Management of Swallowed Thumb Tack
For a patient who has swallowed a thumb tack, obtain plain radiographs immediately to confirm location, then proceed with emergent flexible endoscopy within 2-6 hours for removal, as sharp-pointed objects carry up to 35% risk of full-thickness perforation. 1
Initial Assessment and Imaging
Obtain plain radiographs of the neck, chest, and abdomen to identify the location of the radiopaque thumb tack, though be aware these have false-negative rates up to 47-85% for foreign body detection. 1
If perforation or complications are suspected, obtain a CT scan immediately, which has 90-100% sensitivity compared to only 32% for plain X-rays. 1
Do NOT order contrast swallow studies, as they increase aspiration risk and impair subsequent endoscopic visualization. 2, 1
Obtain complete blood count, C-reactive protein, blood gas analysis, and lactate as part of the initial evaluation. 2
Timing of Intervention
Sharp-pointed objects like thumb tacks require emergent flexible endoscopy within 2-6 hours due to the high perforation risk. 1 This is non-negotiable—the sharp point can penetrate the esophageal or gastric wall at any time, leading to mediastinitis, peritonitis, or death.
The urgency differs significantly from blunt objects: while 80-90% of blunt foreign bodies pass spontaneously, sharp objects have up to 35% risk of causing full-thickness perforation. 1, 3, 4
Endoscopic Management
First-line treatment is flexible endoscopy with the goal of removing the thumb tack before it causes perforation. 1
During endoscopy, use retrieval techniques with baskets, snares, or grasping forceps to extract the thumb tack. 2, 1 Do NOT attempt to push a sharp object distally into the stomach, as this is appropriate only for food boluses, not sharp objects. 2
If flexible endoscopy fails, proceed to rigid endoscopy as second-line therapy, particularly if the thumb tack is in the upper esophagus. 1, 5
Obtain at least 6 biopsies from different esophageal sites during the index endoscopy to evaluate for underlying pathology, as up to 25% of patients with foreign body impaction have an underlying esophageal disorder. 1, 5
Surgical Indications
Proceed immediately to surgery if:
- The thumb tack is irretrievable endoscopically 1
- Esophageal or gastric perforation has occurred with extensive pleural/mediastinal contamination 1
- The thumb tack is located close to vital structures 1
- The patient develops peritonitis or mediastinitis 1
Surgical intervention is required in approximately 1% of all foreign body ingestions, but this percentage is much higher for sharp objects. 6, 4 In one series, objects longer than 6.5 cm required surgery in nearly 75% of cases. 3
Post-Procedure Monitoring
Nurse the patient upright and administer high-flow humidified oxygen if there is concern for esophageal injury. 5
Keep the patient nil by mouth if there are concerns about laryngeal competence. 5
Monitor closely for warning signs of perforation: stridor, obstructed breathing, agitation, fever, severe sore throat, deep cervical or chest pain, and subcutaneous crepitus. 5
Educate the patient about symptoms of mediastinitis (severe chest pain, fever, dysphagia) and instruct them to seek immediate medical attention if these develop. 5
Common Pitfalls
Never adopt a "wait and see" approach with sharp objects—unlike blunt objects that can be observed, sharp-pointed foreign bodies require urgent intervention regardless of symptoms. 1
Do not assume the thumb tack will pass spontaneously; the sharp point makes perforation likely at any point along the GI tract. 1, 3
Failure to obtain diagnostic biopsies during the index endoscopy can lead to missed underlying esophageal pathology. 1, 5
If the thumb tack has already passed beyond endoscopic reach into the small bowel, close radiographic surveillance with serial abdominal X-rays every 12-24 hours is required, with surgical consultation readily available. 3, 4