What is the management approach for patients who have swallowed foreign objects?

Management of Swallowed Foreign Objects

For patients who have swallowed foreign objects, emergent flexible endoscopy (within 2-6 hours) is mandatory for sharp-pointed objects, batteries, magnets, and complete esophageal obstruction, while other esophageal foreign bodies without complete obstruction require urgent endoscopy within 24 hours. 1, 2

Initial Assessment and Imaging

Obtain baseline laboratory studies including complete blood count, C-reactive protein, blood gas analysis, and lactate as part of the initial evaluation 2

Plain radiographs have severe limitations:

• False-negative rates up to 47-85% for foreign body detection 2, 3
• Useful only for identifying radiopaque objects 2
• Never rely on negative x-rays to exclude foreign body ingestion when history is suggestive 3

CT scan is the definitive imaging modality:

• Sensitivity of 90-100% compared to only 32% for plain x-rays 2, 3
• Should be performed immediately if perforation or complications are suspected 2
• Definitively identifies the object, determines exact location, and assesses for early complications 3

Avoid contrast swallow studies - they increase aspiration risk and impair subsequent endoscopic visualization 2, 3

Timing of Endoscopic Intervention

Emergent Endoscopy (Within 2-6 Hours)

Absolute indications requiring emergent intervention: 1, 2

• Sharp-pointed objects - up to 35% risk of full-thickness perforation 1
• Button/disk batteries - risk of pressure necrosis, electrical burns, and chemical injury 1
• Magnets - risk of pressure necrosis between magnets or with other metallic objects, perforation, and fistula formation 1, 3
• Complete esophageal obstruction from food bolus - risk of aspiration and perforation 1, 2

Urgent Endoscopy (Within 24 Hours)

Other esophageal foreign bodies without complete obstruction require urgent but not emergent removal 1, 2

Endoscopic Technique

For food bolus impaction, the recommended sequence is: 1, 2

1. First attempt gentle pushing of the bolus into the stomach using air insufflation and instrumental pushing (90% success rate) 1, 2
2. If pushing fails, use retrieval techniques with baskets, snares, or grasping forceps 1, 2
3. For large foreign bodies jammed in lower esophagus, consider passing a balloon catheter (ERCP stone extraction catheter) past the object, inflating the balloon, and withdrawing to disimpact before retrieval 1

Rigid endoscopy serves as second-line therapy when flexible endoscopy fails, particularly for foreign bodies in the upper esophagus 1, 2

Mandatory Diagnostic Workup During Index Endoscopy

Obtain at least 6 biopsies from different anatomical sites in the esophagus during the initial endoscopy to evaluate for underlying pathology 2

Underlying esophageal disorders are found in up to 25% of patients with foreign body impaction: 1, 2

• Eosinophilic esophagitis (up to 46% of food bolus cases) 2
• Esophageal stricture 1, 2
• Hiatus hernia 1, 2
• Esophageal web or Schatzki ring 1, 2
• Achalasia 1, 2
• Tumors 1, 2

Pharmacologic Management

Pharmacologic interventions have limited evidence and should never delay endoscopic management 2

There is no clear evidence that conservative treatments such as fizzy drinks, baclofen, salbutamol, or benzodiazepines are helpful 2

Surgical Indications

Potential indications for surgical treatment include: 1

• Irretrievable foreign body 1
• Esophageal perforation 1
• Foreign body close to vital structures (aortic arch) 1
• Other complications 1

Upfront surgery should be performed immediately for esophageal perforation with extensive pleural/mediastinal contamination 1

Follow-Up Management

If adequate biopsies were not obtained during initial endoscopy, arrange elective repeat endoscopy 2

For patients diagnosed with eosinophilic esophagitis, withhold PPI for at least 3 weeks before repeat endoscopy if symptoms persist 2

Schedule outpatient review before discharge to confirm the cause of impaction, educate the patient, and institute appropriate therapy for any underlying condition 2

Critical Pitfalls to Avoid

Never delay endoscopy for pharmacologic trials in patients with complete obstruction, sharp objects, batteries, or magnets 2, 3

Failure to obtain diagnostic biopsies during the index endoscopy leads to missed diagnoses, particularly eosinophilic esophagitis 2

Even a single magnet is dangerous if there is any possibility of multiple magnets or co-ingestion with other metallic objects 3

Patients with foreign body impaction are frequently lost to follow-up if not properly scheduled for outpatient review before discharge 2