What is the appropriate management for a patient with a foreign body (object) in the esophagus?

Management of Esophageal Foreign Bodies

For a patient with a foreign body in the esophagus, perform emergent flexible endoscopy within 2-6 hours for complete obstruction (or sharp objects, batteries, magnets) and urgent endoscopy within 24 hours for partial obstruction, with the primary endoscopic technique being gentle pushing of the object into the stomach (90% success rate), followed by retrieval with baskets or forceps if pushing fails. 1, 2

Initial Assessment and Timing

The urgency of intervention depends on the type of foreign body and degree of obstruction:

• Complete esophageal obstruction requires emergent endoscopy within 2-6 hours due to high risk of aspiration and perforation 1, 2, 3
• Sharp-pointed objects, batteries, and magnets mandate emergent endoscopy within 6 hours regardless of symptoms 4, 1
• Partial obstruction without complete blockage requires urgent endoscopy within 24 hours 1, 2, 3

Pre-Endoscopy Workup

Before proceeding to endoscopy, obtain the following:

• Laboratory studies: Complete blood count, C-reactive protein, blood gas analysis, and lactate levels 1, 2, 3
• Plain radiographs of neck, chest, and abdomen can identify radiopaque objects, but have false-negative rates up to 85% for food impaction 1, 2, 3
• CT scan is the key imaging study if perforation or complications are suspected, with 90-100% sensitivity compared to only 32% for plain X-rays 1, 2, 3
• Avoid contrast swallow studies as they increase aspiration risk and impair subsequent endoscopic visualization 2, 3

Endoscopic Management Algorithm

The endoscopic approach follows a systematic sequence:

1. First-line technique: Attempt gentle pushing of the bolus into the stomach using air insufflation and instrumental pushing, which has a 90% success rate 1, 2, 3

2. Second-line technique: If pushing fails, use retrieval techniques with baskets, snares, or grasping forceps 1, 2, 3

3. Alternative approach: If flexible endoscopy fails, consider rigid endoscopy as second-line therapy, particularly for foreign bodies in the upper esophagus 2, 3

Do not delay endoscopy for pharmacologic interventions such as fizzy drinks, baclofen, salbutamol, or benzodiazepines, as there is no clear evidence these are helpful 2, 3

Critical Diagnostic Step During Index Endoscopy

Obtain at least 6 diagnostic biopsies from different anatomical sites in the esophagus during the initial endoscopy 1, 2, 3. This is essential because:

• An underlying esophageal disorder is 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 1, 2
• Other common conditions include esophageal stricture, hiatus hernia, Schatzki ring, achalasia, and tumors 1, 2, 3

Surgical Management

Surgery is required in only 1-3% of cases 3. Indications include:

• Perforation with extensive pleural or mediastinal contamination 4, 1, 3
• Irretrievable foreign body after failed endoscopy 4, 1, 3
• Foreign body close to vital structures 4, 1, 3
• Complications such as mediastinitis, pleural empyema, fistula, or severe bleeding 3

The preferred surgical approach is esophagotomy with foreign body extraction and primary closure for limited contamination with viable tissue edges 4, 1, 3. Minimally invasive techniques should be first-line in referral centers, with rescue esophagectomy reserved for extensive contamination 3.

Follow-Up Management

Before discharge, establish a clear follow-up plan:

• Schedule outpatient review to confirm the underlying cause of impaction, educate the patient, and institute appropriate therapy for any identified esophageal disorder 1, 2, 3
• If adequate biopsies were not obtained during initial endoscopy, arrange for elective repeat endoscopy 1, 2
• For patients diagnosed with eosinophilic esophagitis, withhold PPI for at least 3 weeks before repeat endoscopy if symptoms persist 1, 2, 3

Common Pitfalls to Avoid

• Failing to obtain diagnostic biopsies during the index endoscopy leads to missed diagnoses, particularly eosinophilic esophagitis 1, 2, 3
• Losing patients to follow-up by not scheduling outpatient review before discharge 1, 2, 3
• Delaying endoscopy for ineffective pharmacologic interventions 2, 3
• Performing contrast studies that increase aspiration risk and impair endoscopic visualization 2, 3
• Prolonged observation beyond 24 hours increases risk of major complications including perforation, mediastinitis, and aortoesophageal fistula 5, 6