Editing Ingested foreign body


== '''Oesophageal FB''' ==

=== Underlying conditions that     can provoke impaction: ===

** Eosinophilic oesophagitis
** Schatzki's ring
** Oesophageal carcinoma
** Peptic stricture
** Oesophageal diverticulum
** Post-surgical      (fundoplication, oesophago-gastrostomy)
** Hiatal hernia
** Achalasia
** Prior oesophageal atresia

=== Areas of luminal narrowing: ===

** Upper oesophageal sphincter
** Aortic arch
** GOJ

=== Presentation ===

** Acute onset dysphagia,      especially while eating

=== Complications ===

** Perforation
** Obstruction - drooling or      inability to swallow liquids
** Fistula

=== Indications for pre-endoscopy     CT without PO contrast: ===

** Suspected perforation
** Sharp or pointed foreign      body ingestion
** Suspected packets of      narcotics

=== Treatment approach ===

** Medical management
*** Glucagon is probably not       helpful
*** Meat tenderisers have not       been proven to help
*** Coke is unproven
** All FBs in oesophagus      require removal within 24 hours
** Emergent endoscopy (within 2      hours, or maximum 6) for the following:
*** Complete oesophageal       obstruction - drooling, inability to handle secretions
*** Disk batteries in       oesophagus - contact with both sides can allow discharge of electrical       current
**** Damage to oesophagus can        occur within two hours
**** Multiple studies support        the use of honey/sucralfate in interval between ingestion and retrieval        - neutralises pH
**** Acetic acid can be used        after removal - 50mL of 0.2% acetic acid - reduced tissue destruction
*** Sharp objects in oesophagus
** Urgent endoscopy (24 hours)      for all other objects

== '''Stomach FB''' ==

* Objects greater than 2-2.5cm     in DIAMETER will not pass through pylorus/ICV
* Objects greater then 5-6cm in     LENGTH will not pass through duodenal sweep
* '''Gastroscopy     within 24 hours'''     if
** Sharp object (35% risk of      perforation in upper GIT)
** Objects >5cm in LENGTH at      or above proximal duodenum
** Magnets within endoscopic      reach (even if only one identified - there might be another)
* '''Gastroscopy     within 72 hours'''     if unlikely to pass all the way through
** Blunt objects in stomach      >2cm diameter
** Disk batteries and      cylindrical batteries remaining in the stomach longer than 24 hours
* Otherwise expectant     management
** Weekly radiographic      monitoring
** Normal diet
** Monitor stools
** Failure if
*** Non-progression
*** Symptomatic

== '''Gastric bezoar''' ==

* Collections of non-digestible     materials
* Types:
** Vegetables - phytobezoar
** Hair - trichobezoar
** Medications - pharmacobezoar
* Risk factors:
** Underlying gastric motility      issues (prior gastric surgery, gastroparesis, gastric outlet obstruction)
* Presentation
** Often asymptomatic
** Otherwise gradual symptom      onset over the years
*** Early satiety
*** Pain
*** Nausea/vomiting
*** Weight loss
* Investigation
** Gastroscopy
* Management
** Enzymatic therapy
*** Reasonable to try       first-line
*** Papain, cellulase, soda,       acetylcysteine - no particular best agent
*** Trichobezoars are typically       resistant to dissolution
** Endoscopic
*** Fragment with water jet,       forceps, or direct suction
** Surgical therapy
*** Obviously last-line
*** Rarely required for       complications such as bleeding or perforation
*** Sometimes necessary       depending on the substance involved

== '''Gastroscopy for removal of FB''' ==

=== Anaesthesia ===

** Airway protection is      essential
** ETT if impacted object,      anticipated difficulty removing, multiple objects, duration of impaction      is unknown, and when rigid endoscopy is required

=== Equipment ===

** Suction cap is very good for      food bolus
** Overtube - especially good      for piecemeal removal of food
** Rat-tooth forceps
** Snare and Roth net can be      useful
** Coins are best retrieved      with a rat-tooth forceps, snare, or net
** Round objects such as disk      or button batteries - net
** Rigid scope is associated      with a higher perforation rate, but still low
** C-MAC is good for upper      oesophageal/pharyngeal foreign body

=== Technique ===

** Can practice externally with      a duplicate of the impacted object
** Don't push it into the      stomach
** If a stricture or ring is      identified after clearing a food bolus, dilation should be performed      during the same session (cautiously if eosinophilic oesophagitis is      present)
** Long objects can sometimes      be pulled into a long overtube and removed that way

== '''Unsuccessful retrieval''' ==

* Surgery vs observation
** Factors favouring surgery:
*** Low chance of passing       through
*** Sharp and risk of       perforation
*** Batteries
*** Magnets
* Surgery if no progress over a     week (blunt) or three days (sharp), or considered impossible to pass     through fully

[[Category:UGIS]]