What is the management for an esophageal foreign body?

Management of Esophageal Foreign Bodies

Emergent endoscopy (within 6 hours) is the recommended treatment for esophageal foreign bodies, particularly for sharp-pointed objects, batteries, magnets, and cases of complete esophageal obstruction. 1, 2

Initial Assessment

• Complete blood count, C-reactive protein, blood gas analysis, and lactate should be obtained as part of initial evaluation 2
• CT scan is the key imaging examination for suspected perforation or other foreign body-related complications with 90-100% sensitivity 2
• Plain radiographs can help identify radiopaque objects but have limited utility for food impaction with false-negative rates up to 85% 1, 2
• Contrast studies are not recommended as they may increase aspiration risk and impair subsequent endoscopic visualization 2

Management Algorithm Based on Foreign Body Type

Food Bolus Impaction

• For complete esophageal obstruction: emergent flexible endoscopy (within 2-6 hours) 2
• For partial obstruction: urgent flexible endoscopy (within 24 hours) 2
• Endoscopic approach: first attempt gentle pushing of the bolus into the stomach (90% success rate) 2
• If pushing fails, use retrieval techniques with baskets, snares, or grasping forceps 2
• Cap-assisted endoscopic removal shows higher technical success rates and fewer adverse events compared to conventional methods 3

Sharp-Pointed Objects, Batteries, and Magnets

• Require emergent endoscopy (within 6 hours) due to high risk of perforation 1, 2
• Use of devices such as esophageal overtube and latex protector hood may facilitate safer extraction 4
• Consider endotracheal intubation to protect the airway, especially in children and those at higher risk for aspiration 4

Surgical Management

• Indications for surgery include perforation and foreign bodies that are irretrievable or close to vital structures 1
• Esophagotomy with foreign body extraction and primary closure is the preferred surgical approach 1
• Rigid esophagoscopy should be considered as a second-line approach if flexible endoscopy fails, particularly for foreign bodies in the upper esophagus 2, 5

Diagnostic Workup for Underlying Causes

• Diagnostic biopsies should be taken during the index endoscopy (at least 6 biopsies from different anatomical sites) 2
• An underlying esophageal disorder is found in up to 25% of patients with food impaction 2
• Most common underlying conditions include eosinophilic esophagitis (up to 46% of patients), esophageal stricture, hiatus hernia, Schatzki ring, achalasia, and tumors 2, 6

Complications and Their Management

• Major complications occur as a result of esophageal perforation, particularly with sharp foreign bodies 7
• Potential complications include mediastinitis, paraesophageal abscess, pneumomediastinum, subcutaneous emphysema, pneumothorax, tracheoesophageal fistula, aortoesophageal fistula, aspiration, and asphyxia 7
• Principles of damage control surgery should be applied to hemodynamically unstable patients with traumatic injuries 1

Follow-up

• Arrange for elective repeat endoscopy if adequate biopsies were not obtained during initial procedure 2
• For patients diagnosed with eosinophilic esophagitis, withhold PPI for at least 3 weeks before repeat endoscopy if symptoms persist 2
• Outpatient review to confirm cause of impaction, educate patient, and institute appropriate therapy for underlying conditions 2

Common Pitfalls to Avoid

• Delaying endoscopic intervention, which increases risk of complications 7
• Failure to obtain diagnostic biopsies during index endoscopy, leading to missed diagnoses 2
• Losing patients to follow-up if not properly scheduled for outpatient review before discharge 2