Foreign bodies in the GI tract

Presenter: Dr Kassahun Girma SR I,

moderator: Dr Temesgen , EMCC Consultant
August 28, 2019
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 Outline
• Case
• Introduction
• Epidemiology
• Pathophysiology
• Clinical manifestations
• Patient approach
• Management
• Complications
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 Case
Name: M. T Card no: 577108
Age: 20,
Sex: male
From: Sebeta
Referred from ALERT center
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 History & physical Exam
16/12/2011
C/C: Epigastric pain of 04hrs durations
Hx: A 20 yrs old male pt who presented with epigastric pain of 04hrs duration after
swallowing cork (beer cover)while trying to open it.
He then drunk a lot of water and beer to push it down.
Associated to this he has crampy abdominal pain and chest tightness of the same
duration.

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It was his first attempt of drinking
Otherwise he has no history of choking vomiting, cough, SOB, or LOC

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P/E: GA, Healthy looking
V/S: BP=140/70 PR=96 RR=20 T= ATT
HEENT: Pink conj. & NIS
LGS: no LAP
RSP: no wheezing or stridor
chest is clear and resonant bilaterally
CVS: S1 and S2 well heard, no murmur or gallop

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Abdomen: soft, no tenderness, no organomegally, no SFC
GUS: no CVAT
MSKL: no edema
Neuro: COTPP

ASS’T: Foreign Body Swallow

Plan:- CBC, Bg & RH, CXR, Plain Abd X-ray
-keep at waiting area
-keep him NPO and put him on MF
-Surgical side consulted and suggested GI consultation
- to consult GI side by the next morning after collecting abdominal X-ray for possible endoscopic removal

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 Investigations
CBC, WBC=8.5 (N 75%, L 18%)
HgB= 15.3, Plt= 312,000
Abd X-ray=

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17/12/2011
Added order:
cimetidine 200mg IV TID
plasil 10mg IV TID
40% dextrose on the MF

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 UGIE Findings:

Esophagus: Single superficial vertical mucosal erosion seen on mid esophagus, other wise
no ulcer or other abnormality seen.
Stomach: there was a metallic cork of beer bottle on the body of the stomach, the antral
mucosa seems hyperemic, the foreign body was grasped with rat tooth forceps and
removed together with the scope without any complication.
Esophageal mucosa was inspected after the removal and there was no other trauma
Recommendation: ?PPI for 2 weeks
The Pt was discharged with omeprazole 20mg po bid

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 Introduction
• Majority of foreign body ingestions occur in children between the ages of
six months and three years
• Many of the children are asymptomatic or have transient symptoms at the
time of the ingestion.
• Most cases are brought to medical attention by their parents

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 Epidemiology and Pathophysiology

• Of more than 100,000 cases of foreign body ingestion reported each year
in the United States, 80 percent occur in children
• Ingestion of multiple foreign objects and repeated episodes are uncommon
occurrences and usually occur in children with developmental delay or
behavioral problems

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 Epidemiology and Pathophysiology cont.
• Fortunately;
• most foreign bodies that reach the gastrointestinal tract pass
spontaneously
• Only 10 to 20 percent require endoscopic removal, and
• less than 1 percent require surgical intervention

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 Epidemiology and Pathophysiology cont.
• Common foreign bodies
• Coins
• Button batteries
• Sharp objects
• Food impaction
• Magnets
• Long objects
• Superabsorbent polymers
• Objects containing lead
• Wireless endoscopy capsules

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 Epidemiology and Pathophysiology cont.
Anatomic considerations
• Esophageal foreign bodies tend to lodge in areas of physiologic narrowing

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 Clinical manifestations
• Often asymptomatic or transient symptoms
• When symptoms do occur, they are often related to the location of the
foreign body:

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 Clinical manifestations
• Esophagus
• asymptomatic
• refusal to eat, dysphagia, drooling, or respiratory symptoms including wheezing,
stridor, or choking
• Older children : localize the sensation of something stuck in the neck or lower chest
• retrosternal chest pain: mucosal ulceration of the esophagus
• Longstanding : weight loss or recurrent aspiration pneumonia
• Erosion : Esophageal perforation, Life threatening GI bleeding

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 Clinical manifestations cont.
Stomach and intestines
• Stomach
• Typically asymptomatic
• Symptomatic: features of GOO
• Intestines
• Obstruction, perforation, appendicitis, pyogenic liver abscess

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 Patient approach
• History
• Physical examination
• Imaging

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 Patient approach cont.
Imaging
• initial diagnostic test should be biplane radiographs (anteroposterior and lateral) of
the neck, chest, and abdomen
• Flat objects (eg, coins or disk batteries)
• Esophagus : orient in the coronal plane and appear as a circular object on an
anteroposterior projection
• Trachea : orient in the sagittal plane and are best seen in lateral projection
• In a study of 325 children, only 64 percent of the ingested objects were radio-opaque

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 Patient approach cont.
• If the plain radiograph does not reveal any foreign body or abnormalities, further
evaluation depends on the characteristics of the patient and the suspected
foreign body:
• computed tomography (CT) with 3-dimensional reconstruction if;
• the patient is symptomatic, or
• the suspected foreign body has any dangerous characteristics (large [>2 cm width], long [>5 cm length], or sharp),
or
• the type of foreign body is not definitively known by the caretakers
• Alternative Ix; MRI but contraindicated if any metallic foreign body is present
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 Patient approach cont.
• Ultrasonography has been used to identify the location and nature of
foreign bodies in the esophagus or stomach if appropriate expertise is
available
• We avoid gastrointestinal contrast studies when possible

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 Management
Approach
• Urgent intervention is indicated when any of the following warning signs
are present
• When the ingested object is sharp, long (>5 cm), or a superabsorbent polymer, and is in the esophagus or stomach.
• When the ingested object is a high-powered magnet or magnets
• When a disk battery is in the esophagus (and in some cases in the stomach)
• When the patient shows signs of airway compromise.
• When there is evidence of near-complete esophageal obstruction (eg, patient cannot swallow secretions).
• When there are signs or symptoms suggesting inflammation or intestinal obstruction (fever, abdominal pain, or vomiting)

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 Management
• Expectant management 
• blunt foreign bodies without the above characteristics that are lodged in the
esophagus in an asymptomatic patient, observation for 12 to 24 hours is
reasonable because spontaneous passage often occurs.
• Objects lodged for more than 24 hours or for an unknown duration should be
removed promptly…complications increase
• Complications also were more likely if the foreign body was a sharp or pointed
object, disk battery, non-radio-opaque, or located below the upper third of the
esophagus
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• Approaches for specific types of foreign bodies

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 Management
Coins
Esophagus
• Expectant mgt: asymptomatic and less than 24hrs
• Removal; symptomatic, time of ingestion is not known, coin does not pass spontaneously by 24
hours after ingestion
Stomach
• Expectant mgt: most will pass out uneventfully within one to two weeks
• Remove; if the coin has not passed beyond the stomach by four weeks, any signs or symptoms of
obstruction, abdominal pain, vomiting, or fever or extremely large numbers of post-1982 pennies

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 Management cont.
Batteries 
• When become lodged in the esophagus, they represent a medical
emergency. Emergent removal
• Like coins, most disk or cylindrical batteries pass harmlessly once they reach
the stomach
• because of the potential for direct mucosal injury and toxicity, batteries
should be removed from the stomach under certain conditions
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 Management cont.
• Coin Vs. battery

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 Management cont.
Sharp-pointed objects
• Account 10-15% of all ingested foreign bodies
• 15 to 35% risk of perforation. Ileocecal and rectosigmoid areas
•  lodged in the esophagus; Emergency removal
• Stomach and duodenum; Endoscopic removal
• Distal to ligament of treitze
• Asymptomatic; close clinical and radiologic follow up
• Removal; symptomatic, no progression for more than three days
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 Management cont.

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 Management cont.
Esophageal food impaction
• Most common foreign body in the esophagus in adults
• Children; underlying esophageal pathology
• Removal; acute distress or unable to swallow oral secretions
• If none, delay endoscopic intervention for 24 hrs.
• The food bolus can be removed en bloc or in a piecemeal fashion.
• Esophageal mucosal biopsies; at the time of endoscopic dis impaction
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 Management cont.
Magnet
• Single
• With in the esophagus or the stomach; removal or follow up
• Distal to the stomach; follow up with magnet precautions
• Multiple, Risk??
• With in the esophagus or stomach; removal
• Distal to the stomach; follow up with magnet precautions for symptoms and
progression
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 Management cont.
Long objects
• Include toothbrushes, batteries, and spoons
• Objects longer than 6 to 10 cm generally cannot pass beyond the stomach and should be
removed
• Objects of intermediate length (5 to 6 cm) may pass the stomach, but up to 50 percent
become impacted in the ileocecal region. Thus, these should be removed promptly if they are
in the stomach.
• If they pass into the small intestine they should be followed by serial radiographs, and
surgical removal should be considered if they fail to progress
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 Management cont.
Superabsorbent polymers
• can expand 30 to 60 times in volume when hydrated, present a risk for
bowel obstruction
• radiolucent, so radiographic evaluation generally is not helpful. Contrast*
• If ingestion is suspected, it should be removed immediately.
• If the object has passed beyond the stomach, the patient should be
monitored for symptoms of intestinal obstruction.
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 Management cont.
Objects containing lead
• Acute lead toxicity…non specific symptoms
• Markedly elevated lead levels have been measured within 90 minutes
of ingestion of a foreign body containing lead
• The acid environment of the stomach enhances dissolution of the
metal. PPI*

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 Management cont.
Bezoars
• a foreign body resulting from accumulation of ingested material, most commonly
found as a hard mass or concretion in the stomach.
• Classified as Phytobezoars, Trichobezoars, Pharmacobezoars
• Affected patients remain asymptomatic for many years, and symptom onset is
insidious.
• most common symptoms include abdominal pain, nausea, vomiting, early
satiety, anorexia, and weight loss
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 Management cont.
• Upper gastrointestinal endoscopy is required to establish the diagnosis of
bezoars
• Therapy should be tailored to the composition of the concretion and to the
underlying pathophysiologic process.
• Management options
• Chemical dissolution
• Endoscopic removal
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• Surgery Kassahun G. 41
 Management cont.
Instruments to remove esophageal foreign bodies
• Flexible endoscopy
• Rigid endoscopy
• Magill forceps
• Bougienage
• Foley catheter
• Penny pincher technique
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• Rectal foreign bodies

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 Outline
• Introduction
• Epidemiology
• Classification
• Clinical manifestations
• Diagnosis
• Management
• Complications
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 Introduction
• Present a difficult diagnostic and management dilemma.
• Recognition and management require a systematic approach.
• Foreign bodies consist of all types and sizes, with the most common items
including phallic-shaped items.

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 Epidemiology
•  Published experience with rectal foreign bodies is based mainly on single-
center case series
• Studies of adults have suggested that most patients are men (65 to 100
percent) who are in their thirties or forties (range 16 to 94 years)

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 Classification
• Voluntary versus Involuntary
• Sexual versus Non sexual

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 Classification cont.
The American Association for the Surgery of Trauma has proposed a
Rectal Organ Injury Scale
• Grade I — Contusion or hematoma without devascularization, or partial-thickness laceration
• Grade II — Laceration ≤50 percent circumference
• Grade III — Laceration >50 percent circumference
• Grade IV — Full-thickness laceration with extension into the perineum
• Grade V — Devascularized segment
• Most injuries due to rectal foreign bodies are Grade I.

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 Clinical manifestations and Diagnosis
• Appropriate history and physical examination and radiological evaluation as
needed.
• History and physical examination
• Patients are often reluctant to fully disclose their situation
• Instead may complain of anorectal or abdominal pain, blood per rectum,
or mucus discharge, while not volunteering the presence of a foreign body
• Many patients will only admit to a rectal foreign body when directly asked
about it.
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 Clinical manifestations and Diagnosis cont.
• Many patients present hours or even days after placement following
repeated failed attempts at removal.
• In some cases, patients present following successful removal of the object
but with secondary manifestations from local trauma (eg, mucosal tears,
sphincter disruption or perforation).
• In rare instances, presentation has been delayed for years.

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 Clinical manifestations and Diagnosis cont.
Physical examination
Findings: variable
• Abdominal examination
• Normal
• Tenderness or a palpable mass, or
• Diffuse peritonitis if perforation has occurred.

• Rectal examination
• Normal
• Demonstrate bright red blood or melena
• Foreign body may be palpable or not

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 Clinical manifestations and Diagnosis cont.
Laboratory examination: often unremarkable.
• The presence of leukocytosis and/or metabolic acidosis are concerning for
extensive injury.

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 Diagnosis
Radiological evaluation
• Plain film radiograph (an abdominal flat plate to identify the object and an
upright film to evaluate for pneumoperitoneum)
• CT scan; In patients in whom there is concern related to a radiolucent
object and in those who have concerning findings on initial evaluation

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 Management
• Initially assess for signs of perforation
• Hypotension, abdominal pain, or increasing deep pelvic pain
• Obtain plain films to rule out free air (as quickly as possible) or a computed
tomography (CT) scan in more stable patients
• Patients with peritoneal signs or obvious perforation require urgent
surgical evaluation and treatment.

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 Management cont.
• If the foreign body is still in place, it should ideally be removed in an
emergency room or an outpatient setting
• Clinically stable patients with foreign bodies that are located proximally
can be observed to see if the object will progress to the distal rectum,
which facilitates transanal removal.
• Enemas or stimulant suppositories are not recommended

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 Management cont.

•  The majority of rectal foreign bodies can be removed transanally

• One of the most important factors required for success is
adequate patient relaxation
• Intravenous sedation and perianal nerve blocks:
• Position: dorsal lithothomy is preferred
• Other option is endoscopy

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 Management cont.
• removal of blunt objects: best approach is grasping the object.
• Sharp objects:
• avoid blind attempts at grasping the object
• the object should be manipulated only when it can be visualized
transanally or through a proctoscope or sigmoidoscope

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 Management cont.
Body packers
• care must be made to avoid disrupting the outer barrier holding the drugs
• spillage of the contents into the colon can lead to systemic toxicity and
death
• Removal; manual extraction

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 Management cont.

• If manual extraction is not successful and there is neither obstruction nor

signs of systemic toxicity, admission may be warranted for a period of
observation to attempt to allow the packets to pass closer to the rectum
• A more aggressive approach (which may include surgery and treatment for
drug toxicity) is required if this is not successful and in patients with clinical
features of obstruction, perforation, or systemic absorption.

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 Management cont.
• Following successful removal
• rigid proctoscopy or flexible sigmoidoscopy
• repeat plain film to look for free air from perforations

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 Management cont.
Surgery
• Indicated when
• Transanal approach failed after adequate Iv sedation and perineal nerve
block attempted
• Perforation or peritonitis
• In the absence of perforation milk the object distally into the rectum so that it can
be retrieved transanally. Care when dealing with sharp or breakable objects

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 Management cont.
• Colotomy with removal and primary closure is required if this is not
successful.
• Proximal diversion is not necessary in the absence of perforation, gross
spillage with excessive contamination during colotomy, or necrotic bowel.

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 Management cont.

Foreign body-induced perforation

• Free perforation of the intraperitoneal rectum or colon mandates laparotomy with
appropriate removal.
• Deciding primary repair or a diverting stoma depends upon the patient's condition,
degree of injury, and extent of intra-abdominal fecal soilage
• Small extraperitoneal perforations in hemodynamically stable patients have
been successfully treated with admission, complete bowel rest, and
intravenous antibiotics alone.
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 References
• UpToDate 2018
• Schwartz principles of surgery,10th edition
• Bailey and loves short principles of surgery,26th edition
• Internet
• American society of gastroenterologists

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 Questions?

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 Thank you!

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