From the Guidelines
Management of ingested sharp foreign objects requires emergent flexible endoscopy within 2-6 hours to minimize the risk of full-thickness perforation and other complications. Patients who have ingested sharp objects like bones, toothpicks, needles, or razor blades should be evaluated immediately in an emergency department 1. Initial assessment includes obtaining a detailed history about the object ingested and performing physical examination to check for signs of perforation such as abdominal pain, fever, or hematemesis. Radiographic imaging, including X-rays of the neck, chest, and abdomen, should be performed to locate the object.
Key Considerations
- For objects visible on endoscopy and located in the esophagus or stomach, urgent endoscopic removal is recommended using appropriate retrieval devices like rat-tooth forceps or retrieval nets 1.
- Objects that have passed beyond the duodenum may be managed conservatively with serial abdominal examinations and radiographs to monitor progression 1.
- Patients should be instructed to observe their stools for passage of the object and return immediately if they develop abdominal pain, vomiting, fever, or gastrointestinal bleeding.
- A clear liquid diet is often recommended until the object passes.
- Surgical intervention becomes necessary if complications such as perforation, obstruction, or abscess formation occur 1.
Important Factors
- The risk of complications is higher with objects longer than 6 cm or wider than 2.5 cm, as these may not pass through the intestinal tract naturally.
- Flexible and rigid endoscopy are complementary/cross-over techniques, with flexible endoscopy being the first-line approach and rigid endoscopy being considered as a second-line therapy 1.
- Diagnostic work-up for potential underlying disease, including histological evaluation, is recommended to identify underlying esophageal disorders that may be present in up to 25% of patients 1.
From the Research
Management of Ingested Sharp Foreign Objects
The management of ingested sharp foreign objects is a critical issue, as these objects can cause serious complications such as obstruction, perforation, or hemorrhage 2, 3.
- 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 2.
- Pre-existing intestinal disease such as Crohn's or intestinal stenosis may predispose to complications 2.
- The use of overtubes has made endoscopic removal of sharp objects safer 2.
- In patients at increased risk for complications, early endoscopic retrieval of ingested foreign objects is recommended 2, 4.
Considerations for Management
- Most ingested foreign bodies will pass spontaneously through the gastrointestinal tract, but sharp-pointed objects require careful consideration due to the risk of perforation or other complications 5, 6.
- The relation between the length and width of sharp-pointed foreign bodies and the mode of management remains questionable 5.
- Endoscopy has a high success rate in removing ingested foreign bodies, and is often the preferred method of removal 6, 4.
- Batteries and sharp objects should be removed immediately to avoid complications, while other objects can be observed for spontaneous passage 4.