Ingested Foreign Objects and Food Bolus Impactions

Introduction

Gastrointestinal foreign bodies (GIFBs) and food impactions are a common problem encountered by endoscopists, and, next to gastrointestinal bleeding, are the second most common endoscopic emergency encountered. Previous studies have suggested that between 1500 and 2750 deaths occurred in the United States secondary to GIFBs. More recently, mortality from GIFBs has been shown to be significantly lower, with no GIFB reported deaths reported in over 850 adults and only one death in approximately 2200 children. However, regardless of imprecise morbidity and mortality rates, serious complications and deaths occur as a consequence of foreign body ingestions. Thus, because of their frequent occurrence and potential for negative consequences, it is important to understand which patients are in need of treatment, which techniques best treat GIFBs, and how to manage related complications.

Flexible endoscopy has become the treatment of choice for GIFBs and food impactions because it is safe and highly efficacious. Knowledge of the indications for endoscopic treatment, patient preparation, and accessory selection to achieve treatment success is crucial in the management of GIFBs. In addition, the specific techniques to safely and successfully treat food impactions, true ingested foreign bodies, and colorectal foreign bodies will be covered in detail in this review.

Nonendoscopic Therapies

A number of medical therapies have been considered as treatment of esophageal foreign bodies and food impactions. The smooth muscle relaxant glucagon is the most widely used and studied drug for the treatment of esophageal foreign bodies. Glucagon, given in doses of 0.5 to 2.0 mg, can produce relaxation of esophageal smooth muscle and lower esophageal sphincter by as much as 60%, with the potential to permit passage of the impacted food or foreign body. Success with primary glucagon therapy ranges from 12% to 58% in treating food impactions. However, a small randomized study showed no benefit with the administration of glucagon over placebo. Glucagon used in conjunction with endoscopy has shown that glucagon given at the time of endoscopy promotes clearance of the food bolus. Glucagon may cause nausea, vomiting, and abdominal distention. Glucagon has little effect when a fixed obstruction is present, preventing passage of the foreign body. In a retrospective study, glucagon was ineffective in treating food impactions in patients with eosinophillic esophagitis. Nifedipine and nitroglycerin are not recommended because of side effects and lack of efficacy.

The use of effervescent agents such as carbonated beverages have been described for treating esophageal impactions. These agents are purported to release carbon dioxide gas to distend the lumen and act as a piston to push the object from the esophagus into the stomach. However, the effectiveness of this method is doubtful with perforations and aspirations having been reported associated with the use of gas-forming objects. Similarly, the meat tenderizer papain is not recommended for the treatment of esophageal meat impactions because of risk of complications, including perforation and mediastinitis.

Radiologic methods have been described for the treatment of esophageal foreign bodies. Under fluoroscopic guidance, Foley catheters, suction catheters, wire baskets, and magnets have been used to retract objects. The most commonly described device is the Foley catheter; the balloon tip of the catheter is passed distal to the object, inflated, and then the object is withdrawn into the oropharynx. Success of Foley catheter extraction of esophageal foreign bodies under fluoroscopy has been described as more than 90%. However, all radiographic methods suffer from lack of control of the object, particularly at the level of the upper esophageal sphincter and hypopharynx. Complications may include nosebleeds, laryngospasm, aspiration, perforation, and even death. Data on radiologic methods for foreign body removal is primarily limited to the esophagus. Radiographic methods are generally recommended only if flexible endoscopy is not available.

Endoscopic Methods

Multiple large series have reported the success rate for endoscopic treatment of GIFBs to be more than 95%, with complication rates of less than 5%. Timing and indication for the treatment of GIFBs should always be planned with the knowledge that 80% to 90% will spontaneously pass through the GI tract without complication. Although conservative management may be effective in many cases of GIFB, it is most appropriate to perform selective endoscopy for treatment based on the location, size, and type of foreign body ingested.

Generally, all foreign bodies, including food impactions lodged in the esophagus, require urgent intervention. The risk for an adverse outcome from an esophageal foreign body or food impaction is directly related to how long the object or food dwells in the esophagus. Ideally, no object should be left in the esophagus longer than 24 hours, and preferably the endoscopy should be performed within 12 hours of presentation. In particular, if the patient is in severe distress and unable to handle secretions, the risk for aspiration increases, and endoscopy should be done in the first 6 to 12 hours within presentation. It is not unusual, especially in children and in impaired adults, that there is a significant delay from ingestion to presentation.

Once in the stomach, most ingested objects will pass spontaneously and the risk of complications is much lower, thus making observation acceptable and endoscopic intervention may not be necessary. There are notable exceptions that will almost always require endoscopic intervention due to their increased likelihood of causing a complication or, with some objects, the likelihood that they will not pass from the stomach. Sharp and pointed objects are associated with perforation rates as high as 15% to 35%. Sharp objects should be removed in an urgent fashion due to the risk of complication; removal may not be possible once the object is past the ligament of Treitz. Objects longer than 5 cm and round objects wider than 2 cm may not pass spontaneously and should be removed from the stomach with an endoscope at presentation or if they have not progressed in three to five days.

With the increasing use of device-assisted enteroscopy, case reports have detailed the use of these scopes to retrieve foreign bodies from the small bowel safely and effectively. Balloon enteroscopy has been frequently used for removal of entrapped video endoscopy capsules, as well as migrated esophageal and enteric metal stents. Furthermore, balloon enteroscopy has been shown to be safe and effective in objects that have been present in the small bowel a number of weeks after the objects were observed and given an opportunity to pass spontaneously. Accessories including baskets, hoods, and forceps have been designed for the balloon enteroscopes to enable foreign body retrieval.

The type of sedation selected to facilitate endoscopy for the management of food impactions and ingested foreign objects should be individualized. Moderate sedation is adequate for the treatment of the majority of food impactions and simple foreign bodies in the adult population. Monitored anesthesia care or general anesthesia assistance may be required for uncooperative patients or patients who have swallowed multiple complex objects. This is due to the prolonged time associated with some cases, the necessity to protect the airway, and the need for repetitive esophageal intubation. The possibility of anesthesia assistance should be available even for cases that are initiated with moderate sedation due to potential failure to not complete the case or respiratory complications in these cases. Endoscopy for treatment of foreign bodies in the pediatric population is usually performed with the aid of anesthesia and endotracheal intubation.

For management of impactions and ingestions below the level of the laryngopharynx (esophagus, stomach, small intestine), flexible endoscopy is almost always preferred. Rigid esophagoscopy and flexible nasoendoscopes can be used for esophageal foreign bodies, but provide no additional benefit and are often available to only a few endoscopists. A comparison of rigid versus flexible endoscopes in the treatment of esophageal foreign bodies found significantly less perforations with flexible endoscopes. Use of rigid endoscopes and laryngoscopes is usually performed by otolaryngologists. Rigid esophagoscopy will almost always require general anesthesia with endotracheal intubation. Laryngoscopes with the aid of a Kelly or McGill forceps can be useful for proximal foreign bodies and small sharp objects in the hypopharynx. An anesthesia video laryngoscope can be used for objects at the hypopharynx and upper esophageal sphincter when gastroenterology and otolaryngology flexible scopes have failed to identify and remove the object.

Availability of and familiarity with multiple endoscopic retrieval devices for the removal of foreign bodies and food impactions is critical ( Table 22.1 ). An endoscopy suite and/or travel cart should be equipped with at least the following to allow successful treatment of a variety of GIFBs: a rat tooth or alligator grasping forceps, polypectomy snare, Dormia basket, and retrieval net ( Fig. 22.1 ). Use of a double channel therapeutic endoscope can allow passage of two retrieval devices simultaneously if needed. Removal of foreign bodies with standard forceps is rarely successful and not recommended. A transparent vacuum cap similar to that used for esophageal banding or endoscopic mucosal resection may be used in challenging food impactions. Overtubes of 45 and 60 cm in length should be available to the endoscopist ( Fig. 22.2 ). An overtube allows protection of the airway, multiple exchanges of the endoscope, and mucosal protection from sharp objects. The longer 60-cm overtube is designed to be advanced into the stomach, thereby enabling the retrieval of sharp and complex objects from the stomach without injuring the lower esophageal sphincter. Due to the size of overtubes and potential trauma upon insertion, their use is limited in the pediatric population and patients with suspected eosinophillic esophagitis. An alternative adjunct for extraction of sharp objects is a latex protection hood, which fits onto the tip of the endoscope ( Fig. 22.3 ).

When planning for extraction of complex objects, it may be valuable to go through an ex vivo dry run on a similar object when considering retrieval devices and extraction technique. Success and speed of retrieval of the foreign body have been shown to be directly related to endoscopist experience. When personnel or facilities are not available to accomplish success endoscopically, consideration should be given to transferring the patient to another more experienced center.

Prior to endoscopic therapy, assessment of the patient's airway, ventilatory status, and risk for aspiration are crucial. A neck and chest examination looking for crepitus, erythema, and swelling can suggest a proximal perforation. Lung examination should be performed to detect the presence of aspiration or wheezing. An abdominal examination should be performed to evaluate for signs of perforation or obstruction. If physical exam evidence of aspiration or perforation is present, chest and/or abdominal radiographs should be performed.

Specific Foreign Bodies