Emergency Department Management of Gastrointestinal Foreign Body Ingestion

Table of Contents

 

About This Issue

Gastrointestinal foreign body ingestions, insertions, and impactions are frequently encountered in the ED, among adults and children, and although an estimated 80% to 90% do not cause symptoms or require endoscopic removal, there are certain types of objects and impaction locations that can cause life-threatening sequelae. In this issue, you will learn:

The 3 points of narrowing in the esophagus where foreign bodies may be impacted.

How to narrow down the location (esophageal, gastric, intestinal) and the object type (food, pointed objects, batteries, magnets), and how the results will dictate management.

For sharp or pointed objects, what the likelihood of perforation might be, and safer ways to remove them.

The particular dangers of button battery and magnet ingestion: minutes count to avoid burns and necrosis.

When x-ray is sufficient for location of the object, and when CT will be required.

When endoscopic removal is urgent and when expectant management is called for.

How to manage foreign bodies that have been inserted rectally.

How to locate and remove small fish and chicken bones.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
   1. Etiology
   2. Pathophysiology
      1. Anatomic Considerations
         • Esophageal
         • Gastric and Intestinal
      2. Object Type Considerations
         • Food Impaction
         • Pointed Objects
         • Button Batteries
         • Magnets
         • Colorectal Foreign Bodies
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
10. Diagnostic Studies
    1. Imaging
       1. Radiography
       2. Computed Tomography
       3. Rectal Foreign Body Imaging
    2. Laboratory Studies
11. Treatment
    1. General Management of Ingestions
    2. Expectant Management
    3. Endoscopic Management
    4. Non-Endoscopic Techniques
       1. Bougienage Technique
       2. Foley Catheter Technique
    5. Specific Management Principles
       1. Esophageal Foreign Bodies
       2. Button Battery
       3. Sharp Objects
12. Special Circumstances
    1. Removal of Rectal Foreign Bodies
    2. Sharp Bone Ingestion Removal
    3. Body Packing
13. Controversies and Cutting Edge
    1. Glucagon
    2. Benzodiazepines
    3. Gastric Button Batteries
14. Disposition
15. 5 Things That Will Change Your Practice
16. Risk Management Pitfalls in Gastrointestinal Foreign Body Ingestions
17. Summary
18. Time- and Cost-Effective Strategies
19. Case Conclusions
20. Clinical Pathways
    1. Clinical Pathway for Emergency Department Management of Foreign Body Ingestions Without Esophageal Symptoms
    2. Clinical Pathway for Emergency Department Management of Foreign Body Ingestions With Esophageal Symptoms
21. Tables and Figures
22. References

Abstract

There are over 150,000 reports to American Poison Centers every year due to foreign body ingestions, and many patients will be directed to emergency departments for evaluation and management. This comprehensive review evaluates the current literature related to gastrointestinal foreign body diagnosis and management. A discussion of the utility of various imaging modalities is presented, along with a description of high-risk ingestions and the evidence behind society guidelines and management strategies. Finally, controversies in the management of esophageal impactions are reviewed, including the use of glucagon.

Case Presentations

A 42-year-old woman presents with discomfort after eating fish…

• The patient states that the sensation of a foreign body in the mid-chest, just above the epigastric region began 2 hours ago while eating pan-seared halibut at a local seafood restaurant. She suspects a potential fish bone ingestion.
• Chest and abdominal radiographs were obtained, and the radiologist’s impression is “no acute abnormality or foreign body identified.”
• The patient continues to have some moderate discomfort when swallowing, but is able to drink juice and hold down crackers and a turkey sandwich in the ED.
• You wonder whether the patient can be discharged with expectant management or if further testing is needed…

A mother brings in her 2-year-old son after witnessing him ingesting an object…

• The mother states that she believes he ingested a coin, as he was playing with a toy electric cash register, and she saw him place a metallic circular object into his mouth. The child appears to be fussy, but his vital signs are normal. He is tolerating his secretions.
• A chest radiograph reveals a disc-shaped object in the upper esophagus. It measures approximately 15 mm in diameter and has a halo-like appearance and a step-off edge on the lateral view.
• The patient’s mother asks whether the coin will pass on its own or something more needs to be done…

A 22-year-old man presents with anorectal pain...

• The patient reports 2 days of pain and difficulty with defecation. He denies any abdominal pain, nausea, or vomiting.
• On examination, his abdomen is benign, and on visual genitourinary examination you do not see any external hemorrhoids or fissures. On digital rectal examination, you are easily able to palpate a smooth, hard object within the distal rectum.
• On further inquiry, the patient reports that he inserted a television remote rectally, but he does not want to disclose additional details surrounding the incident. You wonder whether you should proceed with a removal attempt or if any additional testing is needed…

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathways

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

9. * Ikenberry SO, Jue TL, Anderson MA, et al. Management of ingested foreign bodies and food impactions. Gastrointest Endosc. 2011;73(6):1085-1091. (Review) DOI: 10.1016/j.gie.2010.11.010

10. * Birk M, Bauerfeind P, Deprez P, et al. Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGA) clinical guideline. Endoscopy. 2016;48(05):489-496. (Society guidelines) DOI: 10.1055/s-0042-100456

39. * Litovitz T, Whitaker N, Clark L, et al. Emerging battery-ingestion hazard: clinical implications. Pediatrics. 2010;125(6):1168-1177. (Database review; 65,183 cases) DOI: 10.1542/peds.2009-3037

59. * Ploner M, Gardetto A, Ploner F, et al. Foreign rectal body - systematic review and meta-analysis. Acta Gastroenterol Belg. 2020;83(1):61-65. (Systematic review and meta-analysis; 54 studies)

70. * Tseng H-J, Hanna TN, Shuaib W, et al. Imaging foreign bodies: ingested, aspirated, and inserted. Ann Emerg Med. 2015;66(6):570-582. (Review) DOI: 10.1016/j.annemergmed.2015.07.499

86. * Waltzman ML, Baskin M, Wypij D, et al. A randomized clinical trial of the management of esophageal coins in children. Pediatrics. 2005;116(3):614-619. (Randomized, prospective; 168 patients) DOI: 10.1542/peds.2004-2555

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Keywords: gastrointestinal, GI, ingestion, impaction, aspiration, bone, food, esophagus, esophageal, gastric, stomach, intestinal, rectal, coin, battery, button battery, magnet, necrosis, endoscopy, glucagon