very unsafe. If you don't have these issues, you could get away with moderate sedation, so you could do, you know, controlled sedation and take this equipment out, like I said, sometimes we used to do it in the emergency room and just give fentanyl and Versed and get that out. But you have to make sure you assess for risk of airway compromise. Could something then get worse? Does this patient have underlying COPD? Do they have a BMI of 50 that you're going to have a hard time? Is this patient on multiple pain medications or polypharmacy that you're not going to be able to adequately sedate on them? So look at all those comorbidities before you go in there. Tools of the trade. This is where we get technical about things. What are you going to use to remove foreign bodies? So the easiest thing is graspers. Grab and pull. You could have rat tooth graspers, raptor graspers, duckbill graspers, alligator graspers, pelican, tripod, different things. What you need to know is what does your lab have. So the first thing is talk to your endo nurse or tech and be very well versed of, hey, what do we carry? And then figure out what is that you're trying to remove. Is it something small? Is it something big? Do you need a big grasper with a long teeth and a jaw or do you need something smooth just to pluck things out? If it's food, do you want to just nibble out at it? So the tools have to be tailored to what you're trying to remove. Snares. This is my favorite. Usually snares work like that toothbrush I showed earlier. Snares work perfectly, right? So if you have a raptor grasper or one of these rat tooths, you grab the toothbrush as you try to pull, it's just going to slip right off. It's a smooth plastic. You're not going to be able to grab it. So if you take a coin, the grasper is going to slip right off. So if you have a long object or a smooth object, a snare works great. A polypectomy snare. Now again, know that there are different sizes of snares, right? There's a 15 millimeter, 20 millimeter, 30 millimeter snare. So what size of snare do you need? They come as braided and regular snares, right? So you're not trying to do a polypectomy. So the braided snares are better because they're grippier because they have a jagged edge. So it will hold on to the object better and you can pull it out much easier. So always, it's not just, all right, let's get a snare. Well, what kind of snare? What size of snare that you need to do? The other thing is retrieval nets. These are again, a fellow's friend. Let's say, think of a marble, right? A kid swallows a marble. You can't pluck that. That'll slip right off. You can't snare that. That'll slip right off. You can't even get it in a snare. But if you have a net, a retrieval net is basically a snare with a woven piece of cloth. Now you could put that over a marble and retrieve it. Coins, they come in retrieval nets beautifully. So again, retrieval nets come in different sizes, 20 millimeter, 30 millimeter, they go up to eight centimeters. If you have a big piece of food that comes beautifully in a retrieval net, you put a snare, you'll cut right through the food. So if you have a retrieval net, you can capture it and then you have traction to pull it out. So again, don't bite more than you can chew in a way in the sense that if you have a big object, don't try to pull it through the G-junction. It will get stuck. So now again, you're stuck because you have that object in the net and the net is stuck in the G-junction. So be careful of what you're trying to pull. Is it actually going to come out or not? So don't grab so much that you can't pull it through. Retrieval baskets, foreign body hood is a really neat tool. It's this latex hood that you put on the scope and bend it backwards going down. You find your object, grab your object with whatever you're going to grab it with, snares or graspers. And then as you pull the scope back, the G-junction flips the hood forward. So it kind of unsleeves the hood and now the hood covers the sharp object. And now you can pull it through the esophagus without ripping the entire esophagus open. So if you have a sharp object, remember to use the foreign body hood. A word of caution is that hood is made out of latex. So if you have a patient with latex allergy, do not use the hood. The majority of the equipment we use in GI are latex-free. But the hood is made out of latex, so just kind of keep that in mind. So if they have anaphylaxis with the latex, you don't want to tell the family, I got the object out, but now they're intubated in the ICU because I just put them in anaphylactic shock. And then Overtubes. So these are great devices. Has anybody here used the Overtube yet, the esophageal Overtube? So get familiar with this. There are steps involved. You don't want to be fumbling with the Overtube in the middle of a choking situation. So you need to know how to load an Overtube. Call your industry reps, have them demonstrate, how do I put an Overtube on? It's very simple. And I'll go over some of the steps with that in the next slide. Push technique works great, but I'm going to say this with a big word of caution. Be careful. You could turn a 50-minute endoscopy into a five-second endoscopy if you know you can gently nudge it through. So if you go in there, many times the esophagus is in a spasm because of this food impaction. First I give Glucagon. Glucagon is a muscle relaxer. So intravenous IV one milligram Glucagon relaxes the G-junction. Then you want to go around the food bolus first because the food is stuck there for a reason. So you want to look behind the food and make sure that you're not pushing it to a structure. But if you see that behind it is just inflammation, esophagitis, there's no mechanical obstruction, then you come back out in front of the food and gently nudge it down with the scope. And as long as there is no resistance, as you push, the food is sliding, sliding, sliding. Pop it in the stomach. You're done. Literally, 10-second endoscopy, food impaction done. I've done tons of these. But again, with the fellows, you have to be careful because first, as a first-year fellow, you may not still have that feel factor, right? How much is too much? Or is this safe or not? So I always tell the fellows, if you're going down and you're seeing the esophagus move and you're going okay, keep going. As long as you make sure there's nothing behind it. So look behind it, give glucagon, and you can gently nudge it in. You don't need any tool, right? You don't need grasper, forceps, nets, nothing. You can just nudge it in. And once it drops in the stomach, it's just a piece of food. Then it will get digested and pass out. Take a picture, come out, you're done with the procedure. So you have to be careful, but you have to be extra careful that there is no bones or anything in it. Sometimes it could be stuck because there could be sharp bones stuck in it. In that case, take it out, don't push it in. Get a net, get the piece of food out. Increase risk of tears and perforation compared to all the other techniques we just talked about because you're doing it blind. You're just pushing blind. So be careful. There's a lot of feel factor for it. So extraction of the food through the mouth. So the other thing as well, if you can't push it in, you got to take it out. Then you use overtube to protect the airway. You could use grasping forceps or a net or a snare as we mentioned before. And then if you suspect that there is a lesion, if you think there is a malignant lesion, biopsy that. If you think there is eosinophilic esophagitis, you can biopsy that. If the patient does not have major inflammation, you can even dilate it in the same session. So sometimes I'll see this and if I see the food stuck and I pop it through, I'll just stretch the esophagus so they're not back with their next meal with another impaction. If patient has grade C or D esophagitis, don't dilate it because it's so raw that you want to put them on PPI, let the inflammation heal, call them back in four weeks and then look at it again and see if you can dilate it at that point. So this is the overtube part I was talking about earlier. Basically you load the overtube, so it has overtube and a stylet, and you load it on the scope. You back load it and you go down with the scope and do your endoscopy. Now you slide the overtube off of the scope into the esophagus. You take the scope out, you take the stylet out, and now you can go back with the scope. The benefit is now you have a conduit all the way from the bite block past the G-junction in the stomach. It can go in and out, in and out multiple times. So one, if you're going to be removing a sharp object, it's going to come out through the overtube. You don't have to worry about it. Secondly, if let's say you're removing a big food bolus from the esophagus or stomach, you're not going to cause damage to the oropharynx by going in multiple times because what you remove is going to stay continuously through the overtube. So it's a great piece of equipment. The other thing that helps is it prevents aspiration. So you don't have to intubate these patients because what you pull out stays in the overtube and comes out. Nothing drops in the airway. So if you grab something and let's say you have an open airway, as you're coming out, majority of the times you're going to flick it in the oropharynx because as you straighten out, the scope straightens and the food drops. So now you've taken the food out of the esophagus and put it into the airway. With an overtube, you avoid that because everything stays in a controlled environment. The other thing many times I'll do is if it's a big sharp object that I cannot pull through the overtube, I'll just pull it into the overtube. So if you pull it in, then all you got to do is just pull the whole overtube out and the object is still in the overtube. So you don't have to worry about taking it through it. So multiple different helpful resources, just know how to use it. That's the point. And it comes in different diameters and different lengths. So if you have an upper scope, make sure you have an overtube that fits an upper scope. If you have a therapeutic scope, you have a wider overtube, make sure it fits a therapeutic scope. Lengthwise, it comes as 25 centimeters and 40 centimeters. So if you have a mid esophagus impaction, use the shorter overtube. If you have all the way down in the stomach, a foreign body, then use the longer one. So again, point is, know your equipment on what overtube you want to use. EOE, it's a common cause for food impaction. Usually you have that typical younger male, long history of intermittent dysphagia, has history of asthma, and is now coming in with a food impaction. You'll see strictures, and sometimes you'll even see these tears that the food impaction has already caught. So extra caution. And in these patients, especially you would avoid pushing blindly, because there are so many levels of strictures, if you push it past one, you're going to get it caught on the next one. So do not try to do, try that push technique in patients with EOE. Okay, sharp and pointed objects, toothpicks, nails, needles, razors, pens, safety pins, all of these, anything with a sharp edge, extra careful. Use an overtube, use a foreign body hood, and remove them. Because even if they pass the esophagus, they'll perforate the stomach. If they pass the stomach, they will perforate the small bowel. So be careful. And that is this Chavalier-Jackson axiom, advancing points puncture, trailing do not. So if you have a pointed object like that safety pin, if you want to pull it out, you're not going to do that. It's a pointed object coming out, it's going to rip the whole esophagus out. So just a quick medical history, Dr. Chavalier-Jackson was an otolaryngologist in Philadelphia in the late 1800s, early 1900s, 75 years of his career, he took out foreign bodies. And in Philadelphia, there is a museum called the Mutter Museum, that is an exhibit of every single object that he pulled out of people that he's cataloged, and is on display in Philadelphia. So I've never been there, but that's something that was interesting. And in the exhibit, there are 2,374 items that he's pulled out of kids and adults that cataloged and is on display. So I guess there's nothing that he's not seen, but, or had seen. So sharpen foreign bodies, you know, make sure that you remove them before they pass through the stomach, because that's our window of opportunity. I've even gotten things off the proximal jejunum. I've used kind of a Peet's colonoscope and gone a little bit deeper with a push endoscopy to try to take it out. So if anything we can do to avoid surgery, you know, we're going to try and see if we can do that. Consider an overcube, as I mentioned earlier, because 15 to 35% of them will perforate the intestine. If not, it's going to go get stuck in the ileocecal valve as it tumbles down. The mural withdrawal reflex flips these objects if it's pointy. The intestine is a way where it's going to flip it, and it's going to have the blunt edge going down. So the problem for us is that means it's going to have the sharp edge pointing towards us when we go down. So remember to flip it again where you kind of want to take that blunt edge and turn it towards us, and with the sharp edge pointing away as you're pulling it backwards. If endoscopic retrieval is unsuccessful, patients will need surgery. You could wait up to three days by getting serial KUBs. Patient's heart rate is up. Your heart rate is up. So ideally, you want to get it out if you can. Sharp and pointed objects, that's the overtube example. You want to go through the overtube and pull it in, or if you want to trail it, make sure that you have the blunt end pointing towards you and the sharp edge away. Button batteries. This is something you'll get caught especially in children if you're going to take care of pediatric patients. It's an endoscopic emergency, especially if it's still in the esophagus. It can cause rapid injury due to corrosion, and it can cause pressure necrosis and voltage burns because the battery is still active. So it's going to burn the esophagus. Once it's in the stomach, it can pass. I personally still go and grab it from the stomach if it's in a pediatric patient, but it could follow. You could just do daily x-rays and consider retrieval with baskets or nets. Always put an overtube. You don't want to be pulling a burning corrosive battery out the oropharynx. So put an overtube and get it in there and get it protected and avoid graspers. You don't want to take a battery, puncture it, and have all the acid leaking out into the GI tract. So never try a grasper. Try a Roth net or a retrieval net, and you'll be able to get that through. Complications, you'll get vocal cord paralysis if you don't protect the airway, esophageal perforation, stricture, tracheal stenosis, TE fistulas, hemorrhage if it fistulizes into a major blood vessel, and infection and even death. And last point is magnets. You'd be surprised. You'd be thinking, well, how does a magnet hurt a body, right? It's an inert piece. It's not sharp. It's not a piece of magnet. It's the two pieces of magnet. So imagine swallowing two pieces of magnet. One is in the stomach. One goes down. Guess what they do? They pull towards each other. And now they cause fistulas, pressure necrosis, and perforation. So magnets attract each other. So if you have multiple pieces of magnet, take them out, especially if they're in the esophagus or stomach. As it tumbles down, it's going to pull other things, and it's going to cause perforations. And if it's beyond the stomach and they're symptomatic, then they may require surgical removal, although you could still do a push endoscopy and get them out. So these are like two magnets attaching each other from the stomach and the jejunum. And there is a ASGE paper on management of ingested foreign bodies and food impactions. This is guidelines on different tips, tricks, tools, and what are the different ways of what you should let pass and what you should keep. So in summary, recognize the indication for urgent endoscopy, basically anything sharp, anything that makes the patient unstable, or is a risk for impending complication. Recognize the contraindications. If you already fear there is a perforation, don't go in and make it worse. Narcotic packets. You know, Dr. Fang and I were just talking about this earlier. Our guidelines suggest do not remove them. Why? Because if you break the package, the patient's going to die because of you. So if you have somebody who's ingested fentanyl packs, you don't want to rip that package open. And now you have fentanyl powder being absorbed all over their bowels. So ideally, they like to purge them and wash them through and get them to poop them out. I had a patient just this past weekend where the packet was stuck in the esophagus for 24 hours. It wouldn't move. So we went in there and removed it with Rothnet because the fear was it's going to burst if I don't remove it. But you don't want to puncture it. Same concept. Don't go with a Grasper or a Raptor or a Rat Tooth. Put something blunt, capture it, and see if you can safely take it out. Again, we had a controlled environment. We had a patient in the ICU already intubated with a critical care team available, and we were able to safely take it out of the esophagus. But per guidelines, if possible, you can purge it and get it out. Recognize EOE specifically. If you don't look for it, you won't see it. So in your mind, when you go for any young patient foreign body impaction, look for the structures, the rings, the furrows. Sometimes it'll be very subtle. You might not see it. So get some biopsies while you're at it once you remove the thing. But don't be like, yep, food's out, go again, because that patient will be right back at your doorstep within a week or two. And then plan your strategy before endoscopy. What scope to get? What equipment to get? Intubate or not? ICU or OR or ER, where do you need to go? And be familiar with your equipment. So play with these things. That's what these courses are for, is to play with the tools of the trade so you're not fumbling in the middle of a procedure or an active case. And protect the airway when necessary. So that's all we got. Thank you.

foreign bodies

food impactions

gastrointestinal tract

obstructions

ingestion

risks and complications

endoscopy