Foreign body ingestion

Though the majority of ingested foreign bodies (FBs) pass through the gastrointestinal tract without complication, others, such as batteries, high-powered magnets, and sharp objects, can lead to severe injury and even death. The preliminary diagnosis is clinical, often relying on eyewitness reports since most cases involve young children who can't effectively communicate symptoms. Patients are often asymptomatic or only transiently symptomatic, but some present with respiratory distress, dysphagia, retrosternal pain, and/or drooling. Imaging studies may confirm the presence of an FB but should never delay emergency endoscopy in symptomatic patients. Ingestion of button batteries, sharp objects, or multiple magnets typically requires endoscopy within 24 hours. Gastric FBs are usually retrieved with elective endoscopy. Most other ingested FBs are treated conservatively with observation, serial imaging studies, and verification of passage from the GI tract. Complications of FB ingestion include perforation, obstruction, and infection.

For other FB locations, see “Foreign body aspiration,” “Nasal foreign body,” and “Corneal foreign body.”

• ∼ 80% occur in children (peak incidence 6 months to 6 years of age) ^[1][2]
• ∼ 20% occur in adults (most common in individuals with psychiatric illness or mental impairment and in prison populations) ^[3][4]

Epidemiological data refers to the US, unless otherwise specified.

Children and infants ^[1]

Almost all ingestions are accidental, usually involving common household items.

• Coins (most commonly ingested FB) ^[1]
• Button batteries
• Small magnets from toys and household appliances
• Sharp objects (e.g., pins, paper clips, fish bones, or toy parts)

Adults ^[3][4]

• Accidental ingestions, e.g., small bones, dentures
• Intentional ingestions
  • Behavior related to psychiatric illness, e.g., compulsive behavior or self-harm
  • Efforts to conceal controlled substances, e.g., body packing or body stuffing
• Large food boluses

Patients are often asymptomatic or only transiently symptomatic; clinical features depend on the nature and anatomical location of the FB and the time since ingestion. ^[5][6][7]

• Dysphagia and/or odynophagia
• Drooling: suggests complete esophageal obstruction ^[6]
• Retrosternal pain or foreign body sensation
• Refusal to eat
• Bloody saliva
• Nausea, vomiting, and/or retching
• Coughing and/or wheezing: may be caused by extrinsic tracheal compression ^[3]
• Signs of esophageal perforation, e.g., neck swelling, pneumomediastinum, crepitus over the suprasternal notch and neck
• Signs of bowel ischemia or bowel perforation, e.g., abdominal pain

Always consider the possibility of unwitnessed FB ingestion in young children with unexplained drooling, food refusal, and/or breathing difficulties. ^[8]

Clinical features that suggest potential life-threatening complications include drooling, dysphagia, hematemesis, chest pain, and any signs of respiratory distress. ^[5]

Approach ^[5][6]

• Signs of respiratory distress: Establish a secure airway.
• Any concerning features (e.g., drooling, hematemesis): Consult gastroenterology urgently.
• Suspected body stuffing or body packing with ruptured packets: Follow the ABCDE approach in poisoning.
• Obtain a focused history, including time of ingestion, items ingested, and history of GI disease.
• Examine the oropharynx, neck, chest, and abdomen.
• Obtain imaging studies unless emergency endoscopy is indicated. ^[3][5][7]
  • Initial evaluation: AP and lateral x-rays of the neck, chest, and abdomen
  • Suspected complication (e.g., perforation) or inconclusive x-rays: CT scan of the neck, chest, and abdomen
  • Use contrast studies (e.g., esophagogram) cautiously and in consultation with specialists. ^[6][9]
• Consider diagnostic and therapeutic endoscopy if the diagnosis remains unclear.
• Initiate definitive conservative, endoscopic, or surgical management.

Do not delay emergency endoscopy to obtain imaging. ^[5]

Esophageal FB impaction most commonly occurs at the cricopharyngeal muscle, corresponding to the clavicle level on CXR. ^[7]

Definitive treatment ^[4]

Definitive treatment is based on the patient's clinical condition, the type of ingested FB, and the object's anatomical location.

Endoscopic removal ^[1][5][6]

• Indications for emergency endoscopy (within 2 hours of presentation)
  • Respiratory distress
  • Esophageal obstruction
  • Button battery in the esophagus
  • Sharp object in the esophagus
  • Button battery in the stomach or bowel causing symptoms
• Indications for urgent endoscopy (within 24 hours of presentation)
  • Esophageal FBs other than batteries or sharp objects
  • Esophageal food impactions with incomplete obstruction
  • Magnets in the esophagus, stomach, or duodenal bulb
  • Coins causing symptoms (any location)
  • Sharp objects in the stomach or small intestine
  • Objects > 6 cm in length in the stomach ^[6]
• Indications for elective endoscopy (longer than 24 hours after presentation)
  • Coins in the stomach or small bowel if the patient is asymptomatic
  • Objects > 2.5 cm in diameter in the stomach ^[6]
  • Most batteries in the stomach if the patient is asymptomatic ^[10]
• Technique
  • Direct or fiberoptic laryngoscopy for oropharyngeal FBs
  • Flexible or rigid endoscopy for esophageal or gastric FBs

Foreign bodies in the esophagus should be removed within 24 hours of presentation; conservative management is not recommended. ^[1]

Endoscopic removal of drug packets is not recommended because of the risk of package rupture and subsequent drug overdose. ^[4]

Conservative management ^[1][3][6]

80–90% of ingested FBs pass spontaneously through the GI tract without complication. ^[6]

• Indications
  • Blunt or small objects; (< 2.5 cm diameter and 6 cm length) in the stomach or duodenum
  • Some sharp objects, single magnets, and batteries that have already passed through the duodenum (expert consultation recommended)
  • Objects associated with body packing if there is no evidence of drug packet rupture
• Approach
  • Serial abdominal examination for evidence of bowel obstruction or bowel perforation
  • Serial imaging studies to evaluate the passage of the FB through the GI tract
    • Sharp objects: daily
    • Blunt objects: every 3–4 days
  • Examination of all stools for the FB
  • Consult surgery if the patient becomes symptomatic or the FB does not pass out of the GI tract.

Surgical management ^[1][3][6]

• Indications
  • Unsuccessful endoscopic removal
  • Signs of bowel perforation, bowel ischemia, or bowel obstruction
  • Multiple magnets in the bowel with no sign of progression
  • Drug toxicity (for FBs related to body packing)
  • Failure of the FB to pass through the GI tract
    • Sharp objects: longer than 3 days
    • Blunt objects: longer than one week
• Technique: laparoscopy or laparotomy

Disposition ^[1][3][6]

• Hospital admission: recommended for retained sharp objects, multiple magnets, and drug packets
• Outpatient management may be considered for:
  • Coins and short blunt objects in stomach or small bowel
  • Some FBs that have passed through the duodenum
    • Single magnets
    • Batteries < 20 mm diameter and patient age ≥ 5 years
  • Asymptomatic patients after endoscopic FB removal

• Pathophysiology
  • Small blunt items typically pass through the gastrointestinal tract without complication.
  • Objects with sharp edges (e.g., pins and plastic bread clips) may cause mucosal injury.
  • Objects containing toxic materials (e.g., detergent pods) may cause acute inflammation.
• Diagnostics ^[7]
  • X-rays (AP and lateral)
    • Sensitivity depends on the type and radiopacity of the FB.
    • Metallic items are radiopaque and are often visualized in the coronal plane of the esophagus.
    • Small bones, wood, and plastic are often radiolucent.
  • CT scan without contrast
    • High specificity and sensitivity for identifying radiolucent items
    • May identify complications, e.g., obstruction or perforation
• Management
  • See “Management of foreign body ingestion.”
  • Esophageal location: endoscopic removal
  • Gastric or bowel location: conservative management unless diameter > 2.5 cm diameter or length > 6 cm
• Complications: mucosal ulcers or erosions (uncommon)

It is important to distinguish coins from button batteries on x-ray; coins have no step-off or halo effect.

• Pathophysiology ^[4][6]
  • Battery contact with moist tissue → electrolytic reaction → formation of hydroxide radicals → tissue burns and tissue necrosis
  • Serious burns may result within 2 hours of ingestion.
  • High risk of caustic injuries extending to adjacent structures, e.g., trachea or aortic arch
  • Injuries are most common in the esophagus, particularly in children and individuals with esophageal strictures.
• Diagnostics: x-ray ; ^[7]
  • Lateral view: step-off effect
  • AP view: Halo or double-rim effect
• Management ^[4][6][10]
  • See “Management of foreign body ingestion.”
  • Esophageal location: emergency endoscopic removal
  • Gastric location: elective endoscopic removal (emergency removal if the patient is symptomatic)
  • Bowel location: conservative management (emergency removal if the patient is symptomatic)
• Complications
  • Full-thickness mucosal burns
  • Esophageal perforation
  • Tracheoesophageal or aortoesophageal fistula ^[11]
  • Vocal cord paralysis ^[12]

Button batteries in the esophagus must be removed within 2 hours of presentation to prevent significant injury.

• Pathophysiology
  • The clinical course after ingestion of a single magnet is usually uncomplicated.
  • Intestinal obstruction, perforation, and/or ischemia may occur if bowel walls become compressed between multiple magnets or one magnet and a ferrous object. ^[4]
• Diagnostics: x-ray neck, chest, abdomen ^[7][9]
  • Aligned or stacked radiopaque objects suggest multiple magnets or magnet-metal pairs.
  • A narrow gap between magnets suggests bowel wall entrapment.
• Management
  • See “Management of foreign body ingestion.”
  • Single magnet: conservative management if it has passed through the duodenum
  • Multiple magnets or magnet and ferrous object
    • Esophagus or stomach: urgent endoscopy
    • Bowel (asymptomatic): conservative management with inpatient serial imaging, e.g., every 4–6 hours ^[1]
    • Bowel (symptomatic): urgent surgery consultation
• Complications ^[9]
  • Intestinal pressure necrosis
  • Intestinal fistula
  • Volvulus
  • Perforation
  • Obstruction

• Commonly ingested sharp objects
  • Chicken or fish bones
  • Toothpicks
  • Paper clips
  • Straight pins or open safety pins
  • Plastic bread bag clips
• Pathophysiology: high risk of mucosal laceration and/or perforation of the gastrointestinal tract
• Diagnostics ^[7]
  • X-ray neck, chest, and abdomen (AP and lateral): identifies radiopaque objects
  • CT scan
    • Localizes sharp FBs via secondary radiographic signs (e.g., tissue swelling)
    • Identifies complications of sharp FBs (e.g., perforation, abscess)
• Management ^[4]
  • See “Management of foreign body ingestion.”
  • Esophageal location: emergency endoscopic removal
  • Gastric or duodenal location and no severe symptoms: urgent endoscopic removal
  • Symptoms of esophageal, gastric, or bowel perforation: urgent surgery consultation
  • Distal bowel location: conservative management and hospital admission for serial imaging
• Complications: esophageal, gastric, or bowel perforation

Perform diagnostic endoscopy if clinical suspicion for FB ingestion is high, even if imaging studies are negative, as many sharp objects are radiolucent. ^[9]

Food impaction, the most common esophageal FB in adults, is frequently associated with underlying esophageal pathology, e.g., eosinophilic esophagitis. ^[4]

• Clinical features ^[4][13]
  • Acute dysphagia, typically while eating ^[14]
  • Retrosternal pain
  • Aphagia and/or drooling (may be caused by complete esophageal obstruction)
• Management ^[4][6]
  • Complete obstruction: emergency endoscopy
  • Incomplete obstruction: urgent endoscopy
  • Blind forceful advancement of the bolus is not recommended.
  • The effectiveness of intravenous glucagon in dislodging food impaction is uncertain. ^[15]
  • Endoscopic evaluation of the esophagus, including biopsies to identify the underlying cause of impaction

Urgent endoscopy is required to prevent esophagitis, esophageal perforation, and/or fistula formation after a food bolus impaction. ^[4][13]

Food bolus impaction is often associated with an underlying esophageal disease, e.g., eosinophilic esophagitis. ^[4][13]