1. Dr. Ümit Akyüz Yeditepe University Department of Gastroenterology Foreign Bodies and the Gastrointestinal Tract

2. Populations at risk Children Psychiatric patients Alcoholics Elderly with dementia Smugglers

3. Commonly ingested materials CoinsBatteries Sex stimulant devices

4. Some important remarks 80-90% of foreign bodies pass the GI tract without causing further problems. Lodged button batteries in the esophagus may cause liquefaction necrosis due to their alkaline effects… Prompt removal is needed… Sharp subjects longer than 6 cm become lodged in the duodenum, they should be removed promptly.

6. What is your management ? a. Observe b. Endoscope

7. Initial investigations PE CBC, CRP Plain radiographs

8. Foreign Body Ingestion in Children - Peak incidence in children aged 6 mo.– 3 yr. - Serious morbidity <1% of all patients - Management based on: 1. type of foreign object 1. type of foreign object 2. location in GI tr. 2. location in GI tr. 3. asymptomatic/symptomatic 3. asymptomatic/symptomatic

9. Common areas of luminal narrowing and angulation in GI tract.

10. Clinical Features - 50% Asymptomatic - Objects that passed esophagus, do not cause symptoms unless complications (bowel perforation, obstruction) - Majority of FB less than 2 cm. in diameter can pass esophagus spontaneously

11. Symptoms of Esophageal Foreign Bodies Blood in saliva Irritability Coughing * Pain in neck, throat, or chest Drooling* Recurrent aspiration pneumonia Dysphagia/odynophagia* Respiratory distress* Failure to thrive Stridor Fever Tachypnea or dyspnea Food refusal Vomiting* Foreign body sensation in throat WheezingGagging

12. Attention!! Swelling, erythema, tenderness, or crepitus in neck region means…… Oropharyngeal or proximal esophageal perforation Oropharyngeal or proximal esophageal perforation

13. Identification of Ingested Foreign Bodies - Plain radiographs are initial investigation of patients suspected FB ingestion (neck,chest,abdomen PA and lat.) (neck,chest,abdomen PA and lat.) - 64% of ingested objects were radiopaque. - Wooden, plastic,glass objects, fish and chicken bones may not seen on radiographs. - Barium esophagography ± (risk of aspiration, compromise subsequent endoscopy) compromise subsequent endoscopy)

14. Specific Types of Foreign Bodies Coins - most frequently swallowed FB, majority of esophageal FB in children. esophageal FB in children. - esophagus : -symptomatic pt. : endoscope - FB usually passes into stomach within 24 hrs. - FB usually passes into stomach within 24 hrs. - > 24 hr. risk for complications (esophageal - > 24 hr. risk for complications (esophageal perforation, TE fistula, esophagoaortic fistula) perforation, TE fistula, esophagoaortic fistula) - Endoscopic removal - Endoscopic removal

15. Specific Types of Foreign Bodies Coins stomach : - coins 20 mm. or less expected to pass spontaneously through GI tr. - Abdominal film every 7-10 d. to monitor passage of coin. - If after 4 wk. coin remains in stomach, it should be removed endoscopically.

16. Disk (Button) Batteries - > 90% pass through GI tr. within 72 hrs. - Mercuric oxide, Silver oxide, Manganese oxide, lithium + potassium/sodium hydroxide. lithium + potassium/sodium hydroxide. - Severity of injury - Severity of injury 1.battery size (>15 mm. in diameter more likely 1.battery size (>15 mm. in diameter more likely lodge in esophagus) lodge in esophagus) 2.duration of contact with mucosa. 2.duration of contact with mucosa. 3.type of heavy metal (mercury is potentially most toxic) 3.type of heavy metal (mercury is potentially most toxic)

17. Disk (Button) Batteries - Mucosal injury from 3 effects 1. liquefaction necrosis from alkali 2. direct pressure necrosis from FB 3. local pH changes due to electrical current discharge - Most serious morbidities from lodged in esophagus (burn within 4 hrs!!!, perforation within 6 hrs.!!!) (burn within 4 hrs!!!, perforation within 6 hrs.!!!)

18. Sharp or Elongated Foreign Bodies - 15-35% of perforations from FB ingestion caused by sharp objects. - Perforaions likely occur in C loop of duodenum, ligament of Trietz, terminal ileum, IC region and sigmoid colon. - Object longer than 5 cm., wider than 2 cm.,not likely to pass. - High - risk objects and exceeding these dimension require urgent endoscopic removal from stomach or proximal duodenum. - Serial Abd.films, if pin or sharp object stays in place or pt. develop abdominal symptoms, surgical intervention is necessary.

21. Proposed algorithm Plain film: - Free air: Surgery - Free air: Surgery - Asymptomatic: No Tx - Asymptomatic: No Tx ( Remember that lodged button batteries in the esophagus and sharp objects wider than 2 cm. and longer than 6 cm. should be removed as sson as possible even if they have caused no trouble on admission) ( Remember that lodged button batteries in the esophagus and sharp objects wider than 2 cm. and longer than 6 cm. should be removed as sson as possible even if they have caused no trouble on admission) - Symptomatic: Urgent endoscopy - Symptomatic: Urgent endoscopy