Continuing Education Activity

Foreign body (FB) and food impaction are one of the most common gastrointestinal complaints seen in the emergency department. Foreign bodies tend to pass spontaneously without intervention. In the setting of a FB, the healthcare worker's role is to identify those at high risk for complications and that require prompt intervention. This activity reviews the evaluation and treatment of gastrointestinal foreign body and highlights the role of the interprofessional team in the care of patients with this condition.

Objectives:

• Identify the epidemiology of gastrointestinal foreign bodies.
• Review the appropriate evaluation of gastrointestinal foreign bodies.
• Outline the management options available for gastrointestinal foreign bodies.
• Summarize interprofessional team strategies for improving care coordination and communication to improve the outcomes of patients with a gastrointestinal foreign body.

Introduction

Foreign body (FB) and food impaction are one of the most common gastrointestinal complaints seen in the emergency department.[1] Encountered in both the adult and pediatric populations, foreign bodies tend to pass spontaneously without intervention in most instances (80 to 90%). In the setting of a FB, the role of the healthcare worker is to identify those patients that have a high risk for complications, and that will require prompt intervention.[2]

Etiology

The majority of foreign body ingestions are unwitnessed and resolve without ever involving a healthcare professional. Adults usually are symptomatic at the time of presentation to the clinic or the emergency department for a foreign body.[3] Children presenting with foreign bodies usually do so because the event was witnessed by a parent or family member.[4] Once a foreign body reaches the stomach, it will most likely continue through the GI tract and pass without intervention.[2] Complications, and the severity of them, are usually related to what object and how many were ingested. It also depends on the location of impaction and time since ingestion.[5] 

The most common complication seen is impaction, which is most frequently within the esophagus. There are three sections of the esophagus where foreign bodies are at higher risk of becoming impacted due to narrowing. First, and most commonly, is at the thoracic inlet where the cricopharyngeus muscle is located. The second section is at the aortic arch, and the third section is at the gastroesophageal junction. Objects impacted in these locations can be seen on X-rays, at the level of clavicles, carina, and just above the gastric bubble, respectively.[2] For adults that have underlying esophageal pathologies, such as eosinophilic esophagitis, strictures, or malignancy, impaction can be seen at the level of abnormality.[5] Foreign bodies that are too long to pass the pylorus would be unlikely to pass spontaneously as well.[2]

Epidemiology

Foreign bodies and food impactions can be seen in both the pediatric and adult populations. Foreign body ingestion is more commonly seen in the pediatric population, specifically ages 6 months to 6 years old. At these ages, children begin to explore their surrounding world, often doing so with their hands, increasing their risk for swallowing objects. Ingested objects are typically coins or small balls (small and shiny things). High-risk objects include button batteries, neodymium magnets, and sharp or pointed objects.[4] 

Mental or cognitive impairment, as well as neglect, can play a role in foreign body ingestions, especially if it occurs repetitively.[2] Ingestion in older age groups or of unusual objects requires consideration of other factors, including psychiatric concerns, self-harm, eating disorders such as bulimia, or drug packing.[6] 

Food impaction is more commonly seen in the adult population, especially in those that already have underlying esophageal pathology such as achalasia, diverticula, webs, and or strictures.[5] Additional risk factors in adults include self-harm, alcohol or substance abuse, lack of teeth, or dentures.[1] Elderly populations with low vision can sometimes mistake small objects for a pill as well.

Pathophysiology

The foreign body, when ingested, can lodge in the GI tract resulting in complete or partial obstruction. Furthermore, it can erode the GI mucosal wall and lead to migration and perforation. This is more likely to be seen in patients with prior GI diseases such as eosinophilic esophagitis, gastroesophageal reflux disease (GERD), congenital GI anomalies, and neuromuscular disorders. The most common site for obstruction is at the thoracic inlet (at the level of clavicles and cricopharyngeus muscle). 10% to 15 % lodge at the level of carina and aortic arch and rest at the esophagogastric junction. The foreign bodies which pass through the stomach do not cause any problem. However, some may get trapped at the ileocecal valve, causing problems.[6]

History and Physical

Children with foreign body ingestion can present with a broad range of symptoms. Commonly patients are asymptomatic or will have mild complaints such as a sore throat, chest discomfort, or globus sensation.[2] Additional symptoms are usually secondary to complications. Dysphagia, odynophagia, refusal to eat, and inability to tolerate secretions are symptoms that can be seen with impaction.[4] When collecting a history, it is essential to find out what was ingested, the number of objects ingested, and when it occurred.

Additionally, it is important to evaluate the circumstances surrounding the event and if it has happened before in the household. Repeated ingestions can be seen in neglect, abuse, or can be a sign of cognitive/mental disorders. High-risk objects are batteries, magnets, and those that are sharp and pointed. Sharp or pointed items have the potential to cause perforation and spillage of gastric content leading to peritonitis or mediastinitis, depending on the location.[2] Button batteries can cause severe tissue damage and burns. Patients can present with severe pain, nausea, and vomiting with mediastinitis. Patients that have ingested magnets or co-ingestion of a magnet with additional metallic objects may present with symptoms such as bowel obstruction, volvulus, or peritonitis.[4] 

Adults tend to present with food impactions more commonly than foreign body ingestion; however, the history and presentation can be similar. Adults usually are symptomatic at the time of presentation with complaints primarily consisting of globus sensation, dysphagia, and chest pain.[3] It is important to ask what it was that they ingested or had been eating and at what time it occurred. Their ability to tolerate PO following the event is important to assess as well. Any medical history is vital information to learn from the patient, especially if they have esophageal pathology or a history of food impaction.[5] Adults often point to certain specific sites of discomfort in the chest, but most often, this does not correspond with the actual site of impaction. 

The physical exam in the majority of these patients does not offer any additional information since patients are usually asymptomatic or with minimal symptoms. It is essential first to evaluate the patient's airway and breathing.[6] FB presence in the posterior pharynx is uncommon on physical exam but should still be routinely examined. A buildup of saliva may be seen in the mouth. The inability to swallow liquids and drooling of saliva is indicative of an esophageal obstruction that needs urgent endoscopy. Examination of the ears and nose of pediatric patients to assess for other foreign bodies should be done.[2] A patient presenting with signs of shock, dyspnea, and respiratory distress is suggestive for perforation secondary to FB.[5]

Evaluation

Radiography is the first-line modality for evaluating patients with a possible foreign body. 83% of ingested foreign bodies are radiopaque. However, it is essential to note that smaller objects might not be visible in thicker body parts. Frontal and lateral neck and chest X-rays, as well as an abdominal X-ray, should be obtained.[7] Radiolucent foreign bodies will be seen as edges or irregularities on the radiograph.[6] X-rays show one-third of foreign bodies.[5] 

For button batteries that were ingested, X-rays should be obtained on anyone less than 12 years of age. For those older, films should be obtained if the battery is larger than 12mm. Button batteries can be distinguished from coins on plain film by a double density circular opacity being present.[4] Although not used widely, handheld metal detectors are useful in identifying the location of a foreign body. Initial radiographs should be obtained to look for high-risk objects, but if being managed conservatively, a metal detector could be used to monitor the progression of a foreign body through the GI tract.[8] 

It is important to remember that if patients are presenting with symptoms, such as chest pain, abdominal pain, nausea, and vomiting, a more extensive workup, including labs, should be initiated to rule out alternative diagnoses. If patients present with suspected acute esophageal obstruction, imaging is not necessary to localize and should not delay urgent endoscopy.

Treatment / Management

When a foreign body is identified and localized in the GI tract, the management plan can then be decided upon. Once an object that is not high-risk reaches the stomach, it will likely continue through the GI tract and be expelled without any intervention. These patients can be discharged with parental instructions to inspect the stool for the object.[2] A button battery, in an asymptomatic patient that has already passed into the stomach, can also be managed from home. Parents should be instructed to watch for signs of obstruction or GI injury. The patient should maintain a regular diet, participate in physical activity, and their stool should be inspected for the battery. If the battery doesn't pass within 10 to 14 days, repeat imaging may be required.

If the battery is within the esophagus at the time of presentation, prompt endoscopy is required since damage can occur as early as 2 hours of ingestion. Ingestion of an individual magnet can usually be managed at home similarly as described above. However, if several magnets or co-ingestion of a magnet and other metal occurs, then prompt intervention is required. Neodymium and other high powered earth magnets are most concerning and have the power to attract each other through several layers of the bowel wall. Immediate endoscopy should be performed in these instances. Patients may be required to go to the OR if they are presenting with signs of obstruction, peritonitis, or perforation.[4] Glucagon and diazepam should not be used in the pediatric population since it can induce vomiting and lead to aspiration.[2]

For adults presenting with possible food impaction, medical management can be attempted; however, endoscopy is often required. Complications are usually related to the location of the object and the time since ingestion.[5] Esophageal foreign bodies can cause mucosal wall edema and weakening, which increases the risk of bleeding and perforation. For this reason, esophageal FBs should be removed as quickly as possible.[1] 

The American Society for the Gastrointestinal Endoscopy Committee recommends an otolaryngology consultation for foreign bodies suspected to be at the level of the cricopharyngeus muscle or above.[5] There is a variable success with the use of glucagon to relieve food impaction. Diazepam has been used concurrently with glucagon in some instances. This form of management is safe, with relatively few adverse effects.[9] Glucagon has been shown to decrease the tone at the lower esophageal sphincter.[10] This mechanism, which helps relieve food impaction, can also induce vomiting, which could potentially lead to perforation and distal obstruction.[9] 

A study showed that the use of glucagon successfully relieved one-third of food impaction and suggested that the cost of initial medical management with glucagon was significantly lower than initial treatment with endoscopy.[10] The older the patient and the earlier they present to the emergency department are independent predictors of a foreign body being present on endoscopy. It is thought that perhaps older patients have decreased esophageal motility, therefore, decreasing the probability of a foreign body being able to dislodge spontaneously.

Dysphagia and pain were associated with the presence of a foreign body on endoscopy and present in the upper one-third of the esophagus. Patients with confirmed presence of food impaction on endoscopy were observed to be older and frequently had psychological disorders. These food impactions generally were found in the lower one-third of the esophagus. For these patients, prompt endoscopy is recommended. In younger patients that are asymptomatic, surveillance, or trial of medical management may be a better initial option.[3]

Differential Diagnosis

A patient presenting with a witnessed foreign body ingestion or globus sensation may seem straightforward; however, other pathologies should be considered as well. Some of these other conditions are the following:

1. Esophagitis
2. Pharyngitis
3. Laryngitis
4. Peritonsillar or retropharyngeal abscess
5. GERD
6. Acute coronary syndrome in adults
7. Gastritis
8. Gastroparesis
9. Pyloric stenosis[6]

Treatment Planning

Foreign bodies that seem to be dangerous because of their shape and size should be effectively removed. There are many options available, including endoscopy, laparoscopy, and laparo-endoscopic removal of foreign bodies.[11] The procedure of choice is endoscopic removal and is fruitful in the majority of patients. Successful removal from endoscopy is highly successful in children and in patients with a short duration of ingestion.[12]

Prognosis

Most foreign bodies pass spontaneously without any intervention, and only 1% can cause perforation. A high risk of perforation is present when the foreign body has sharp ends. The common sites of perforation are at points of narrowing in the GI tract.[13] Early diagnosis and immediate treatment are essential to improve the prognosis of foreign bodies lodging in unusual locations. Up to a 10% mortality rate has been reported because of missed or delayed diagnosis.[14]

Complications

Complications and their severity are usually related to the object ingested, its location, and the amount of time that has passed since the ingestion.[5] One of the main concerns with a foreign body or food impaction in the esophagus is the pressure placed on the mucosal walls and the resulting edema. This causes weakening of the esophageal walls increasing the risk of bleeding and perforation.[1]

Button batteries, which are not chemically inert, impacted in the esophagus can cause severe tissue damage and burns caused by the build-up of sodium hydroxide. Fistulization into major blood vessels can occur, resulting in severe, even fatal hemorrhage. Damage can begin to develop as early as 2 hours after ingestion. Complications from the ingestion of magnets usually occur if numerous magnets or a magnet with additional metallic objects were ingested. The magnets can cause an attraction to one another through several layers of the bowel wall. This can lead to obstruction, volvulus, and fistula formation. Tissue necrosis and perforation can occur, leading to peritonitis. Deep pressure ulcerations can occur within the first 8-24 hours following ingestion.[4][15][5]

Consultations

The following consultations are required in cases of GI foreign bodies:

• Surgery
• Gastroenterology
• Radiology
• Nutrition
• Otolaryngology
• Psychiatry
• Pediatrics

Deterrence and Patient Education

Parents should be educated about the dangers of leaving magnets and batteries easily accessible to small children around the house. They should be made aware of the necessity to be seen promptly if there is a suspicion of ingestion of one of these objects. If a child is asymptomatic following the ingestion of a coin or small object, parents can be educated that monitoring at home and inspecting the stool for 10 to 14 days is an acceptable response.[4] 

Adults that have food impaction, especially those that are older, should be seen for endoscopy since their chances of spontaneously passing the food bolus is less likely due to impaired esophageal motility.[3] Patients with cognitive impairment should be continuously supervised to prevent any unwanted ingestion of foreign bodies.

Enhancing Healthcare Team Outcomes

Cooperation and teamwork amongst the interprofessional team can enhance the outcomes of these cases. Radiology technicians who perform an AP or PA chest radiograph should automatically obtain a lateral film if a foreign body is visualized, regardless if one was not already ordered.[2] Otolaryngology and GI specialties should be accessible for consultation and intervention without delay.[5] 

A nutritionist should be on board to advise on types of food to be ingested to expel the foreign body as soon as possible. Psychiatric evaluation and treatment may prevent repetitive foreign body ingestion in psychiatric patients. Surgeons should be notified in every case so that they are ready to operate in case of perforation, mediastinitis, and peritonitis.