- Anticipate the need for intubation for airway protection before urgent endoscopic retrieval.
- Attempt an endoscopic extraction of drug-containing packets.
- Defer endoscopic extraction of food bolus impaction later than 12 to 24 hours.
- Defer endoscopic extraction of a sharp or pointed foreign body.
- Attempt endoscopic extraction of a rectal foreign body.
- Defer endoscopic extraction because of radiographic evaluation.
Foreign-body ingestion and food bolus impaction are frequent, and associated with a wide array of clinical presentations. Clinical trials are rare, but substantial clinical experience provides strong levels of recommendation.
Foreign-body ingestion and food bolus impaction
True foreign-body (i.e. non-food) ingestion and food bolus impaction account for 4% of urgent endoscopies. Coins, buttons, plastic items, batteries, and bones are commonly swallowed by children. Accidental food bolus impaction is mostly seen in adults, most frequently involving a food mass (“steakhouse syndrome”), animal bones, fish bones, and rarely dentures or toothpicks are among the most common foreign bodies ingested by adults. Intentional true foreign body ingestion is most frequently seen in patients with psychiatric illness, prisoners, and drug dealers (‘body-packing’). Impaction caused by a foreign body or food bolus is associated in 30% of cases with underlying oesophageal conditions, including eosinophilic oesophagitis, motility disorder, stenosis, and diverticula. (1)
Most ingested foreign bodies pass spontaneously, but 10–20% of cases require endoscopic removal and up to 1% could require surgical extraction or treatment of a complication.
Initial evaluation is essential in all presenting cases but should not delay urgent treatment. Precise history (type of foreign body and time of onset) and physical examination are mandatory. Most patients are asymptomatic. Symptoms generally arise when the foreign body becomes stuck in the oesophagus or when a complication occurs (obstruction, perforation, etc). Radiographic evaluation is not always necessary, and it is not useful in non-complicated, non-bony food impaction. Plain or bi-plane radiography is recommended for evaluation of radiopaque foreign bodies, but contrast studies should be avoided because they can delay treatment, impair visualisation during subsequent endoscopy, and worsen complications. CT scan is the preferred imaging modality, in the rare situation where any is necessary, although it is rarely needed (2)
Data are conflicting about the use of effervescent agents (so-called fizzy drinks) and pharmaceutical treatments (e.g. glucagon) for food bolus dis-impaction. (3-4)
Overall, clinical evaluation, imaging, and medication trial should not delay endoscopic extraction. Indeed, endoscopic extraction is the cornerstone of the management of foreign-body ingestion. An urgent procedure is required if the foreign body is lodged in the upper third of the oesophagus (Figure 1), is causing complete oesophageal obstruction, or if the patient has ingested magnets, a button battery, or a sharp object. All foreign bodies impacted in the oesophagus should be extracted within 24 hours. Blunt foreign bodies should be removed from the duodenum after 4–8 days, and from the stomach within 3-4 weeks. A sharp foreign body beyond the duodenum should be extracted by surgery if it fails to progress after 3 days. Of note, conservative management is preferred to endoscopic extraction of illicit drug packages.
General anaesthesia with endotracheal intubation is required to ensure airway protection. Standard flexible gastroscopes may be used in most cases. Special equipment (e.g. overtube, transparent cap, or flexible hood) must be used to protect the oesophageal mucosa in case of sharp foreign bodies (Figure 1, Figure 2). Numerous retrieval devices (retrieval forceps, biopsy forceps, baskets, standard polypectomy snares and retrieval nets) can be used depending on the type, size, and shape of the foreign body and its location.
Endoscopic extraction is successful in 95% of cases. (2,5) Severe complications (oesophageal perforation) are uncommon but require early recognition and prompt treatment. In the setting of oesophageal food bolus impaction, underlying conditions should be investigated.
Overall, although most foreign bodies will naturally pass through the digestive tract, endoscopists should recognise specific situations where intervention is required. In such cases, timing and adequate equipment are key factors.
Figure 1: Chicken bone impaction in the oesophagus
A middle-aged patient was admitted after accidental ingestion of a chicken bone. The patient had chest pain and hypersialorrhea, but no crepitus or fever. No biological or imaging work-up was performed. The patient was urgently transferred to the endoscopy unit 2 hours after ingestion for endoscopic extraction. A rapid-sequence intubation was performed given the aspiration risk. A transparent cap was placed at the tip of a 9.8 mm diameter gastroscope (A, B). The chicken bone was found impacted in the upper third part of the oesophagus (A). No sign of perforation was noted. Endoscopic extraction was performed with alligator-tooth forceps (B). A 4cm bone was retrieved intact (C). No significant mucosal damage was observed after extraction (D), and the patient was discharged on the same day.
Figure 2: Dental bridge ingestion
An elderly patient was admitted in the endoscopy suite 4 hours after the accidental ingestion of his dental bridge. The patient was asymptomatic. No biological or imaging workup had been performed. A latex hood was placed at the tip of a gastroscope (A). The dental bridge was found in the stomach, with no sign of mucosal damage (B). It was approximately 6 cm long with two sharp edges. Endoscopic extraction was performed with a 10 mm polypectomy snare (C). The latex hood unfolded while passing through the gastroesophageal junction, which protected the oesophageal wall (D, E). No significant mucosal damage was observed after extraction and the patient was discharged the next day.
- Mosca S, Manes G, Martino R, Amitrano L, Bottino V, Bove A, et al. Endoscopic management of foreign bodies in the upper gastrointestinal tract: report on a series of 414 adult patients. Endoscopy 2001;33(8):692–6.
- ASGE Standards of Practice Committee, Ikenberry SO, Jue TL, Anderson MA, Appalaneni V, Banerjee S, et al. Management of ingested foreign bodies and food impactions. Gastrointest Endosc 2011;73(6):1085–91.
- Tibbling L, Bjorkhoel A, Jansson E, Stenkvist M. Effect of spasmolytic drugs on esophageal foreign bodies. Dysphagia 1995;10(2):126–7.
- Lee J, Anderson R. Best evidence topic report. Effervescent agents for oesophageal food bolus impaction. Emerg Med J EMJ. 2005 Feb;22(2):123–4.
- Li Z-S, Sun Z-X, Zou D-W, Xu G-M, Wu R-P, Liao Z. Endoscopic management of foreign bodies in the upper-GI tract: experience with 1088 cases in China. Gastrointest Endosc 2006 Oct;64(4):485–92.
Xavier Dray is a gastroenterologist who specialises in digestive endoscopy. After his fellowship at the Assistance Publique – Hôpitaux de Paris (APHP), Paris, France, he graduated in Medicine in 2003, and then obtained a master’s degree in biostatistics, epidemiology and clinical research. He was Research Assistant at the Johns Hopkins University School of Medicine in Baltimore, MD, USA, from 2006 to 2008, and then obtained a PhD in Biology. He is now a professor of medicine, leading the Centre for Digestive Endoscopy at Sorbonne University, Hôpital Saint-Antoine, APHP, Paris, France. His research focuses on technical innovations for gastrointestinal endoscopy, with a special interest in artificial intelligence and embedded systems. He has built fruitful collaborations with several teams and working groups, and he has founded a start-up company (Augmented Endoscopy), in the field of capsule endoscopy.