Preparation and planning

Airway management: Initial management of patients with FOI and EFI includes assessment of ventilatory status and airway protection. Most adult cases of FOI and EFI may be managed with moderate sedation. In the presence of wheezing, stridor, or dyspnea, however, emergent endotracheal intubation may be indicated. Similarly, endotracheal intubation is appropriate for facilitating airway protection in patients who are unable to manage their secretions (e.g., due to very proximal EFI) and are thus at high aspiration risk[9]. Endotracheal intubation may likewise be indicated for patients with FOI or EFI that is difficult to remove and in cases with multiple objects requiring removal. An overtube may be used to provide additional airway protection, and these are discussed in a forthcoming section[9]. Notably, pediatric GI endoscopy often requires general endotracheal anesthesia, in part due to the fact that smaller and more compliant airways have a higher risk of airway obstruction during endoscopy[46].

Timing and urgency of intervention: Once FOI or EFI is diagnosed, the provider must decide whether intervention is necessary, and if so, how urgently intervention is required. The need for and timing of an intervention for FOI and EFI are dependent on multiple factors; these include patient age and clinical condition, the location and characteristics of the ingested material (Table ​(Table2),2), time since ingestion, and the technical capabilities of the endoscopist and facility[47]. Based on these factors and the perceived risks of aspiration, obstruction, perforation, and other potential complications, as well as the likelihood of procedural success, the timing and nature of endoscopic intervention is determined. As stated previously, patients unable to effectively manage their secretions (e.g., due to complete esophageal obstruction from EFI) or with sharp or disk battery FOI require emergent endoscopic intervention (preferably within 2 h, and at the latest within 6 h)[9]. Other scenarios (e.g., asymptomatic blunt foreign object in the esophagus or incompletely obstructing EFI) need not be managed emergently but should undergo endoscopic intervention within 24 h as delay beyond this time interval decreases the likelihood of successful removal and increases the risk of complications, including but not limited to perforation[48-50]. In cases of FOI where the object has made it past the esophagus, most patients who are clinically stable, in no acute distress, and without signs of GI obstruction will not require urgent endoscopy as the ingested object will often pass spontaneously[3,6,51]. For such patients, conservative outpatient management is reasonable[9,52,53], although endoscopic removal may also be appropriate depending on the circumstance (e.g., disk and cylindrical batteries in the stomach that have not progressed in 48 h), especially given the high success rate and low risk of adverse events in the majority of cases[6,22,54,55]. If endoscopy is foregone, patients may resume a regular diet but should monitor their stool for passage of the ingested object. In the absence of symptoms, weekly imaging (e.g., X-rays, depending on the type of FOI) should be obtained to follow the progression of small blunt objects that have not yet passed in order to ensure their passage. Specific clinical circumstances are discussed in forthcoming sections.

When to avoid endoscopic intervention: As mentioned above, endoscopy can be foregone in cases where patients are asymptomatic and spontaneous passage is believed to be likely. Special note should be made of the importance of avoiding endoscopic intervention in cases of internal concealment of illicit drugs (i.e., “body packers” or “drug mules”). Here, multiple packets of contraband are typically swallowed and pose a risk for obstruction or rupture. Endoscopic removal should generally not be attempted because of the high risk of rupturing a packet, which can lead to fatal drug overdose. Therefore, these patients should be managed conservatively with close monitoring, serial imaging, and assessments for potential toxicity; surgical intervention may be indicated should removal become necessary[8].

Short, blunt objects

FOI involving short, blunt objects such as coins and buttons occurs most often in the pediatric population. When there is suspicion of such FOI in a pediatric patient, X-ray radiographs should be ordered, as impaction in the esophagus may be asymptomatic in a substantial proportion of cases[107]. Coins lodged in the esophagus should be treated with endoscopic retrieval within 12 to 24 h to allow an appropriate pre-anesthetic fast in patients who are asymptomatic[6,80]. In contrast, endoscopic retrieval of coins in the esophagus should be performed emergently in symptomatic patients who are unable to swallow secretions or have acute respiratory symptoms. If more than an hour has elapsed since the last imaging study, imaging should be repeated to confirm that the object is still in the esophagus prior to proceeding with endoscopy. Objects lodged at or above the level of the cricopharyngeus are generally best removed laryngoscopically, while impactions below this level can be removed via flexible upper endoscopy[58,107,108]. If a coin or similar object is found in a patient with several days of symptoms, the possibility of esophageal erosion by the object should be considered, and additional diagnostic evaluation, such as CT imaging, should be performed[37,80].

In adults, endoscopic removal can usually be achieved under moderate sedation, whereas in pediatric patients, general endotracheal anesthesia is typically required, as mentioned earlier[57]. Coins can be easily retrieved with a forceps device (e.g., rat-tooth, alligator) or a snare; smooth, spherical objects are best retrieved with a Roth retrieval net[29,109], as demonstrated in a prospective study[72]. Objects that cannot be readily grasped in the esophagus may be advanced into the stomach to facilitate grasping and retrieval[47]. The use of an overtube with an inner diameter greater than that of the ingested object provides an additional degree of safety, particularly if multiple objects are suspected or present[29]. Alternative techniques, including use of Foley balloon catheters and nasogastric tubes outfitted with magnets, have also been reported (e.g., in cases where endoscopy is not readily available)[110,111], but these approaches generally offer no advantage over or are inferior to endoscopic removal[29,68,112]. The major disadvantage to such techniques is that they provide: (1) minimal control of the object as it is being removed; (2) no airway protection; and (3) no visualization of the esophagus to assess for underlying pathology or complications (e.g., mucosal injury)[47]. Once the ingested (blunt, short) object enters the stomach, conservative outpatient management is usually appropriate[6,9,29], and the majority of objects will pass spontaneously within 4 to 6 d. However, spherical objects > 2.5 centimeters in diameter (or smaller in pediatric patients) are less likely to pass the pylorus, and if retained for > 3-4 wk (or less, depending on composition) or remaining in the same location for > 1 wk, should generally be removed endoscopically[8,29,47,54]. A regular diet can usually be continued while patients monitor their stools for passage of the foreign body. As long as a patient remains asymptomatic, radiographs evaluating the progression of small blunt objects can be performed weekly[8,13]. If symptoms of fever, vomiting, or abdominal pain arise, immediate CT imaging is warranted followed by prompt endoscopic and/or surgical evaluation[3,6,8,29].

Sharp and pointed objects

A myriad of sharp and/or pointed FOIs have been described, and these may be accidental or intentional. In children, most such ingestions are accidental; in adults, sharp bones (e.g., fish, chicken) and toothpicks (Figure ​(Figure6A-C)6A-C) are usually ingested accidentally, whereas most other sharp and/or pointed FOIs (e.g., pins, needles, razorblades, nails, straightened paper clips) are intentional[29,80]. Patients suspected of sharp and/or pointed FOI must be thoroughly evaluated to define the nature, location, and potential complications related to the object. Since many such objects are not readily visible by plain films, CT imaging may be considered in lieu of (and may be more cost-effective than) simple radiographs[35-38,113], and endoscopy should follow a negative radiologic examination to ensure absence or passage of the FOI, or to provide therapy[56].

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Figure 6

Endoscopic extraction of embedded toothpick. An 82-year-old woman with remote history of accidental toothpick ingestion and presumed spontaneous passage underwent colonoscopy for fecal incontinence. A, B: Upon reaching the rectosigmoid junction, polypoid inflammatory changes were visualized at the base of both ends of what appeared to be an embedded toothpick; C: Colorectal surgery was called to the procedure room, and a multidisciplinary decision was made to attempt endoscopic removal. Using standard biopsy forceps, the toothpick was grasped and, using gentle traction, successfully removed in two pieces.

Sharp and/or pointed FOIs represent a potential medical emergency given their potential for serious complications, with earlier intervention associated with a lower risk of complications[29,105,114,115]. As with other FOIs, sharp objects lodged at or above the cricopharyngeus should be retrieved via direct laryngoscopy, while objects below this area should be retrieved via flexible endoscopy[116]. Objects will generally pass through the GI tract uneventfully once entering the stomach, though the risk of potential complication is not insignificant[13,80]. Therefore, retrieval should be pursued if within safe endoscopic reach (e.g., in the stomach or proximal small bowel)[29,82,117]. Otherwise, these pointed objects, as with others, may be followed with noninvasive imaging studies to document their passage or failure to progress, in which case surgical consultation should be obtained[8,29]. In the interim, patients should be advised to immediately report abdominal pain, persistent fever, vomiting, hematemesis, or melena.

In the management of sharp and/or pointed FOI, Chevalier Jackson’s axiom: “Advancing points puncture, trailing do not”[8] can be helpful to remember. In this, the father of modern endoscopy of the upper airway and esophagus referred to the ability to minimize risk of mucosal injury during retrieval of sharp objects by orienting the object with its sharp point trailing during extraction. Endoscopic retrieval of such objects can be accomplished with a variety of accessories and devices, including a forceps or snare, depending on the particular object and endoscopist experience[6,47,72]. To further provide mucosal as well as airway protection, overtube use is advisable, or alternatively, the endoscope tip can be fitted with a protector hood, as mentioned previously[23,77,81]. Some endoscopists prefer endotracheal intubation for removal of sharp-pointed objects, but this is seldom required from a procedural perspective if an overtube or protector hood is used[47,82].

Long objects

Although typically not sharp, long and/or large (> 5 cm) objects (e.g., toothbrushes, pens, eating utensils, dental appliances) may carry considerable risk of complications when ingested (Figure ​(Figure7).7). The majority of such objects are unlikely to spontaneously traverse the duodenal sweep and should thus be removed[3,6,118]. Width/thickness of the object should also be considered in addition to length. The GI tract of younger (pediatric) patients is smaller, thus modified dimension criteria should be applied in these patients.

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Figure 7

Endoscopic extraction of multiple long objects. A, B: A 36-year-old male was found to have multiple foreign ingested objects in the stomach, including a toothbrush (A), pen cartridge, and several forks (B); C: On subsequent encounters, the same patient was found to have other ingested objects, including pencils; D: Items recovered during endoscopy are shown in.

In general, endoscopic retrieval of long or large objects can be performed after an interval of pre-procedural fasting as long as the patient is asymptomatic. A variety of devices and accessories can be used for endoscopic retrieval; commonly, the object is best grasped with a snare or Roth retrieval net and then maneuvered into an overtube[80] (Figure ​(Figure8).8). Once this is achieved, the entire apparatus (i.e., foreign object, overtube, and endoscope) can then be removed from the patient in one motion so as to avoid losing grasp of the object within the overtube[29,119].

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Figure 8

Retrieval of foreign object with Roth retrieval net. A 27-year-old man who reportedly swallowed glass while working under a skylight that shattered. A glass shard was removed from the cecum via colonoscopy with a retrieval net[148].

Batteries

Due to their small size, slippery texture, as well as increasing prevalence in many everyday electronics (e.g., hearing aids, watches, toys, calculators, etc.), disk and button battery ingestion is on the rise, with children under the age of 5 responsible for most cases[6,120,121]. Direct pressure applied to the mucosa by the battery (leading to pressure necrosis), leakage of strongly alkaline contents (causing chemical damage), and generation of an electrical current (due to the production of hydroxide at the negative pole of the battery, resulting in a high pH), contribute to the high risk of liquefactive necrosis and mural perforation that can rapidly occur when a disk battery is lodged in the esophagus[29,122,123]. Lithium battery ingestions are particularly dangerous given their generally larger size and ability to generate more electrical current in a short period of time[124]. Thus, the use of honey (dosed at 10 mL every 10 min) in the prehospital setting, or sucralfate (dosed at 10 mL every 10 min) in the emergency department setting, has been suggested to coat the battery and delay hydroxide generation and exposure[125,126]. In fact, the National Capital Poison Center has recently updated their Battery Ingestion Triage and Treatment Guideline to incorporate the aforementioned suggestions (for up to 12 h after ingestion of a lithium coin battery)[127]. Of note, however, honey should not be given to children under the age of 1 year due to the risk of infantile botulism[128].

Once discovered on imaging, batteries lodged in the esophagus should be emergently removed, as damage to the esophageal mucosa and deeper tissues can occur within hours[129,130]. Endoscopic retrieval using a retrieval net is often successful for this indication[72]. An alternative method is to use a through-the-scope balloon, whereby a balloon is passed through the working channel beyond the foreign body. The balloon is then inflated, and the entire endoscope and balloon are withdrawn, thus pulling the battery up and out of the body[8]. To protect the airway, an overtube or endotracheal tube is necessary with the aforementioned method. In cases where retrieval of the battery from the esophagus is not possible, the foreign body should be advanced into the stomach, grasped or otherwise captured therein, and then removed. The National Capital Poison Center now also recommends endoscopic irrigation of the injured esophagus with 150 mL of 0.25% acetic acid immediately after battery removal (in an attempt to neutralize injury from alkaline batteries)[127,130], but no studies have been performed to evaluate whether this intervention improves outcomes, and the risks may outweigh the benefits in cases where there is no endoscopically visible chemical injury.

Batteries that have spontaneously progressed beyond the esophagus do not necessarily need to be retrieved unless the patient has signs or symptoms of GI tract injury[129]. A large-diameter (> 20 mm) battery remaining in the stomach longer than 48 h, as documented by repeat imaging, however, should be removed (even in the absence of signs or symptoms of injury)[6,131]. Use of emetics and cathartics has been reported, but this practice is not recommended and may be harmful[6,29,131]. Once beyond the duodenum, the majority of batteries, even those that are large and/or long, will be passed out of the body within 72 h[120] unless a pathologic narrowing (e.g., from adhesions) is present. Radiographs can be obtained every 3 to 4 d to ensure progress and ultimate passage[6].

Magnets

Ingestion of magnets can cause severe GI injury and even death. The number of magnets is important, as ingestion of a single magnet is unlikely to result in GI complications, whereas ingestion of more than one magnet may be exceedingly hazardous because of the attractive force generated between magnets, which can lead to fistulization, obstruction, mural necrosis, and perforation[6,80].

Imaging should be considered following magnet ingestion to localize the magnet(s), determine their size, and evaluate for the development of complications. It has been suggested that, when possible, any and all magnets be removed, even if only one magnet is reported or visualized on imaging, as undetected magnets or other ingested metal objects together with a magnet can lead to significant injury[132]. In many instances, however, if a magnet is not large and is already beyond the reach of an upper endoscope or enteroscope, careful monitoring for continued passage through the GI tract is preferable[80,133].

Drug packets

Internal concealment of narcotics or other illicit drugs wrapped in plastic or contained in latex condoms, referred to as “body packing,” is a form of drug trafficking[134,135]. Although historically a phenomenon seen only in adults, cases of pediatric body packers (i.e., smuggling “mules”) have been reported[80,136,137]. Drug packets can usually be seen by non-invasive imaging modalities (particularly CT)[138,139]. Use of activated charcoal to bind drug and decrease drug absorption or bowel irrigation with polyethylene glycol solution to promote evacuation may be attempted, but data to support these practices are limited. Paraffin or mineral-oil-based laxatives should be avoided due to their ability to degrade latex and thus increase risk of drug exposure[140]. When imaging is equivocal and/or patient history is unreliable, diagnostic endoscopy can be considered to confirm the presence, location, and number of drug packets. Endoscopic removal, however, should typically not be attempted given the risk of packet rupture, drug leakage, and potentially fatal ensuing events. A Swiss study of 132 patients found the risk of drug packet rupture when left to pass the GI tract on its own to be nil (though the authors acknowledged that variations in risk may exist between different countries based on the quality of the packaging)[141]. Surgical intervention is generally indicated in cases with failure of the packet(s) to progress spontaneously, signs or symptoms of GI obstruction, or suspected packet rupture[47]. On a similar note, endoscopic removal of detergent packets (also known as “laundry pods”) is not recommended, as these packets dissolve quickly, and attempted removal can lead to aspiration and other complications[142].

Small intestinal foreign objects

If an object has already passed through the upper GI tract, it will typically continue to pass through the small intestine, into the colon, and out of the body. In some instances, however (e.g., in the setting of jejunal or ileal strictures related to Crohn’s disease or radiation), retention may occur in the midgut, i.e., in the small intestine beyond the reach of a standard upper endoscope. In such instances, enteroscopy (e.g., push, balloon-assisted, and laparoscopically assisted) can facilitate access to and removal of retained objects as well as identification of a cause for retention. For example, case reports and series have described the successful use of anterograde and retrograde balloon enteroscopy to retrieve retained video endoscopy capsules (Figure ​(Figure99)[143-146] as well as other FOIs[147]. Although data on enteroscopy for retrieval of ingested foreign bodies from the midgut are currently limited, accessories such as hoods, baskets, and forceps, do exist for balloon enteroscopes, and thus it represents an option in select cases. In the interim, clinical decision making regarding enteroscopy in the management of FOIs should consider variables such as the nature of the FOI, patient stability, underlying disease and anatomical factors, anterograde vs. retrograde approach, availability of appropriate endoscopic accessories, need for fluoroscopy, and endoscopist expertise[6].

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Figure 9

Laparoscopically-assisted enteroscopic foreign object retrieval from the deep small bowel. Retrieval of a retained video capsule in the distal ileum via laparoscopically-assisted anterograde enteroscopy in a patient with Crohn’s disease.