Does an esophageal foreign body need to be removed emergently?

Esophageal Foreign Body Removal: Timing and Management

Esophageal foreign bodies require emergent removal (within 2-6 hours) in cases of complete esophageal obstruction, sharp objects, button batteries, or when signs of perforation are present to prevent potentially fatal complications such as mediastinitis. 1

Indications for Emergent Removal

• Complete esophageal obstruction: Requires intervention within 2-6 hours
• High-risk foreign bodies:
  • Button batteries (especially in children)
  • Sharp objects (fish bones, pins, etc.)
  • Objects close to vital structures (aortic arch)
  • Foreign bodies with signs of tissue embedding
• Evidence of complications:
  • Perforation
  • Mediastinal contamination
  • Respiratory symptoms

Risk Assessment Algorithm

1. Evaluate airway status first

   • Ensure airway is patent before proceeding with any intervention

2. Assess foreign body characteristics:

   • Type: Sharp objects and button batteries require immediate removal
   • Location: Objects in upper esophagus may require rigid endoscopy
   • Duration: Longer impaction time increases perforation risk

3. Evaluate for complications:

   • Pain, fever, tachycardia suggest perforation
   • Respiratory symptoms may indicate aspiration or airway compression
   • CT scan with contrast if perforation is suspected 1

Management Approach

Endoscopic Management (First-line)

• Flexible endoscopy is the first-line approach with success rates up to 90% 1
• Rigid endoscopy should be considered for objects in the upper esophagus or with concomitant respiratory symptoms 2
• Combined approaches using flexible endoscope through a Weerda diverticuloscope may be helpful in difficult cases 2

Surgical Management (1-3% of cases)

Surgical intervention is indicated when:

• Foreign body is irretrievable endoscopically
• Perforation with extensive contamination is present
• Foreign body is close to vital structures
• Complications such as mediastinitis or fistula have developed 2, 1

The surgical approach depends on the location of impaction:

• Upper esophagus: Left cervicotomy
• Mid/lower esophagus: Thoracotomy or thoracoscopy (minimally invasive preferred) 2, 1

Complications of Delayed Removal

Delayed intervention significantly increases morbidity and mortality:

• Esophageal perforation leading to mediastinitis (potentially fatal)
• Paraesophageal abscess formation
• Pneumomediastinum and subcutaneous emphysema
• Tracheoesophageal or aortoesophageal fistula (latter can be rapidly fatal) 3

Post-Procedure Care

• Monitor for at least 2 hours post-procedure
• Watch for signs of perforation: pain, breathlessness, fever, tachycardia
• Arrange follow-up endoscopy to evaluate for underlying conditions, as up to 25% of patients have disorders such as eosinophilic esophagitis 1

Common Pitfalls to Avoid

• Delaying intervention: Increases risk of perforation and complications
• Overlooking underlying conditions: Investigate for esophageal strictures, eosinophilic esophagitis, or tumors
• Inadequate imaging: Plain radiographs have high false-negative rates; CT is preferred for suspected complications
• Forceful endoscopic manipulation: Can convert a simple impaction into a perforation

Remember that mortality from esophageal perforation ranges between 10-20%, with delay in treatment being the most important predictor of poor outcomes 2.