1. GI Foreign Body & Food Bolus
Overview & Retrieval Management

2. 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

3. 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)

4. Typical Pediatric Foreign Bodies

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

6. Unintentional Foreign Bodies

7. 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

8. Intentional Foreign Bodies

9. 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

10. 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

11. Food Bolus Impaction

12. Common Areas of Constriction

13. 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

14. 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

15. 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

16. 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!

17. 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

18. 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

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

20. Overtubes

21. Additional Devices Retrieval basket Snare
Graspers Rat tooth forceps Alligator forceps

22. 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

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

24. 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

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

26. 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

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