Managing Foreign Objects in the GI Tract Tips & Tricks STEPHEN LANDRENEAU, MD Take home o Perform emergent endoscopy in cases of: Esophageal obstruction due to food bolus impaction or foreign object. Disk batteries or sharp objects in the esophagus o Perform urgent endoscopy in cases of: Magnets Sharp objects in the stomach or duodenum o Endoscopy for all sharp objects; > 2.5cm diameter; > 6 cm length o Do not attempt endoscopic removal of drug packets o Endoscopy should not delay surgical intervention if sign of perforation 1
Outcomes o 80 % pass spontaneously o Most ingestions are in pediatric patients o If intentional, intervention may be required o Most sharp objects pass uneventfully o Mortality is exceedingly low 2
Objects ingested o Bones * o ID cards * o Dentures * o Safety pins o Coins * o Plastic spoons/silverware * o Meat * o Ink Pens * o Medication Packages o Razor Blades * o Batteries * o Wood/Sticks * o Toothbrushes * o Drug Packets * I ve Personally Removed 3
Shabani, Zamani, Hassanian-Moghaddam. Endosc Int Open 2016;4:E443-445 4
Sites of obstruction o Upper esophageal sphincter o Aortic Arch o Lower esophageal sphincter o Pylorus o Ileocecal valve o Small bowel adhesions Presentation o Non-impaired adults & older children Straight forward history o Impaired adults, small children, psychiatric disease May give no history Symptoms may occur in minutes, days, or never Neck tenderness or swelling Drooling, Coughing Regurgitation, fullness, reluctance to eat o Perforation Not a GI problem 5
Evaluation & management o Exam o Imaging o Surgical Consultation o Endoscopy Emergent Urgent Nonurgent Emergent endoscopy o Complete esophageal obstruction o Disk batteries in the esophagus o Sharp pointed objects in the esophagus ASGE Standards of Practice Committee. Gastrointest Endosc 2011;73:1085-1091 6
Urgent endoscopy o Esophageal foreign objects o Food impaction without complete obstruction o Sharp objects in stomach or duodenum o Objects > 6 cm in length at proximal duodenum o Magnets within endoscopic reach ASGE Standards of Practice Committee. Gastrointest Endosc 2011;73:1085-1091 Nonurgent endoscopy o Coins in the esophagus Can observe 12-24 hours if no symptoms o Objects in the stomach with diameter > 2.5 cm o Batteries in the stomach Can observe 48 hours if no symptoms ASGE Standards of Practice Committee. Gastrointest Endosc 2011;73:1085-1091 7
Adverse events o Superficial mucosal injury o Bleeding o Perforation o Aspiration Tools of the trade 8
More tools Food bolus impaction o Most common foreign object encountered o En bloc removal- snare, net, banding cap o Piecemeal removal- graspers, forceps, etc. o Gentle pressure to advance bolus into stomach o Reduction in size via piecemeal, followed by gentle pressure 2 series, no perforations in 375 patients. o Caution after prolonged impaction o Avoid proteolytic agents o Glucagon 9
Short-blunt objects o Coins: grasping forceps, snare, net o Smooth round objects: net, basket o Esophageal objects may be passed into the stomach for removal o Even if asymptomatic: Remove objects > 2.5 cm in the stomach Objects that remain in the stomach by 3 weeks Small bowel objects in the same location > 1 week Long objects o Objects > 6 cm unlikely to pass duodenum o Long (> 45 cm) overtubes can facilitate removal Snare, forceps, or basket to maneuver into overtube Removal of scope, object, and overtube together 10
Sharp pointed objects o Chicken and fish bones, toothpicks, needles, dental work, etc. o Esophageal objects are an emergency o Consultation ENT, Surgery o Forceps, Net, Snares o Orient so sharp point is trailing o Overtube, protector hood o If beyond reach of scope, daily radiographs o Surgery if complication or fails to progress for 3 days. Disk batteries o A pediatric problem o Liquefactive necrosis and perforation occurs in the esophagus o Removal Net, Basket, combination TTS balloon and overtube Can be pushed into stomach if esophageal retrieval difficult o Once distal to esophagus they pass uneventfully o If large diameter and retained in stomach beyond 48 hours, remove 11
Magnets o Adhere to each other and other ingested metal objects o Necrosis of interposed bowel Results in fistula, perforation, volvulus, obstruction, peritonitis o All magnets should be removed Even if radiograph or history suggests only 1 magnet Net, basket Narcotic packages o Not a GI problem o Endoscopic removal is not recommended Rupture during endoscopic removal based on a case report 1 case report of endoscopic removal in esophageal obstruction. 1 case series of endoscopic removal o Shabani, Zamani, Hassanian-Moghaddam. Endosc Int Open 2016;4:E443-445 12
Keys o Emergent endoscopy if: Esophageal obstruction due to food bolus impaction or foreign object Disk batteries Sharp objects in the esophagus o Urgent endoscopy if: Magnets Sharp objects in the stomach or duodenum o Endoscopy for all sharp objects; > 2.5cm diameter; > 6 cm length o Do not attempt endoscopic removal of drug packets o Endoscopy should not delay surgical intervention if sign of perforation 13