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