What is the care plan for a patient with a plastic foreign body (FB) in the esophagus?

Management of Plastic Foreign Body in the Esophagus

For a plastic foreign body in the esophagus, emergent flexible endoscopy within 2-6 hours is the treatment of choice, with surgical intervention reserved for cases of perforation, irretrievable objects, or extensive contamination. 1

Initial Assessment and Imaging

• Obtain complete blood count, C-reactive protein, blood gas analysis, and lactate as part of initial evaluation 2
• CT scan with contrast is the imaging study of choice if perforation or complications are suspected, with sensitivity of 90-100% compared to only 32% for plain radiographs 2
• Plain radiographs have limited utility with false-negative rates up to 85% for non-radiopaque objects 2
• Avoid contrast swallow studies as they increase aspiration risk and impair subsequent endoscopic visualization 2

Timing of Endoscopic Intervention

The urgency depends on clinical presentation:

• Emergent endoscopy (<6 hours) is mandatory for complete esophageal obstruction due to risk of aspiration and perforation 1, 2
• Urgent endoscopy (within 24 hours) is appropriate for incomplete obstruction without respiratory compromise 2
• Sharp-pointed objects, batteries, and magnets also require emergent removal even if not causing complete obstruction 1

Endoscopic Technique

Flexible endoscopy is the first-line approach with 90-93% success rates and superior safety profile compared to rigid endoscopy 1, 3

Procedural approach:

• First attempt gentle pushing of the object into the stomach using air insufflation and instrumental pushing (90% success rate) 2
• If pushing fails, use retrieval techniques with baskets, snares, or grasping forceps 2
• Protect the airway during extraction—consider endotracheal intubation in high-risk patients (younger children, those with drooling or respiratory symptoms) 4
• Maintain control of the object during extraction to avoid aspiration 4

When to consider rigid endoscopy:

• Rigid endoscopy should be second-line if flexible endoscopy fails, particularly for objects in the upper esophagus (the "Achilles' heel" of flexible endoscopy) 1, 3
• The bivalved Weerda diverticuloscope allows dilation of the upper esophageal sphincter and can be combined with flexible endoscopy 1
• Rigid endoscopy has higher complication rates (3.2% esophageal rupture) and always requires general anesthesia 3

Surgical Indications

Surgery is indicated for perforation with extensive contamination, irretrievable foreign bodies, objects close to vital structures (aortic arch), or failed endoscopic attempts 1

Surgical approach selection:

• The approach depends on location of the foreign body: left cervicotomy for cervical esophagus, right/left thoracotomy or thoracoscopy for thoracic esophagus, laparoscopy for distal esophagus 1
• Minimally invasive techniques should be first-line in referral centers 1
• Esophagotomy with foreign body extraction and primary closure is preferred when there is limited contamination and viable tissue edges 1
• Rescue esophagectomy with delayed reconstruction is reserved for extensive contamination 1

Post-Procedure Management

• Obtain at least 6 biopsies from different esophageal sites during the index endoscopy to evaluate for underlying pathology 2
• Up to 25% of patients have underlying esophageal disorders (eosinophilic esophagitis, strictures, webs, achalasia, tumors) 2, 5
• If adequate biopsies were not obtained, arrange elective repeat endoscopy 2
• Schedule outpatient follow-up before discharge to confirm diagnosis, educate patient, and institute therapy for underlying conditions 2

Critical Pitfalls to Avoid

• Do not delay endoscopy for pharmacologic interventions—there is no clear evidence that fizzy drinks, baclofen, salbutamol, or benzodiazepines are helpful 2
• Do not use contrast studies as they impair visualization and increase aspiration risk 2
• Failure to obtain diagnostic biopsies leads to missed diagnoses, particularly eosinophilic esophagitis which is found in up to 46% of food bolus obstructions 2
• Patients are frequently lost to follow-up if not scheduled for outpatient review before discharge 2
• In hemodynamically unstable patients with perforation, apply damage control surgery principles with abbreviated source control followed by ICU resuscitation 1