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Foreign Body Ingestion: Dos and Don'ts

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ENDOSCOPY Frontline Gastroenterol: first published as 10.1136/flgastro-2020-101450 on 6 October 2020. Downloaded from EDUCATION IN PRACTICE Foreign body ingestion: dos and don’ts Aymeric Becq,1,2 Marine Camus,1,2 Xavier Dray 1,2 1Endoscopy Department, Hôpital INTRODUCTION Emesis, retching, blood- stained saliva, Saint Antoine, APHP, Sorbonne Foreign body ingestion comprises a true hypersialorrhoea, wheezing and/or respira- Université, Paris, Île- de- France, France foreign body (ie, non- food) ingestion and tory distress in non- communicative patients 2Paris On- call Endoscopy Team, food bolus impaction. Foreign body inges- (children and psychiatric patients) are Assistance Publique Hopitaux de tion is not uncommon and accounts for suggestive of foreign body impaction.7 Paris, Paris, Île- de- France, France roughly 4% of urgent endoscopies under- Oesophageal impaction (food bolus) is often 1 2 Correspondence to taken. True foreign body ingestion is symptomatic: retching, vomiting, foreign Professor Xavier Dray, Endoscopy mostly encountered in paediatric popula- body sensation, dysphagia, odynophagia, Unit, Hôpital Saint Antoine, APHP, tions with 75% of cases occurring in less sore throat and retrosternal pain. Hypersia- Sorbonne Université, 75012 1 Paris, Île- de- France, France; than 5- year- old children. Coins, buttons, lorrhoea and inability to manage secretions xavier. dray@ aphp. fr plastic items, batteries and bones are suggest complete oesophageal obstruction, common culprits.3 Food bolus impaction warranting urgent endoscopic retrieval.7 Received 1 July 2020 Revised 27 August 2020 on the other hand is mostly seen in adults, Cervical crepitus, neck swelling or pneumo- Accepted 30 August 2020 usually accidental (95% of cases). Steakhouse mediastinum are suggestive of oesophageal syndrome, animal bones, toothpicks and fish perforation. Choking, stridor, wheezing or bones are the most frequent.2 True foreign dyspnoea can be seen as a result of aspiration body ingestion (coins and dentures) is rare in or tracheal compression by the foreign body. copyright. adults. Intentional true foreign body inges- Radiographic evaluation is not always tion can be seen in patients with psychiatric necessary and should not delay urgent treat- illness, prisoners (secondary gain) and drug ment. It is not useful in non- complicated dealers (‘body packing’). Underlying oesoph- non- bony food impaction.7 Plain (or biplane ageal conditions including eosinophilic if not contributive) radiographic evaluation oesophagitis (10% in adults, up to 50% in of the neck, chest and abdomen is recom- children), motility disorder, stenosis and mended to assess the presence, number, diverticula are frequent.2 4 Most ingested location, size and shape of the radiopaque http://fg.bmj.com/ foreign bodies will pass spontaneously.5 foreign body. Also, signs of complications However, 10%–20% require endoscopic can be detected such as aspiration, free medi- removal, and less than 1% require surgical astinal or peritoneal air and subcutaneous extraction or treatment of a complication.6 emphysema. Contrast studies can delay This review focuses on the management of treatment, impair visualisation during subse- on November 20, 2020 by Teresa Jobson. Protected foreign bodies located in the upper gastro- quent endoscopy and worsen complications. intestinal tract, in adults. The quality of A barium swallow is contraindicated when evidence of the guidelines is low; however, perforation is suspected, and aspiration of substantial clinical experience provides hypertonic contrast agents can cause acute strong levels of recommendation.7 8 The pulmonary oedema.2 X- ray contrast study management of rectal foreign bodies mostly for the evaluation of non- radiopaque objects relies on surgical, transanal extraction and is is not recommended. A CT scan is the not detailed herein. preferred method in this setting, although © Author(s) (or their employer(s)) rarely needed.7 2020. No commercial re- use. See rights and permissions. Published INITIAL EVALUATION ENDOSCOPY: SETTING AND by BMJ. Precise history (type of foreign body, time EQUIPMENT To cite: Becq A, Camus M, of onset) is essential. Physical examination is Informed consent must be obtained before Dray X. Frontline also mandatory. Most patients are asympto- endoscopy, although it may be challenging in Gastroenterology Epub ahead 2 of print: [please include Day matic. Symptoms arise when the foreign body psychiatric patients and in prisoners. Usually, Month Year]. doi:10.1136/ is stuck in the oesophagus or when a compli- oesophagogastroduodenoscopy (OGD) is flgastro-2020-101450 cation occurs (obstruction and perforation).9 performed under conscious sedation, with Becq A, et al. Frontline Gastroenterology 2020;0:1–7. doi:10.1136/flgastro-2020-101450 1 ENDOSCOPY Frontline Gastroenterol: first published as 10.1136/flgastro-2020-101450 on 6 October 2020. Downloaded from patients on left lateral position and slight lowering of the Special equipment must be used to protect the head, so as to reduce the risk of aspiration.2 General anaes- airways and the oesophageal mucosa in case of sharp or thesia with endotracheal intubation is required in difficult bulky foreign bodies.16 For instance, an overtube can cases to ensure airway protection (younger children, poor be placed over the endoscope prior to the procedure. A tolerance, multiple foreign bodies, anticipated difficult long overtube advanced passed the gastro- oesophageal extraction and when rigid oesophagoscopy is needed). junction (GEJ), a hood placed upside down at the tip A nasogastroscope with an external diameter less than of the endoscope (which unfurls at the GEJ when the 6 mm and a 2 mm large operating channel should be used endoscope is pulled out), or a transparent distal cap in children aged less than 1 year. Only small polypectomy (from elastic band ligation or mucosectomy kits) can retrieval nets (20 mm width), polypectomy snares and be used for the removal of sharp or pointed foreign Dormia baskets can pass through the operating channel. bodies located distal to the oesophagus.16 Standard flexible gastroscopes with an external diam- eter of 9.8 mm and a 2.8 mm large operating channel or therapeutic gastroscopes with a>3.2 mm single operating MANAGEMENT channel are used otherwise. Double-channel endoscopes, Endoscopic extraction of food bolus impaction and foreign body ingestion from the upper digestive tract allowing the combined use of devices, small-calibre endo- 2 17 scopes, allowing a transnasal approach, and enteroscopes is successful in 95% of cases. When endoscopic can be used in specific settings.7 Lastly, several studies extraction fails, rigid oesophagoscopy for the upper have suggested that rigid oesopharyngoscopy can be safely oesophageal foreign body can be considered. Referral 10 11 to a tertiary endoscopy centre should be discussed in used for body extraction. The choice between rigid 2 and flexible oesophagoscopy mainly depends on the size, difficult cases (2% in adult series). Surgical manage- 2 shape and location of the ingested foreign body. The avail- ment is required in 1% of cases. ability of the equipment and trained physician also play a In 30% of cases, no foreign body is identified by 2 role.12 Flexible oesophagoscopy performed by gastroen- OGD. Enteroscopy and surgery should be consid- terologists is easy technically wise and allows a complete ered for long, sharp/pointed foreign bodies, batteries evaluation of the oesophagus.13 Rigid oesophagoscopy or magnets that have passed the duodenojejunal angle performed by ENTs can be useful when the foreign body because of the risk of complication (perforation). In other cases, outpatient management is suggested with is located at the pharyngoesophageal junction because in copyright. such cases, flexible oesophagoscopy is limited by a small daily stool observation and radiographic evaluation working space and poor visual field. Rigid oesophago- every 72 hours to monitor the progress through the 7 scopes on the other hand have a larger working channel gastrointestinal tract. Patients should be informed thus making it possible to use a large forceps (with a of the clinical signs of perforation prompting rapid stronger grasp).14 For foreign bodies that have passed the consult. oesophagus, rigid oesophagoscopy should be attempted Overall, 80% of foreign bodies pass through the 5 only when flexible endoscopy has failed as the complica- digestive tract. In 20% of cases, they remain impacted 15 tion rate is higher (10% vs 5%). in the narrower segments of the digestive tract, mainly http://fg.bmj.com/ 2 Numerous retrieval devices are available. The chosen in the oesophagus (50%–75%). Oesophageal impac- device will depend not only on the size and shape of tion carries the highest risk of complication (25% the foreign body but also on the length and operating higher than other parts of the digestive tract) that channel width of the endoscope and the endoscopist’s can be life threatening given the proximity to vital 18 preference and habits.16 Foreign body retrieval forceps organs. Urgent endoscopic extraction, irrespective of such as rat- tooth (most common), alligator- tooth or a full stomach or not, must be performed without delay on November 20, 2020 by Teresa Jobson. Protected shark- tooth forceps (reusable) are most often used. in the following cases: (1) foreign body in the upper Retrieval forceps with 2 to 5 prongs can be useful third part of the oesophagus, (2) complete obstruc- 7 to retrieve
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