GI Foreign Body & Food Bolus Overview & Retrieval Management

Educational Objectives Identify the patient populations Describe the criteria for endoscopic intervention Identifying symptoms, physiological risks, and complications Available endoscopic equipment Identify the risk factors

Pediatrics and Foreign Bodies 80% of all Foreign Body cases occur in children Age range: 6 mo.– 5 yrs. 90,906 cases (Source: 2006 the American Association of Poison Control Centers) 98% unintentional Most common: Buttons Pen or bottle caps Marbles Coins Disk batteries (i.e. used in watches and calculators)

Typical Pediatric Foreign Bodies

Adults & Foreign Bodies Unintentional Compromised mental perception Diminished mental capacity Alcohol related Elderly population Partials or dentures Bulimic population – “the purging tool”

Unintentional Foreign Bodies

Adults & Foreign Bodies Intentional Psychiatric patients Prisoners Achieve several goals: Excused from work detail Enjoy a change in environment Enjoys euphoria from narcotics Attention Typically repeat offenders

Intentional Foreign Bodies

Food Bolus Impaction Can occur in children and adults A result of under chewing or not chewing food Underlying esophageal pathology common Adult study found 97% presenting with meat impaction had esophageal disease upon endoscopic examination Anastomotic stricture Nissen fundoplication Partial esophagectomy Schatzki’s ring Peptic stricture Esophageal web Tumor Eosinophyllic esophagitis Achalasia

Food Bolus Impaction Typical Patients: Typical foods: “Young and the Restless” “Old and the Toothless” Typical foods: Meat (steak, chicken, beef, pork, hotdogs, lamb) Some fruits and vegetables Fish/Fish bones Cocktails and hors-d’oeuvres

Food Bolus Impaction

Common Areas of Constriction

Determining the Need for Endoscopic Intervention Presence or absence of symptoms When ingestion / impaction occurred? What is it? Where is it stuck? Patient size Perceived risk Known pathology Unknown pathology

Radiography in Patient Management Most ingested foreign objects are radiopaque Run biplanar neck, chest and abdominal films as indicated Don’t forget the check the patient’s back! Exceptions: wood, plastic, glass X-rays still advised No role for contrast studies Provide no new information Increased aspiration risk Compromises endoscopy

Foreign Body Management Considered benign with inconsequential risk factors, patient will be monitored 3 Weeks allowed for gastric passage Radiologic assessment weekly Stool observation by patient

Foreign Body Management Adjunctive agents – not recommended Adolph’s meat tenderizer Carbonated beverages Promotility agents, i.e. Reglan Lubricating agents, i.e. mineral oil Sedation selection IV narcotic sedation vs. general anesthesia with endotracheal intubation Consideration based on item being retrieved, patient age and patient condition Experienced Endoscopist and nurse Familiarity matters!

Benefits of Preparation Provide the highest level of care and safety to the patient Decreased amount of time under anesthesia or sedation for the patient Complications minimized Staff frustration minimized Time spent by staff performing the procedure minimized Cost savings to facility

ASGE Guidelines Standards of Practice Committee prepared a list of “equipment that should be readily available” Retrieval net Overtubes in both esophageal and gastric lengths Retrieval basket Polypectomy snare Polyp grasper Rat tooth forceps Alligator forceps Dormier basket Foreign body protector hood

Retrieval Nets Highly acclaimed by GI physicians and nurses Fully enveloping Protective, pouch-like design Assures capture Minimizes risk to patient airway

Overtubes

Additional Devices Retrieval basket Snare Graspers Rat tooth forceps Alligator forceps

Sharp and Pointed Objects Complication risks as high as 35% Lodged in the esophagus a medical emergency Immediate endoscopic removal Visible in stomach or proximal duodenum with Xray Endoscopic removal Negative radiologic exam Endoscopic evaluation Jackson’s axiom “leading points puncture, trailing points do not” Orient the pointed end so it is trailing distally during extraction Remember to protect the esophagus Foreign body hood Overtube

Risks and Complications Sedation related complications including allergic reactions Aspiration Losing the “specimen” Device failure Human error Patient movement Mucosal injury Perforation

Minimizing the Risk Meticulous inspection of the volume, content, location, fixation Clear secretions / airway protection Relaxation and insufflation Gentle advancement of scope and devices Debulking / debriding needed in some food bolus cases Suction in some cases HAVE THE RIGHT ACCESSORIES

Minimizing the Risk DO NOT push hard DO NOT advance dilators DO NOT blindly advance devices DO NOT persist excessively

Summary Endoscopic retrieval is a tricky business that it requires decision making & technical skill; if there is more experience around, use them Foreign Body and Food Bolus removal can be incredibly nerve racking Foreign Body and Food Bolus removal requires risk management Protection of the patient’s airway is critical Be prepared for “anything” Practicing a “dry run” can be one of the keys to success Stay abreast of latest technology in retrieval device choice and documented reports of retrieval device successes Equip your facility with the retrieval devices necessary according to the ASGE guideline for foreign body retrieval

GI Foreign Body & Food Bolus Overview and Retrieval Management Vantage Endoscopy: Mark Malinowski