REMOVAL OF INGESTED FOREIGN BODY

By Monzur Ahmed

Recently I had to perform two back to back urgent endoscopies in patients who had swallowed foreign bodies. Both procedures were done under GA with the patient intubated. One patient swallowed button batteries and magnets (a potentially deadly combination) whilst the other ingested a metal nail file and one limb of a pair of tweezers. The video shows the use of Roth net, snare and Gaurdus overtube.

CASE 1
19 year old female
History of personality disorder
Multiple previous admissions for swallowed foreign bodies
Now:
- admitted after staggered paracetamol overdose over 3 days and ingestion of several button batteries + neodymium magnets
- AXR: multiple button batteries / magnets in stomach
- Urgent out of hours OGD under GA by a colleague: stomach full of food, unable to retrieve foreign bodies
Next day: repeat OGD under GA (see video)

CASE 2
31 year old female
History of schizophrenia, learning difficulties, personality disorder, asthma
Multiple ingestion of foreign bodies in past
Admitted after swallowing metal nail file + tweezers 24 hrs ago
AXR: nail file in stomach, tweezers in small bowel
OGD performed 48 hours after ingestion, under GA (see video).​

Most ingested foreign bodies (80%–90 %) pass spontaneously. However, approximately 10 %–20 % of cases of foreign body ingestion require endoscopic removal, while less than 1 % will need surgery for foreign body extraction or to treat complications. The ESGE 2016 guidelines [1] on foreign body removal may be summarised as follows:

A.NON-ENDOSCOPIC MEASURES
Recommended:
-diagnostic evaluation based on the patient’s history and symptoms. Physical examination focused on the patient’s general condition and to assess signs of any complications.
-CT scan in all patients with suspected perforation or other complication that may require surgery.
-plain radiography to assess the presence, location, size, configuration, and number of ingested foreign bodies if ingestion of radiopaque objects is suspected or type of object is unknown.
-clinical observation without the need for endoscopic removal for management of asymptomatic patients with ingestion of blunt and small objects (except batteries and magnets). If feasible, outpatient management is appropriate.
-close observation in asymptomatic individuals who have concealed packets of drugs by swallowing (“body packing”). We recommend against endoscopic retrieval. We recommend surgical referral in cases of suspected packet rupture, failure of packets to progress, or intestinal obstruction.
Not recommended:
-radiological evaluation for patients with non-bony food bolus impaction without complications.
-barium swallow, because of the risk of aspiration and worsening of the endoscopic visualisation.

B. ENDOSCOPIC MEASURES
Recommended:
-emergent (preferably within 2 hours, but at the latest within 6 hours) therapeutic OGD for foreign bodies inducing complete oesophageal obstruction, and for sharp-pointed objects or batteries in the oesophagus.
-urgent (within 24 hours) therapeutic OGD for other oesophageal foreign bodies without complete obstruction.
-treatment of food bolus impaction in the oesophagus by gently pushing the bolus into the stomach. If this procedure is not successful, retrieval should be considered. The effectiveness of medical treatment of oesophageal food bolus impaction is debated. It is therefore recommended, that medical treatment should not delay endoscopy.
-In cases of food bolus impaction, ESGE recommends a diagnostic work-up for potential underlying disease, including histological evaluation, in addition to therapeutic endoscopy.
-urgent (within 24 hours) therapeutic OGD for foreign bodies in the stomach such as sharp-pointed objects, magnets, batteries and large/long objects. We suggest nonurgent (within 72 hours) therapeutic OGD for medium-sized blunt foreign bodies in the stomach.
-use of a protective device in order to avoid oesophagogastric / pharyngeal.damage and aspiration during endoscopic extraction of sharp pointed foreign bodies. Endotracheal intubation should be considered in the case of high risk of aspiration.
-ESGE suggests the use of suitable extraction devices according to the type and location of the ingested foreign body.
-After successful and uncomplicated endoscopic removal of ingested foreign bodies, ESGE suggests that the patient may be discharged. If foreign bodies are not or cannot be removed, a case-by-case approach depending on the size and type of the foreign body is suggested.
​
REFERENCE
1.Birk M, Bauerfeind P, Deprez PH et al 2016, Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline, Endoscopy 2016; 48: 1–8
https://www.esge.com/.../guidelines/2016_s_0042_100456.pdf