What are the current guidelines for evaluating and managing a suspected foreign‑body ingestion, including imaging, timing of endoscopic removal, and indications for surgery?

Foreign Body Ingestion Management Guidelines

Immediate Risk Stratification and Imaging

All patients with suspected foreign body ingestion require plain radiographs (anteroposterior and lateral views of neck, chest, abdomen, and pelvis) as the initial imaging modality, but a negative X-ray does NOT rule out foreign body ingestion—CT scan must be performed in symptomatic patients or those with high clinical suspicion. 1

Imaging Algorithm

• Plain radiographs first to identify radiopaque objects, determine location, size, shape, and detect pneumoperitoneum 2, 3
• CT scan is mandatory when:
  • Plain films are negative but symptoms persist (X-rays miss up to 47% of esophageal foreign bodies and 85% of fish bones, food bolus, and non-radiopaque objects) 1
  • Perforation is suspected 1, 4
  • Patient remains symptomatic despite negative radiographs 1
  • CT has 90-100% sensitivity versus only 32% for plain X-rays 1, 4

Laboratory Workup

• Obtain for symptomatic patients or those requiring intervention: complete blood count, C-reactive protein, blood gas analysis, serum creatinine 1, 5
• Add lactate and procalcitonin if perforation suspected 2, 1

Endoscopic Timing Based on Object Type

EMERGENT Endoscopy (Within 2-6 Hours)

The following require emergent flexible endoscopy within 2-6 hours: 1, 4

• Complete esophageal obstruction (inability to swallow saliva)
• Sharp-pointed objects (35% perforation risk) 1, 4
• Button/disk batteries (risk of pressure necrosis, electrical burns, chemical injury)
• Multiple magnets (risk of pressure necrosis, perforation, fistula formation)

URGENT Endoscopy (Within 24 Hours)

Perform urgent endoscopy within 24 hours for: 1, 5, 4

• Esophageal foreign bodies without complete obstruction
• Food bolus impaction without complete obstruction
• Persistent esophageal symptoms even with negative imaging 1

Endoscopic Technique

During endoscopy, first attempt gentle pushing of the foreign body into the stomach using air insufflation and instrumental pushing (90% success rate), then use retrieval techniques (baskets, snares, grasping forceps) if pushing fails. 5, 4

• Rigid endoscopy is second-line when flexible endoscopy fails, particularly for upper esophageal foreign bodies 5, 4

Critical Diagnostic Step During Index Endoscopy

Obtain at least 6 biopsies from different esophageal sites during the initial endoscopy—underlying esophageal disorders are found in up to 25% of patients (eosinophilic esophagitis in 46% of food bolus cases). 5, 4

Common underlying conditions include: 5

• Eosinophilic esophagitis
• Esophageal stricture
• Hiatus hernia
• Esophageal web or Schatzki ring
• Achalasia
• Tumors

Location-Specific Management

Esophageal Foreign Bodies

• All esophageal foreign bodies require intervention due to aspiration and perforation risk 1
• Avoid contrast swallow studies—they increase aspiration risk and impair endoscopic visualization 5
• Pharmacologic interventions (fizzy drinks, baclofen, salbutamol, benzodiazepines) have no clear evidence and should not delay endoscopy 5

Anorectal Foreign Bodies

• Obtain abdominal X-ray before digital rectal examination to prevent accidental injury from sharp objects 2
• CT scan for non-radiopaque anorectal objects 1
• Low-lying objects: attempt bedside extraction first 2
• High-lying objects (above rectosigmoid junction): endoscopic extraction first-line 2
• Perform proctoscopy or flexible sigmoidoscopy after removal to evaluate bowel wall 2

Surgical Indications

Surgery is indicated for: 2, 4

• Hemodynamic instability
• Signs of perforation
• Irretrievable foreign body
• Esophageal perforation with extensive pleural/mediastinal contamination (requires immediate upfront surgery)
• Foreign body close to vital structures

Do NOT attempt transanal extraction if perforation or hemodynamic instability present. 2

Common Pitfalls to Avoid

• Never rely on negative plain films alone—false-negative rates are unacceptably high for many foreign bodies 1
• Never discharge symptomatic patients without CT scan if plain films are negative 1
• Never skip diagnostic biopsies during index endoscopy—this leads to missed diagnoses, particularly eosinophilic esophagitis 5, 4
• Never delay imaging for hemodynamically unstable patients—proceed directly to surgery 2
• Never attempt endoscopic retrieval of suspected drug packages—risk of package disruption 2

Follow-Up Requirements

• Schedule outpatient review before discharge to confirm cause, educate patient, and institute therapy for underlying conditions 5
• If adequate biopsies not obtained, arrange elective repeat endoscopy 5
• For eosinophilic esophagitis diagnosis, withhold PPI for at least 3 weeks before repeat endoscopy if symptoms persist 5