What is the management for suspected glass particle ingestion leading to abdominal distension?

Management of Suspected Glass Particle Ingestion with Abdominal Distension

In patients with suspected glass particle ingestion presenting with abdominal distension, initial management should focus on clinical assessment with imaging (CT scan preferred over plain radiographs), followed by conservative management with close monitoring unless peritoneal signs develop, in which case emergency surgical intervention is indicated. 1, 2

Initial Clinical Assessment

Obtain a focused history and perform a thorough physical examination specifically looking for:

• Peritoneal signs (rebound tenderness, guarding, rigidity) 3, 1
• Abdominal distension and tenderness on palpation 2, 4
• Vital sign abnormalities suggesting shock or sepsis 3
• Signs of perforation including fever, subcutaneous emphysema, and localized tenderness 1

Laboratory evaluation should include:

• Complete blood count with differential 1, 5
• Electrolytes and renal function 3, 5
• Arterial blood gas and lactate levels to assess for bowel ischemia 3
• Liver function tests 5
• C-reactive protein 5

Diagnostic Imaging Strategy

CT imaging is the diagnostic modality of choice with 90-100% sensitivity and 93.7-100% specificity for detecting glass foreign bodies, making it essential when plain radiographs are negative or inconclusive. 1

• Plain abdominal radiographs have a false-negative rate up to 47% for foreign bodies and should not be relied upon alone 1
• CT should include contrast-enhanced protocol to evaluate for complications such as perforation, bowel wall thickening, or free fluid 1, 5
• Imaging helps determine the location, size, and number of glass particles 1

Conservative Management Protocol

Most glass particles that reach the stomach will pass spontaneously through the gastrointestinal tract without intervention, typically within 29 hours. 2, 6

Conservative management includes:

• Hospital admission for close observation 2, 4
• Serial physical examinations every 4-6 hours 4
• Continuous vital signs monitoring 4
• Serial imaging (daily abdominal radiographs or CT) to track fragment progression 4
• Hematimetric control to detect occult bleeding 4
• NPO or clear liquid diet initially, advancing as tolerated 2

Monitor specifically for:

• Development of peritoneal signs indicating perforation 2, 7
• Hematochezia or melena suggesting gastrointestinal bleeding 4
• Worsening abdominal pain or distension 4
• Fever or signs of sepsis 1

Indications for Endoscopic Intervention

Endoscopic removal should be considered when:

• Glass fragments remain in the esophagus or stomach and are accessible 1, 6
• Sharp-pointed fragments pose high perforation risk 1, 7
• Multiple large fragments are present in the stomach 4, 6

Important caveat: Endoscopic retrieval of glass fragments may be technically challenging in approximately 5% of cases due to shape and size, which can hamper retrograde passage through esophageal sphincters 6

Surgical Indications

Emergency surgery is mandatory when:

• Peritoneal signs develop indicating perforation 1, 2, 7
• CT demonstrates transmural necrosis or free air 1, 5
• Foreign body is irrecoverable endoscopically and causing obstruction 1
• Complications such as hemorrhage, mediastinitis, or empyema occur 1
• Clinical deterioration despite conservative management 3

Surgical intervention is required in only 1-3% of foreign body ingestion cases. 1

Risk Stratification

Patients at higher risk for complications include those with:

• Pre-existing intestinal disease (Crohn's disease, strictures) 7
• Prior abdominal surgery with adhesions 7
• Multiple or large sharp fragments 7
• Prolonged retention beyond 72 hours 7

Expected Clinical Course

With appropriate conservative management:

• Glass particles typically pass within 24-72 hours 2, 6
• Patients may experience transient hematochezia during passage, which usually resolves spontaneously 4
• Progressive improvement in abdominal pain should occur within 3-5 days 4
• Complete fragment elimination should be confirmed by imaging before discharge 4

Critical pitfall: The absence of peritonitis does not exclude bowel ischemia, and lactate levels may be normal even with significant intestinal injury. 3 Therefore, maintain high clinical suspicion and low threshold for repeat imaging if symptoms persist or worsen.

Psychiatric evaluation is mandatory before discharge in cases of intentional ingestion to prevent recurrence. 8, 5