1. FOREIGN BODY IN GI TRACT Associate Prof. Dr. Meltem Ergun Yeditepe University Department of Gastroenterology

2. OBJECTIVE 1. Identify the presentation of foreign body ingestion 2. To learn the emergency evaluation 3. Risk factors for foreign body ingestion 4. Who needs endoscopic treatment 5. How to follow up

3.  Patients with foreign bodies in the gastrointestinal (GI) tract commonly present to the ED.  Foreign bodies in the upper GI tract are usually swallowed, purposefully or accidentally.

4. Foreign Body Ingestions : Risk Factors ƒDevelopmental immaturity ƒPsychiatric illness ƒAltered level of consciousness ƒStructural dental abnormalities ƒIllicit concealment (drugs) ƒHigh risk foods –Chicken bones –Fish bones

5. Presentation ƒComplete esophageal obstruction ƒPerforation

8. Swallowed denture

9. Foreign Body Ingestions : Most Common Types ƒMeat : most common in adults ƒChicken bones : most common cause of perforation ƒSewing needles ƒSafety pins ƒPills –Doxycycline & AZT can cause esophageal ulcers if impacted

10. Barium swallow showing complete esophageal obstruction from a meat bolus

11. Esophageal obstruction from a meat bolus

12. Can opener in the cervical esophagus

13. Aluminum pull-top can opener in the esophagus

14. Safety pin in the cervical esophagus

15. 2 year old with safety pin in the cervical esophagus

16. Pork bone stuck in cervical esophagus

17. Fishbones Causing Dysphagia ƒOnly 20 to 35 % of patients with dysphagia after eating fish prove to have a fish bone ƒMost of these are in the posterior pharynx and retrievable with Magill forceps ƒFor persistent symptoms, endoscopy is necessary since only 33 to 50 % of fishbones show on X-ray

18. Fishbone in the cervical esophagus

19. Esophageal Foreign Bodies : Symptoms ƒStridor ƒChoking ƒGagging ƒCoughing ƒDrooling / spitting ƒRefusal to eat ƒVomiting ƒChest or neck pain –The person can often point to the level of the obstruction ƒDysphagia ƒOdynophagia

20. Coin Ingestions ƒQuarters are 24 mm. in diameter ƒEsophagus is 17 x 23 mm. in size ƒCoins tend to lodge in frontal (coronal) plane in esophagus (sagitally if in trachea) ƒUp to 30 % of children with coins lodged in the esophagus may be asymptomatic

21. Coin in upper esophagus

22. Diagnosis of Esophageal Foreign Bodies ƒCXR / neck films always indicated –Should get in 2 planes in case more than one coin ingested ƒConsider dilute barium or gastrografin swallow for radiolucent foreign bodies like food

23. "Invasive" Removal of Esophageal Foreign Bodies ƒFlexible fiberoptic endoscopy –Usually method of choice –General anesthesia may be required in children –If food impaction, may be pushed into stomach rather than removed

24. Indications to Emergently Remove Objects from the Esophagus ƒSharp object (e.g. : open safety pin) ƒButton battery ƒBone fragment ƒHigh complete obstruction (risk of aspiration) ƒAny potentially corrosive agent ƒAny sign of esophageal perforation

25. Followup of Patients After Endoscopic Removal of Esophageal Foreign Body ƒObserve in E.D. until sedatives wear off (at least 4 hours) ƒReinsert endoscope after object removal (to rule out perforation) ƒDo followup barium swallow in adults –Not necessary in children unless esophagitis present and risk of stricture

26. X-ray Signs of Possible Perforation of the Esophagus ƒAir in : –Cervical soft tissues –Subcutaneous –Supraclavicular –Mediastinum ƒPneumothorax ƒPleural effusion ƒRetropharyngeal swelling

27. Prevertebral air from hypopharyngeal perforation

28. Most Likely Sites of Esophageal Foreign Body Impaction ƒSites of esophageal narrowing : –Cricopharyngeus (15 to 17 cm. from incisors) –Aortic arch (22 to 24 cm. from the incisors) –Left mainstem bronchus (28 to 30 cm. from incisors) –Gastroesophageal sphincter (40 cm. from incisors) ƒPathologic narrowing of esophagus –Intrinsic : tumors, strictures –Extrinsic : tumors, vascular lesions

29. Button Battery Ingestions ƒProbably > 2000 reported cases per year in U.S. ƒButton batteries are 6 to 23 mm. in diameter ƒUsed in calculators, cameras, electronic games, hearing aids, watches, etc. ƒTypes : –Mercuric oxide –Manganese dioxide –Zinc-air

30. Dangers of Button Battery Ingestions ƒEsophageal impaction –Corrosion & esophageal perforation –Some deaths reported ƒDissolution & heavy metal poisoning –No confirmed cases yet - probably because any released mercury is converted to elemental mercury –Lethal dose of mercuric oxide is 0.5 to 1.0 grams, & there is 1.0 to 21 g. mercuric oxide in a battery

31. Stomach and Intestinal Foreign Bodies ƒOnly 1 % of objects that reach the stomach will require surgical removal ƒOnly 2 to 7 % of high risk objects (pins, nails, toothpicks) will need surgery ƒ90 % of foreign bodies will pass in less than 7 days ƒIf it persist more than 3 days surgical intervention ƒObjects longer than 6 cm early endoscopic intervention is recommended. ƒRounded objects >2.5 cm (cannot pass the pylorus)

32. Abdominal film of a 41 year old psychiatric patient with abdominal pain

33. Surgical exploration of the same patient revealed a 2 by 3 cm lesser curve gastric ulcer and an interesting variety of swallowed objects

34. Indications for Surgical Removal of A Stomach or Intestinal Foreign Body ƒSigns of obstruction –Persistent vomiting –Progressive abdominal distention ƒAbdominal pain / peritonitis ƒGastrointestinal bleeding ƒFailure to move distally for > 2 weeks (?)

35. Indications to Admit a Patient with a Foreign Body in the Stomach or Intestine ƒHigh risk object –Sharp point(s) –Cocaine packets –> 6.5 cm. in length –Potential toxin ƒMultiple objects (?) ƒPreexistent GI disease (?)

36. Endoscopic Techniques for Removal of Sharp Foreign Bodies ƒAlligator forceps ƒWire snare ƒMagnet ƒSuction ƒPreplace protective tube over endoscope to protect esophagus during withdrawl of sharp object ƒCan manipulate open safety pins to close them

37. Management of Cocaine Packet Ingestion ƒX-ray to locate & count bags ƒIf symptoms of bag rupture : –Pretreat with labetolol or phentolamine –Emergent surgical removal ƒIf asymptomatic : –Sorbitol or osmotic cathartic –Do followup X-rays to document clearance –Save passed bags for police

38. Surgery endications ƒPerforation ƒEndoscopic extraction is not successful ƒIntestinal- fail to move ƒRectal >10 cm ƒSigmoid colon

39. Rectal Foreign Bodies ƒShould get pelvic / abdominal X-rays first ƒEmergent surgery indicated if any sign of perforation ƒMay require perianal block or general anesthesia for removal ƒCan insert foley beyond object & inflate balloon to assist removal ƒAfter removal do sigmoidoscopy to look for mucosal injury or perforation

40. X-ray of vibrator lost in the rectum

41. X-ray of hand shower misplaced in the rectum

42. LET’S TAKE A BREAK