What is the management for a foreign body in the esophagus?

Management of Esophageal Foreign Bodies

Emergent flexible endoscopy within 2-6 hours is required for complete esophageal obstruction or symptomatic patients, while urgent endoscopy within 24 hours is appropriate for asymptomatic partial obstruction, with the primary goal of removing the foreign body and obtaining diagnostic biopsies to identify underlying esophageal disorders present in up to 25% of cases. 1, 2, 3

Initial Assessment and Risk Stratification

Determine urgency based on clinical presentation:

• Complete obstruction or severe symptoms (stridor, respiratory distress, inability to handle secretions) → emergent endoscopy within 2-6 hours due to aspiration and perforation risk 1, 2, 3
• Sharp objects (fish bones, chicken bones, needles) → emergent endoscopy within 2-6 hours regardless of symptoms, as these carry high perforation risk leading to mediastinitis, aortoesophageal fistula, or paraesophageal abscess 4, 5
• Button batteries → emergent endoscopy within 2-6 hours due to risk of pressure necrosis and fistula formation 1, 4
• Partial obstruction, asymptomatic → urgent endoscopy within 24 hours 1, 2, 3

Critical pitfall: Delayed intervention is the dominant risk factor for mortality and complications including pressure necrosis, perforation, and mediastinitis 6, 5

Diagnostic Workup

Laboratory studies:

• Complete blood count, C-reactive protein, blood gas analysis, and lactate levels 2, 3

Imaging approach:

• Biplanar radiographs (AP and lateral) to confirm presence, location, and distinguish esophageal from tracheal position 1
• CT scan if perforation suspected (90-100% sensitivity vs. only 32% for plain X-rays) 2, 3
• Do NOT perform contrast swallow studies - these increase aspiration risk and impair subsequent endoscopic visualization 1, 2, 3

Note that plain radiographs have false-negative rates up to 85% for food impaction 2

Endoscopic Management Algorithm

First-line approach: Flexible endoscopy 1, 2, 3

Technique sequence:

1. First attempt: Gentle pushing of the foreign body into the stomach using air insufflation and instrumental pushing (90% success rate) 2, 3
2. If pushing fails: Use retrieval techniques with baskets, snares, or grasping forceps 1, 2, 3
3. If flexible endoscopy fails: Consider rigid endoscopy as second-line, particularly for objects in the upper esophagus 1, 2, 3

Critical diagnostic step during endoscopy:

• Obtain at least 6 diagnostic biopsies from different esophageal sites during the index endoscopy 2, 3
• Underlying esophageal disorders are found in up to 25% of patients with foreign body impaction 1, 2, 3
• Eosinophilic esophagitis is present in up to 46% of patients with food bolus obstruction 2, 3
• Other conditions include strictures, hiatus hernia, Schatzki ring, achalasia, and tumors 2, 3

Common pitfall: Failing to obtain diagnostic biopsies leads to missed diagnoses and recurrent impactions 2

Pharmacologic Interventions

Do not delay endoscopy for pharmacologic treatments - fizzy drinks, baclofen, salbutamol, and benzodiazepines lack clear evidence of benefit and should not postpone definitive endoscopic management 2

Surgical Indications (1-3% of cases)

Surgery is required when: 2, 3

• Irretrievable foreign body after failed endoscopy
• Esophageal perforation with extensive pleural/mediastinal contamination
• Foreign body close to vital structures
• Complications: mediastinitis, pleural empyema, fistula, or severe bleeding

Surgical approach:

• Esophagotomy with foreign body extraction and primary closure for limited contamination and viable tissue edges 2
• Minimally invasive techniques should be first-line in referral centers 2
• Rescue esophagectomy for extensive contamination 2

Post-Procedure Monitoring

Immediate care:

• Keep nil by mouth if concerns about laryngeal competence 1, 3
• Nurse upright with high-flow humidified oxygen if significant esophageal injury 3

Monitor for complications:

• Stridor, obstructed breathing, agitation 1, 3
• Fever, deep cervical or chest pain (signs of mediastinitis) 1, 3
• Crepitus (subcutaneous emphysema from perforation) 3, 5

Follow-Up Management

Before discharge:

• Schedule outpatient review to confirm underlying cause, educate patient, and institute appropriate therapy for identified esophageal disorders 2, 3
• For eosinophilic esophagitis diagnosis, withhold PPI for at least 3 weeks before repeat endoscopy if symptoms persist 2, 3

Common pitfall: Losing patients to follow-up by not scheduling outpatient review before discharge 2

Age-Specific Considerations

In children:

• Children aged 3 years or younger account for 77.1% of choking episodes 1
• Most common objects: coins (13% of episodes), toys/toy parts, batteries, and food items 1
• Same timing principles apply: emergent removal within 2-6 hours if symptomatic, urgent within 24 hours if asymptomatic 1

In adults:

• Most common objects: fish bones and chicken bones in Asian countries, meat bolus in Western countries 4, 5
• About 80% pass spontaneously, 20% require endoscopy, <1% require surgery 4