What is the management approach for a patient who has ingested a sharp object?

Management of Patients Who Have Swallowed Sharp Objects

Emergent flexible endoscopy (preferably within 2 hours, at latest within 6 hours) is the recommended approach for patients who have ingested sharp-pointed objects due to the high risk of full-thickness perforation (up to 35%). 1

Initial Assessment and Imaging

• Perform a focused medical history to determine:

  • Type and size of the sharp object ingested
  • Time of ingestion
  • Presence of symptoms (pain, dysphagia, drooling, respiratory distress)
  • Psychiatric history or incarceration status (common in intentional ingestions)

• Obtain immediate radiographic examination:

  • Plain radiographs of the neck, chest, and abdomen to confirm presence, location, and size of the ingested object 1
  • Do not delay endoscopy for additional imaging if a sharp object is confirmed or strongly suspected

Management Algorithm Based on Object Location

1. Esophageal Sharp Objects

• Immediate intervention: Emergent flexible endoscopy (within 2-6 hours) 1
• Requires anesthetic input and often general anesthesia with endotracheal intubation to protect the airway
• Retrieval techniques using baskets, snares, and grasping forceps should be employed 1
• If flexible endoscopy fails, rigid endoscopy may be considered as a second-line approach, particularly for objects in the upper esophagus 1

2. Gastric Sharp Objects

• Intervention: Urgent endoscopic removal recommended for sharp objects that have reached the stomach
• Risk of perforation remains high even after passing the esophagus
• Objects longer than 6 cm are significantly more likely to require surgical intervention 2

3. Small Bowel/Colon Sharp Objects

• For sharp objects that have passed beyond the stomach:
  • If the patient is asymptomatic and the object is small (<2-3 cm): Close observation with serial radiographs to monitor passage 2
  • If the patient develops signs of peritonitis, obstruction, or the object fails to progress: Surgical intervention 2

Special Considerations

Button Batteries

• Require even more urgent intervention (within 2 hours if possible) due to risk of rapid tissue necrosis, electrical burns, and chemical injury 3
• Post-removal evaluation for mucosal damage and scheduled follow-up endoscopy within 2-4 weeks is recommended 3

Magnets

• Multiple magnets are particularly dangerous as they can attract across bowel loops causing pressure necrosis 3
• Require prompt endoscopic or surgical removal

Surgical Intervention

• Indications for surgery include:

  • Irretrievable foreign body
  • Perforation
  • Foreign body close to vital structures (e.g., aortic arch)
  • Development of peritonitis or other complications 1
  • Larger objects (average size requiring surgery: 6±3 cm) 2

• Immediate surgery should be performed in cases of esophageal perforation with extensive pleural/mediastinal contamination 1

Outcomes and Follow-up

• The majority of sharp object ingestions (69-79%) do not require intervention and pass spontaneously 2
• Only about 4% of patients with sharp object ingestion require surgical intervention 2
• For patients managed non-operatively:
  • Provide clear return precautions (worsening pain, vomiting, fever)
  • Consider serial radiographs to confirm passage
  • Recommend a high-fiber diet to facilitate passage

Pitfalls and Caveats

• Do not delay endoscopy for additional imaging studies when a sharp object is confirmed in the esophagus
• Psychiatric patients and incarcerated individuals commonly present with intentional ingestions and may have secondary gain, requiring careful evaluation 2
• Even after successful endoscopic removal, patients should be evaluated for underlying esophageal disorders, which can be found in up to 25% of patients 1
• Larger sharp objects (>6 cm) have a significantly higher risk of requiring surgical intervention 2