FORIEGN BODY UPPER GI
TRACTDr.G.Sathish kumar M.B.,B.S., D N B ., FMIBS.,
Consultant general &laparoscopic surgeon.
Sri vijaya hitech hospital and sudha institute of
medical seinces , erode , tamilnadu, india.
INTRODUCTION
The majority of foreign body ingestions occur in children between the ages of six months and three years .
Fortunately, most foreign bodies that reach the gastrointestinal tract pass spontaneously.
Only 10 to 20 percent will require endoscopic removal, and less than 1 percent require surgical intervention .
Although mortality from foreign body ingestion is extremely low, deaths have been reported .
Classification of foreign bodies
● Size
Length greater/smaller than 6 cm
● Surface consistency
– Sharp/pointed versus blunt
– Rounded versus sharp edges
●Material/contents, for example
– Food
– Drugs
– Battery
– Magnet
● Characteristics
– Radio-dense+/-
– Metallic+/-
– Chemically inert +/-
Food (typically meat) bolus impaction above a pre-existing esophageal stricture or ring is by far the most common cause of esophageal body obstruction in adults
Bones (chicken/fish), dentures, medication packaging, batteries and coins are uncommon in adults
Coins are the most common foreign body in children (76 % in one large series).
diagnosis
Detailed History and examination
Biplane radiographs identify most true foreign objects, steak bones, and free mediastinal or peritoneal air.
A contrast examination generally should not be performed because of aspiration risk, and contrast coating of the foreign body and esophageal mucosa can compromise subsequent endoscopy.
CT scanning may be useful, although it may not detect radiolucent objects. The sensitivity of CT may be improved with 3-dimensional reconstruction.
Management
Type of object
Location of the object
Clinical status
Expectant management is appropriate for the
majority of patients since most objects will
pass uneventfully
Specific approach varies with the type of
ingestion and the clinical setting
Always practice with equipment prior to
procedure
timing
Emergent endoscopy
Patients with esophageal obstruction (ie, unable to
manage secretions)
Disk batteries in the esophagus
Sharp-pointed objects in the esophagus
Urgent endoscopy
Esophageal foreign objects that are not sharp-pointed
Esophageal food impaction in patients without complete obstruction
Sharp-pointed objects in the stomach or duodenum
Objects 6 cm in length at or above the proximal duodenum
Magnets within endoscopic reach
Non-urgent endoscopy
Coins in the esophagus may be observed for 12 to 24 hours in asymptomatic patients
Blunt objects in the stomach that are >2.5 cm in diameter
Disk batteries and cylindrical batteries that are in the stomach in patients without signs of GI injury may be observed for up to 48 hours (however, disk batteries that are larger than 20 mm are unlikely to pass and should be removed)
Blunt objects that fail to pass the stomach in three to four weeks
Blunt objects distal to the duodenum that remain in the same location for more than a week (deep small bowel enteroscopyor surgery may be required depending on the location of the object)
Airway management
Airway protection is important for all patients
undergoing endoscopic foreign body removal
Oropharyngeal suction is required
Impactions in the esophagus require intubation
to protect the airway
Overtubes may be used to prevent an object
from accidentally being dropped into the patient's
airway
Equipment
Endoscopes
Most ingested foreign bodies are best treated with flexible endoscopes
However, rigid esophagoscopy may be helpful for proximal foreign bodies impacted at the level of the upper esophageal sphincter.
Video endoscopes.
Retrieval devices
rat-tooth and alligator forceps, polypectomy
snares, polyp graspers, Dormier baskets, Roth net, magnetic probes, and banding caps.
Before endoscopy, practicing grasping a similar object to the ingested foreign body may help determine the most appropriate available retrieval device and in what fashion to grasp the object.
Food bolus impaction
most common esophageal foreign body in adults.
Extraction may involve en bloc removal by using various grasping devices (polypectomysnare, retrieval net or banding cap) or removal by a piecemeal approach.
high incidence of esophageal pathology(stricture /eosinophilic esophagitis) is associated with food impaction.
it is safe to perform dilation after food bolus extraction when an esophageal stricture is present.
Short-blunt objects.
Object may be advanced into the stomach where it is easier to grasp
Endoscopy done using appropriate equipment Basket/Net for most objects
Long overtube to protect GEJ
If no long overtube not avalable give 1 mg of glucagon to relax GEJ prior to FB removal
If object has passed into stomach may observe for 4 w weeks unless > 2.5 cm
Management of long objects
Objects greater than 6 cm should be removed as they will not pass duodenal C sweep i.e. –toothbrush/spoon/chopstick
Grab with snare and remove via an overtube If overtube not available use 1mg of glucagon
Coins
Coins are by far the most common foreign body ingested by children
esophageal coin should be removed promptly if the patient is symptomatic or if the time of ingestion is not known.
If the child is asymptomatic and the coin does not pass spontaneously by 24 hours after ingestion, it should be removed. coins that reach the stomach can be managed expectantly.
If the coin has not passed beyond the stomach by four weeks, endoscopic removal is
Sharp-pointed objects
Chicken and fish bones, straightened paperclips, toothpicks, needles,pins, bread bag clips, and dental bridgework.
must be evaluated to define the location of the object.
Sharp-pointed objects lodged in the esophagus are a medical emergency.
Direct laryngoscopy is an option to remove objects lodged at or above the cricopharyngeus.
Sharp objects in the stomach often pass
- 35% complication rate, therefore all objects should be removed
Equipment for removal
Endoscope
Forceps, Snare or Roth net
Hood
Overtube
•Technique
Orientation of the sharp end to be trailing reduces mucosal injury
mucosal injury during retrieval can be minimized by orienting the object with its point trailing during extraction, by using an overtube, or by fitting the endoscope with a protector hood.
protector hood
Management of batteries
Button battery (hearing aids, watches, games,
toys, and calculators) are the most common
battery ingested
•Liquefaction necrosis/perforation can occur
rapidly
•Batteries lodged in the esophagus should be
emergently removed
•Overtube or endotracheal tube is essential to
Batteries generally removed with roth net/basket
Alternately push battery into the stomach and retrieve
If a battery has passed beyond the stomach no need to remove unless intestinal injury
Batteries >20 mm should be removed
No role for acid suppressive medications
Once past the duodenum, 85% pass out of the body within 72 hours.
A radiograph every 3 to 4 days is adequate to assess the progress through the GI tract.
Management of magnets
Magnets are rarely ingested
Dangerous as they can cause severe injury
Magnet can trap mucosa and cause necrosis
and fistula formation
All magnets need to be removed Can be
removed with a net or snare
Body Packing
Internal concealment of illegal drugs wrapped in plastic or contained in balloons or latex condoms is seen in regions of high drug trafficking
Diagnosis is made by plain X-rays or CT scan
Endoscopic drainage is contraindicated as leakage can be fatal
Surgical removal only suspected leakage or bowel obstruction
Take Home
Emergent removal of esophageal food bolus impactions and foreign bodies in patients with evidence of complete esophageal obstruction
Remove all objects with a diameter larger than 2.5 cm from the stomach
Remove sharp-pointed objects or objects longer 6 cm in the proximal duodenum or above
Emergent removal disk batteries in the esophagus
Urgent removal of all magnets within endoscopic reach
Coins within the esophagus may be observed in asymptomatic patients but should be removed within 24 hours of ingestion if spontaneous passage does not occur
Always practice with equipment prior to procedure
Thank you