What is the treatment for an esophageal foreign body, specifically a fish fork, lodged in the esophagus?

Treatment of Fish Fork Lodged in Esophagus

A fish fork lodged in the esophagus requires emergent flexible endoscopy within 2-6 hours for removal, as sharp foreign bodies carry high risk of perforation, mediastinitis, and mortality up to 22%. 1, 2, 3

Immediate Management Algorithm

Initial Assessment and Imaging

• Obtain baseline labs including complete blood count, C-reactive protein, blood gas analysis, and lactate to assess for systemic complications 1

• Perform CT scan of chest and neck if perforation is suspected or if the clinical presentation suggests complications, as CT has 90-100% sensitivity compared to only 32% for plain X-rays 1

• Avoid contrast swallow studies as they increase aspiration risk and impair subsequent endoscopic visualization 1

• Look specifically for pneumomediastinum, mediastinal air, subcutaneous emphysema, or paraesophageal fluid collections on imaging, which indicate perforation 2, 3, 4

Endoscopic Removal Strategy

Emergent flexible endoscopy (within 2-6 hours) is the first-line treatment for sharp foreign bodies like a fish fork, as delays increase perforation risk and complications 1, 3, 5

• Use low-flow CO2 insufflation rather than air to minimize mediastinal contamination if perforation occurs 6

• Remove the fork using appropriate grasping instruments (rat-tooth forceps, snares, or baskets) with careful technique to avoid causing additional mucosal injury 2, 5

• Carefully inspect the esophageal wall after removal for evidence of perforation, as sharp objects frequently cause mucosal injury 2, 3

• If rigid endoscopy is needed (if flexible endoscopy fails), consider this as second-line approach, particularly for upper esophageal foreign bodies 1

Management Based on Perforation Status

If No Perforation Detected

• Keep patient NPO initially and advance diet cautiously after confirming no delayed perforation 1

• Obtain diagnostic biopsies during the index endoscopy to evaluate for underlying esophageal pathology (stricture, eosinophilic esophagitis, malignancy) 1

• Arrange outpatient follow-up to confirm healing and address any underlying esophageal disorder 1

If Perforation is Identified

The management pathway depends on perforation characteristics and patient stability:

For Contained Perforation Without Instability

• Consider endoscopic band ligation as an immediate endoscopic closure technique for acute perforations, which has been successfully reported 2

• Initiate non-operative management if patient meets criteria: hemodynamically stable, no free extravasation of contrast, no systemic sepsis 6

• Non-operative management requires:

  • ICU-level monitoring with surgical expertise available 24/7 6
  • NPO status with broad-spectrum antibiotics 6
  • Nasogastric tube placement for esophageal decompression 6
  • Early nutritional support via enteral feeding or TPN 6
  • Percutaneous drainage of any peri-esophageal collections 6

For Free Perforation or Unstable Patient

Immediate surgical intervention is mandatory if the patient has hemodynamic instability, obvious non-contained contrast extravasation, or systemic signs of severe sepsis 6

• For cervical esophageal perforation: Direct repair should be attempted whenever feasible; if not feasible, perform esophagostomy with cervical drainage 6, 7

• For thoracic esophageal perforation: Operative repair is the treatment of choice; if primary repair not feasible, perform diversion, exclusion, or resection 6

• Buttress repairs with vascularized tissue (muscle flap) to decrease leakage risk 7

• Surgery must be performed within 24 hours as delayed surgical management (>24 hours) increases morbidity and reduces odds of successful primary repair 6

Critical Complications to Monitor

Sharp foreign bodies like fish forks are particularly prone to causing:

• Mediastinitis (most life-threatening complication) 2, 3, 4
• Paraesophageal or retropharyngeal abscess 2, 3
• Pneumomediastinum and pneumothorax 2, 3
• Tracheoesophageal fistula 3
• Aortoesophageal fistula (rare but catastrophic) 3

Mortality without appropriate management ranges from 3.92-50%, making timely intervention critical 7, 2

Common Pitfalls to Avoid

• Do not delay endoscopy waiting for "spontaneous passage" with sharp objects—they require active removal 3, 5

• Do not perform blind extraction attempts without endoscopic or surgical visualization 5

• Do not discharge patients immediately after removal without confirming absence of delayed perforation, as some perforations manifest hours later 2, 4

• Do not miss underlying esophageal pathology that predisposed to impaction—obtain biopsies during index endoscopy 1