What is the management for two metallic foreign bodies in the right upper abdomen?

From the Guidelines

Surgical removal of the two metallic foreign bodies in the right upper abdomen is the recommended management approach, especially if they are causing symptoms or pose a risk of complications, with a preference for a laparoscopic approach if the patient is stable and the foreign bodies are not causing immediate harm. The initial step should involve a thorough assessment with imaging studies, such as CT scans, to precisely locate the foreign bodies and evaluate surrounding structures, as CT has been reported to be 5 to 15 times more sensitive than radiography in detecting foreign bodies 1. Given the small size of the metallic bodies, with one measuring about 6 mm in length and the other about 10 mm in length, using thin (1 mm) slice thickness on CT scans is crucial because foreign bodies may be very small and missed on CT if thicker slices are obtained 1. Key considerations in the management include:

• Precise localization of the foreign bodies to determine the best surgical approach
• Evaluation for complications such as cellulitis, muscle/fascial edema, abscesses, sinus tracts, and vascular or tendon injuries, for which CT with IV contrast may be beneficial 1
• Assessment of the patient's stability and the potential for immediate harm from the foreign bodies to decide between a laparoscopic or open surgical approach
• Administration of preoperative antibiotics to prevent infection
• Postoperative care including pain management and monitoring for signs of infection or other complications.

From the Research

Management of Metallic Foreign Bodies

The management of two metallic foreign bodies in the right upper abdomen depends on various factors, including the size, shape, and location of the objects, as well as the patient's symptoms and medical history.

• According to the European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline 2, diagnostic evaluation based on the patient's history and symptoms is recommended.
• The ESGE also recommends plain radiography to assess the presence, location, size, configuration, and number of ingested foreign bodies if ingestion of radiopaque objects is suspected or the type of object is unknown 2.
• Computed tomography (CT) scan is recommended in all patients with suspected perforation or other complications that may require surgery 2.

Endoscopic Measures

• The ESGE recommends emergent therapeutic esophagogastroduodenoscopy for foreign bodies inducing complete esophageal obstruction, and for sharp-pointed objects or batteries in the esophagus 2.
• Urgent therapeutic esophagogastroduodenoscopy is recommended for other esophageal foreign bodies without complete obstruction, as well as for foreign bodies in the stomach such as sharp-pointed objects, magnets, batteries, and large/long objects 2.
• The use of a protective device is recommended to avoid esophagogastric/pharyngeal damage and aspiration during endoscopic extraction of sharp-pointed foreign bodies 2.

Conservative Management

• Asymptomatic patients with ingestion of blunt and small objects (except batteries and magnets) can be managed with clinical observation without the need for endoscopic removal 2.
• Outpatient management is appropriate if feasible 2.
• A study published in 1987 found that 80% of ingested foreign bodies that reach the stomach will pass uneventfully through the gastrointestinal tract 3.
• However, the risk of complications is increased with long, sharp metal objects and animal bones, and may be higher in patients with adhesions due to prior abdominal surgery or pre-existing intestinal disease 3.

Role of Sonography

• Sonography has been shown to be effective in diagnosing perforating foreign bodies of the digestive tract, especially in cases where conventional radiography is unclear 4.
• A case report published in 2019 found that sonography was useful in diagnosing a perforation of the gastric antrum caused by a foreign body, even when radiographs, CT, and gastroscopy were negative 5.
• Sonography can be used as a problem-solving tool when radiolucent foreign bodies are suspected, especially when the results of CT and gastroscopy are negative 5.