Recommendations and statements
Foreign body ingestion and food bolus impaction
Ingestion of true foreign bodies (i. e. nonfood objects) occurs more frequently in
children than in adults. In adults, esophageal food bolus impaction is a much more
common problem with an estimated annual incidence of 13/100 000 people [9]. True foreign body ingestion in adults, either intentional or unintentional, appears
more often in the elderly population; in patients with psychiatric disorders developmental
delay, or alcohol intoxication; and in prisoners seeking secondary gain [1]
[2]
[3]
[4]
[5]
[6]
[7]. A classification of foreign bodies is listed in [Table 1]; some examples are shown in [Fig.1].
Table 1
Classification of swallowed foreign bodies.
|
Type
|
Examples
|
|
Blunt objects
|
Round objects: coin, button, toy
Batteries, magnets
|
|
Sharp-pointed objects
|
Fine objects: needle, toothpick, bone, safety-pin, glass pieces
Sharp irregular objects: partial denture, razor blade
|
|
Long objects
|
Soft objects: string, cord
Hard objects: toothbrush, cutlery, screwdriver, pen, pencil
|
|
Food bolus
|
With or without bones
|
|
Others
|
Packets of illegal drugs
|
Fig. 1 Examples of foreign bodies retrieved from the upper gastrointestinal tract (courtesy
of Dr. Patrick Druez).
Nonendoscopic measures
ESGE recommends diagnostic evaluation based on the patient’s history and symptoms.
ESGE recommends a physical examination focused on the patient’s general condition
and to assess signs of any complications (strong recommendation, low quality evidence).
For communicative adults, history of ingestion including timing, type of ingested
foreign body and onset of symptoms is usually reliable. In mentally impaired adults
and in cases of intentional foreign body ingestion for secondary gain (e. g. by prisoners),
a medical evaluation can be difficult. Patients with esophageal foreign bodies, particularly
impacted food boluses, are almost always symptomatic and can specify the onset of
symptoms and localize discomfort exactly. However, the area of discomfort often does
not correlate with the site of impaction [1]
[2]
[4]
[10]. Esophageal foreign bodies result in symptoms such as dysphagia, odynophagia, or
retrosternal pain; sore throat, foreign body sensation, retching, and vomiting are
also very common. Respiratory symptoms include choking, stridor, or dyspnea and can
result from aspiration of saliva or from tracheal compression by the foreign body.
Hypersalivation and inability to swallow any liquids are suspicious for complete esophageal
obstruction [3]
[4]
[5]
[6]
[7]
[10]
[11]
[12]
[13]
[14]
[15]. When the foreign body has passed the esophagus, the majority of patients remain
asymptomatic but a sensation of foreign body, with dysphagia, can persist for several
hours and thus can mimic a persisting foreign body impaction.
Physical examination is mandatory to detect ingestion-related complications such as
small-bowel obstruction. Symptoms indicating perforation include fever, tachycardia,
peritonitis, subcutaneous crepitus, and swelling of the neck or chest. Lung examination
should be performed to assess the presence of wheezing or aspiration [2]
[3]
[4]
[5]
[6]
[7].
ESGE does not recommend radiological evaluation for patients with nonbony food bolus
impaction without complications. We recommend plain radiography to assess the presence,
location, size, configuration, and number of ingested foreign bodies if ingestion
of radiopaque objects is suspected or type of object is unknown (strong recommendation,
low quality evidence).
When a history of foreign body ingestion is elicited, a radiographic evaluation of
the neck, chest and abdomen is recommended to assess the presence, location, size,
configuration, and number of ingested objects. Furthermore, complications such as
aspiration, free mediastinal/peritoneal air, or subcutaneous emphysema can be detected
[1]
[2]
[3]
[4]
[5]
[6]
[7]
[10]
[11]
[12]
[13]
[14]
[16]
[17]
[18]
[19]
[20]. To minimize exposure to radiation, plain radiography is recommended as the initial
screening method, but false-negative rates are as high as 47 % [5]. Therefore, biplanar radiography is recommended if the object is not detected on
plain radiographs.
Most true foreign bodies can be identified radiographically; however, thin metal objects,
wood, plastic, and glass, and fish or chicken bones are not readily seen ([Table 2]). For radiographic evaluation of food bolus impaction, false-negative rates of about
87 % have been reported, so X-ray is not sufficient and not required in patients with
nonbony food bolus impaction and without clinical signs of perforation [1]
[2]
[3]
[4]
[5]
[6]
[7]
[10]
[11]
[13]
[14]
[16]
[17]
[18].
Table 2
Classification of foreign bodies according to their radiodensity.
|
Radiodensity
|
Foreign body
|
|
Can mostly be identified on radiography
|
True foreign bodies (i. e. nonfood objects)
Steak bones
|
|
Cannot (regularly) be identified on radiography
|
Food bolus
Fish or chicken bones
Wood
Plastic
Glass
Thin metal objects
|
ESGE recommends computed tomography (CT) scan in all patients with suspected perforation
or other complication that may require surgery (strong recommendation, low quality
evidence).
In adults, fish bones and other bone fragments are the most commonly ingested foreign
bodies and are likely to become lodged in the upper esophagus with a high risk of
perforation [1]
[2]
[3]
[6]
[7]
[11]
[14]
[15]
[21]. However, radiography does not always reliably detect radiolucent foreign bodies,
especially fish bones. Even when fish bones are sufficiently radiopaque to be visualized
on radiographs, large soft-tissue masses and fluid can obscure the minimal calcium
content of the bone, particularly in obese patients [22]. Results of a prospective study with 358 patients who had swallowed fish bones revealed
that radiography had a sensitivity of only 32 % [23]. In these cases, CT scan, with a sensitivity from 90 % to 100 % and a specificity
of 93.7 % to 100 %, is significantly superior to radiography [6]
[17]
[18]
[22]
[24].
If perforation is suspected based on the clinical or radiological findings, CT is
indicated. With CT, the shape, size, location, and depth of the impacted foreign body
and the surrounding tissue can be visualized, which is important in determining treatment
options and evaluating the risks of endoscopic management. CT not only provides better
anatomic information, but can also detect other complications such as abscess formation,
mediastinitis, or aortic/tracheal fistulas [13]
[16]
[17]
[18]
[19]
[24]
[25]
[26].
Another difficulty is that the presence of free gas under the diaphragm is almost
never seen in foreign body perforation of the gastrointestinal tract. Because the
perforation is caused by impaction and progressive erosion of the foreign body through
the intestinal wall, the site of perforation becomes covered by fibrin, omentum, or
adjacent loops of bowel. This limits the passage of large amounts of intraluminal
air into the peritoneal cavity. Free intraperitoneal air is therefore a poor radiologic
sign. The region of perforation can be identified on CT scan as a thickened intestinal
segment, localized pneumoperitoneum, regional fatty infiltration, or associated intestinal
obstruction [26].
Besides for perforation, there are indications for surgical treatment in foreign body
ingestion in cases of complications that cannot be resolved endoscopically (e. g.
bleeding) or after unsuccessful attempts at endoscopic recovery. Impaction of the
foreign body out of endoscopic reach and small-bowel obstruction also require surgery.
ESGE does not recommend barium swallow because of the risk of aspiration and worsening
of the endoscopic visualization (strong recommendation, low quality evidence).
In the setting of radiological diagnostic evaluation, use of a barium swallow is not
recommended because of the risk of aspiration and because coating of the foreign body
and esophageal mucosa with contrast interferes with endoscopic visualization [1]
[2]
[3]
[4]
[5]
[18]
[19]. If an esophageal foreign object is assumed to be present but cannot be detected
on plain radiography, oral administration of a water-soluble radiocontrast medium
(e. g. Gastrografin; Bracco Diagnostics Inc.) can be considered, except when esophageal
obstruction is suspected clinically. In the latter cases, water-soluble agents are
contraindicated because they are hypertonic and can cause pulmonary edema if aspirated
[7]. Generally, radiocontrast evaluation should not delay any necessary endoscopic procedure.
ESGE recommends clinical observation without the need for endoscopic removal for management
of asymptomatic patients with ingestion of blunt and small objects (except batteries
and magnets). If feasible, outpatient management is appropriate (strong recommendation,
low quality evidence).
The majority of ingested foreign bodies (80 % – 90 %) pass through the gastrointestinal
tract spontaneously and without complications [1]
[2]
[3]
[6]
[7]
[27]. Impaction, perforation, or obstruction often occur at areas of physiological narrowing
or angulations. Areas of physiological narrowing include the upper esophageal sphincter,
aortic arch, left main stem bronchus, lower esophageal sphincter, pylorus, ileocecal
valve, and anus; the duodenal sweep is a physiological angulation. Once foreign bodies
have traversed the esophagus, most objects pass within 4 – 6 days, or in rare cases
in up to 4 weeks. Generally, objects greater than 2 – 2.5 cm in diameter will not
pass through the pylorus or ileocecal valve and objects longer than 5 – 6 cm will
not pass through the duodenal sweep [1]
[2]
[7]
[20]
[27].
Conservative outpatient management by means of clinical observation is appropriate
for asymptomatic patients with blunt objects in the stomach that are smaller than
2 – 2.5 cm in diameter and 5 – 6 cm in length. Patients should be instructed to be
aware of signs of perforation or small-bowel obstruction and to observe their stools
continuously. In the absence of symptoms, weekly radiographs are sufficient to document
the progression of the foreign body. If the foreign body fails to pass beyond the
stomach within 3 – 4 weeks, it should be extracted endoscopically [1]
[2]
[3]
[6]
[7]
[27].
ESGE recommends close observation in asymptomatic individuals who have concealed packets
of drugs by swallowing (“body packing”). We recommend against endoscopic retrieval.
We recommend surgical referral in cases of suspected packet rupture, failure of packets
to progress, or intestinal obstruction (strong recommendation, low quality evidence).
The term “body packing” refers to smuggling of drugs by concealment in the gastrointestinal
tract. Illegal drugs (most often cocaine or heroin) are packed within latex condoms
or balloons and are swallowed or inserted into the rectum in several parcels. The
packets can usually be seen radiographically. Rupture and leakage of the contents
can lead to fatal intoxication. Therefore, endoscopic removal should not be attempted
and a conservative approach is recommended instead, comprising inpatient treatment,
clinical observation, whole bowel irrigation, and radiographic follow-up for observing
passage of the parcels. Since the failure rate of the conservative approach is only
2 % – 5 %, it is always advisable in asymptomatic individuals with “body packed” drugs.
Symptomatic individuals present signs of either intoxication or bowel obstruction
and will require surgery. In cases of impaction of the packets in the bowel, surgical
referral is also indicated [1]
[2]
[3]
[6]
[7].
Endoscopic measures
ESGE recommends emergent (preferably within 2 hours, but at latest within 6 hours)
therapeutic esophagogastroduodenoscopy for foreign bodies inducing complete esophageal
obstruction, and for sharp-pointed objects and batteries in the esophagus. We recommend
urgent (within 24 hours) therapeutic esophagogastroduodenoscopy for other esophageal
foreign bodies without complete obstruction (strong recommendation, low quality evidence).
Esophageal foreign objects and food bolus impacted in the esophagus should be removed
within 24 hours because delay decreases the likelihood of successful removal and increases
the risk of complications [1]
[2]
[3]
[4]
[5]
[6]
[7]
[21]. The risk for major complications (i. e., perforation with or without mediastinitis,
retropharyngeal abscess and aortoesophageal fistula) increases 14.1 times with foreign
bodies impacted for more than 24 hours in the esophagus [28].
Patients with clinical signs of complete esophageal obstruction (i. e., hypersalivation
and inability to swallow liquids) have a high risk for aspiration and require an emergent
(preferably within 2 hours, but at the latest within 6 hours) endoscopic intervention.
The rate of perforation caused by ingested sharp-pointed objects is up to 35 %, therefore
it is recommended that these foreign bodies should be extracted from the esophagus
in an emergent setting also [1]
[2]
[3]
[4]
[5]
[6]
[7]
[13]
[21]
[25]
[28]
[29]. Button batteries or small disk batteries (as used in watches, hearing aids, calculators,
and other small electronic devices) can very quickly cause damage in the esophagus,
resulting in perforation or fistula due to pressure necrosis, electrical discharge,
or chemical injury. The narrow lumen of the esophagus allows mucosal contact with
both poles of the battery with subsequent electrical burns. Furthermore, necrosis
can result from leakage of the alkaline substances contained in the battery. Batteries
also contain heavy metals, but in small amounts that are unlikely to result in toxicity.
Ingestion of cylindrical batteries is rare (0.6 % of ingestions) and cause symptoms
less frequently [1]
[2]
[3]
[5]
[6]
[7]
[13].
ESGE suggests treatment of food bolus impaction in the esophagus by gently pushing
the bolus into the stomach. If this procedure is not successful retrieval should be
considered (weak recommendation, low quality evidence).
The effectiveness of medical treatment of esophageal food bolus impaction is debated.
It is therefore recommended, that medical treatment should not delay endoscopy (strong
recommendation, low quality evidence).
The primary method to treat food bolus impaction is the push technique, with success
rates of over 90 % and minimal complications. Before the food bolus is pushed into
the stomach, an attempt to bypass the bolus with the endoscope should be made to assess
any obstructive esophageal pathology beyond the impacted food. Even if this is not
possible, most food boluses can be safely pushed into the stomach by using air insufflation
and gentle pushing pressure. Placing the endoscope on the right side of the bolus
may allow an easier and safer passage into the stomach because the gastroesophageal
junction angulates to the left of the patient. Larger boluses can be broken apart
with an endoscopic accessory before pushing the smaller pieces into the stomach safely.
If significant resistance is encountered, pushing should not be continued because
of the high incidence of underlying esophageal pathology. Applying excessive force
in these cases will lead to an increased risk of perforation. Impacted food boluses
that cannot be pushed into the stomach, especially those containing bones or sharp
edges, must be treated with en bloc retrieval or piecemeal removal after fragmentation,
using different types of grasping forceps, polypectomy snares, retrieval net, or Dormia
basket [1]
[2]
[3]
[4]
[5]
[6]
[7]
[10]
[14]
[29]
[30]
[31].
Medical treatment of esophageal food bolus impaction with glucagon has been investigated
in several studies [1]
[2]
[3]
[4]
[32]
[33]
[34]. Whether a similar effect can be achieved by using butylscopolamine has not been
studied and remains questionable. The utility of glucagon in easing the passage of
the bolus into the stomach has been reported to be variable and there seems to be
less success in the setting of a fixed anatomic obstruction. Esophageal food bolus
impaction is frequently associated with an esophageal anatomic abnormality (e. g.
strictures): thus medical treatment will not be very effective in most cases and should
therefore not delay endoscopic removal. Although the success rate with glucagon is
low, some authors recommend its use as an initial therapy for esophageal food bolus
impaction because of its safety and limited side-effect profile. However, the use
of glucagon is commonly associated with nausea and vomiting and could potentially
increase the risk of perforation and aspiration in the presence of a severe impaction.
In cases of food bolus impaction, ESGE recommends a diagnostic work-up for potential
underlying disease, including histological evaluation, in addition to therapeutic
endoscopy (strong recommendation, low quality evidence).
An underlying esophageal pathology is found in more than 75 % of patients presenting
with food bolus impaction [1]
[2]
[3]
[4]
[5]
[6]
[7]
[10]
[12]
[14]
[15]
[19]
[25]. The most frequently associated abnormalities are esophageal (mainly peptic) strictures
(more than 50 %) and eosinophilic esophagitis (about 40 %). Less frequently, esophageal
cancer or esophageal motility disorders, such as achalasia, diffuse esophageal spasm,
and nutcracker esophagus, are causes of food bolus impaction. Lack of appropriate
follow-up for patients has been shown to be a predictor for recurrent food impactions
[5]. Therefore, in all patients a diagnostic work-up after extraction of foreign bodies
is recommended to detect any underlying disease [14]
[29].
Typical endoscopic features in individuals suffering from eosinophilic esophagitis
are longitudinal and vertical furrows, trachealization of the esophagus, esophageal
edema, and mucosal fragility (“crêpe paper esophagus”). The presence of white exudates
is an additional typical finding and these are thought to be clusters of eosinophils.
Fixed rings and strictures are complications of eosinophilic esophagitis and potentially
result in permanent narrowing of the esophagus. However, in about 10 % of patients
the findings are either very subtle or the esophagus appears normal. Biopsies of the
upper, middle, and lower thirds of the esophagus, and from those areas where visible
white exudates suggest nests of eosinophils, should be obtained at the initial procedure
or in a repeat endoscopy to evaluate for eosinophilic esophagitis [30]
[35]
[36]
[37]. Esophageal strictures or Schatzki rings can be safely and effectively dilated concurrently
in the absence of substantial mucosal damage. Often there is mucosal abrasion or erythema
as a result of the food having been lodged in the esophagus for an extended period.
In this case, the patient should be prescribed proton pump inhibitor therapy with
dilation being performed 2 – 4 weeks later [3]
[4]
[5]
[6]
[7].
ESGE recommends urgent (within 24 hours) therapeutic esophagogastroduodenoscopy for
foreign bodies in the stomach such as sharp-pointed objects, magnets, batteries, and
large/long objects. We suggest nonurgent (within 72 hours) therapeutic esophagogastroduodenoscopy
for medium-sized blunt foreign bodies in the stomach (strong recommendation, low quality
evidence).
Although the majority of sharp-pointed objects in the stomach will pass without incident,
the risk of complications is as high as 35 %. Therefore, it is recommended to retrieve
a sharp-pointed object in the stomach or proximal duodenum endoscopically if this
can be accomplished safely, considering the patient’s fasting status and risk of aspiration
[2]
[6]
[7].
Because of the attracting forces between ingested magnets or between a single magnet
and metallic foreign bodies swallowed at the same time, ingestion of magnets can cause
pressure necrosis, fistula, perforation, occlusion, or volvulus. Urgent (within 24
hours) endoscopic removal is recommended even if only one magnet is evident on radiographs
or the patient’s history suggests ingestion of only one magnet. Additional, undetected
magnets or other ingested metal objects together with a magnet can lead to severe
gastrointestinal injury [1]
[2]
[3]
[5].
Some authors suggest endoscopic retrieval of batteries beyond the esophagus emergently,
others only when there are coexisting signs of gastrointestinal injury [1]
[2]
[3]
[5]
[6]
[7]. Most button and small disk batteries in the stomach will pass the gastrointestinal
tract without any complications. The risk of electrical burns resulting from ingested
batteries in the stomach is low compared with the risk from batteries lodged in the
esophagus. Taking into account the danger of liquefaction necrosis due to battery
leakage, removal of batteries from the stomach within 24 hours seems to be appropriate.
Once the duodenum has been passed, 85 % pass through the remaining intestine within
72 hours.
Medium-sized foreign bodies with a diameter wider than 2 – 2.5 cm will normally not
pass the pylorus and should retrieved. Objects longer than 5 – 6 cm usually become
lodged in the duodenal curve and must be removed as an urgent procedure because of
a risk of perforation in 15 % – 35 % of cases. An overview on timing of endoscopy
according to the type of ingested foreign body and its location in the gastrointestinal
tract is given in [Table 3] [1]
[2]
[3]
[5]
[6]
[7].
Table 3
Timing of endoscopic intervention in foreign body ingestions: emergent is preferably
within 2 hours, but at latest within 6 hours; urgent, within 24 hours; nonurgent,
within 72 hours.
|
Object type
|
Location
|
Timing
|
|
Battery
|
Esophagus
|
Emergent
|
|
Stomach/small bowel
|
Urgent
|
|
Magnet
|
Esophagus
|
Urgent
|
|
Stomach/small bowel
|
Urgent
|
|
Sharp-pointed foreign body
|
Esophagus
|
Emergent
|
|
Stomach/small bowel
|
Urgent
|
|
Blunt and small foreign body < 2 – 2.5 cm diameter
|
Esophagus
|
Urgent
|
|
Stomach/small bowel
|
Nonurgent
|
|
Blunt and medium-sized foreign body > 2 – 2.5 cm diameter
|
Esophagus
|
Urgent
|
|
Stomach/small bowel
|
Nonurgent
|
|
Large foreign body > 5 – 6 cm
|
Esophagus
|
Urgent
|
|
Stomach/small bowel
|
Urgent
|
|
Food bolus
|
Esophagus
|
Emergent (urgent if without symptoms or without complete obstruction)
|
ESGE recommends the use of a protective device in order to avoid esophagogastric/pharyngeal
damage and aspiration during endoscopic extraction of sharp-pointed foreign bodies.
Endotracheal intubation should be considered in the case of high risk of aspiration
(strong recommendation, low quality evidence).
Airway protection is of special concern during foreign body removal and food bolus
extraction. Standard-sized overtubes that extend past the upper esophageal sphincter
not only protect the airways but also facilitate passage of the endoscope during removal
of multiple objects or during piecemeal extraction of an impacted food bolus. Endotracheal
intubation may be needed if the patient is not cooperative or if there is a high risk
of aspiration (i. e., full stomach, proximal esophageal location of the foreign body,
food bolus impaction).
Overtubes also help to protect the esophageal/pharyngeal mucosa from lacerations during
retrieval of sharp objects ( [Fig. 2]). Longer overtubes of 45 – 60 cm that extend past the lower esophageal sphincter
should be used during removal of sharp-pointed objects distal to the esophagus. Use
of a transparent cap or latex rubber hood ([Fig. 3]) is recommended to prevent mucosal injury from sharp-pointed objects if there is
no overtube available. There is one randomized controlled trial demonstrating that
transparent cap-assisted endoscopy is a safe and effective method in the management
of foreign bodies in the upper esophagus, with a significantly shorter operation time
and clearer visual field compared with conventional esophagogastroduodenoscopy [2]
[3]
[4]
[5]
[6]
[7]
[12]
[29]
[38].
Fig. 2 Overtube used in endoscopic retrieval of ingested foreign bodies (Guardus overtube
– permission granted by US Endoscopy).
Fig. 3 Latex rubber hood used to prevent mucosal injury during retrieval of a scalpel blade.
ESGE suggests the use of suitable extraction devices according to the type and location
of the ingested foreign body (weak recommendation, low quality evidence).
Flexible endoscopy is the best diagnostic and therapeutic approach in the management
of foreign bodies and food bolus impaction in the upper gastrointestinal tract, with
success rates greater than 95 % and complication rates of 0 % – 5 % [2]
[3]
[5]
[6]
[11]
[12]
[14]
[19]
[25]
[29]
[39]. The choice of retrieval device is determined by the size and shape of the foreign
body ( [Table 4]; [Fig. 4] and [Fig. 5]), by the endoscope length and instrument channel, and by the endoscopist’s preference
and practice. Removal of foreign bodies with standard biopsy forceps is rarely successful
because of the forceps’ small opening width, and cannot therefore be recommended [3]. Retrieval forceps have a large variety of jaw configurations: rat-tooth, alligator-tooth,
or shark-tooth. Retrieval graspers with two to five prongs can be useful for retrieving
soft objects, but not for harder or heavy objects because the grip is not secure enough.
Polypectomy snares are widely available and inexpensive. Endoscopic baskets may be
useful for round objects, and retrieval nets or bags can provide a more secure grasp
for some foreign bodies (coins, batteries, magnets) and for en bloc removal of food
boluses.
Table 4
Overview of retrieval devices.
|
Object type
|
Appropriate retrieval devices
|
|
Blunt objects
|
Grasping forceps, retrieval graspers, polypectomy snare, basket, retrieval net
|
|
Sharp-pointed objects
|
Grasping forceps, polypectomy snare, basket, retrieval net
Transparent cap, latex rubber hood
|
|
Long objects
|
Polypectomy snare, basket
|
|
Food bolus
|
Grasping forceps, retrieval graspers, polypectomy snare, basket, retrieval net
|
Fig. 4 Retrieval graspers and grasping forceps (image provided by Olympus Europe, Hamburg,
Germany).
Fig. 5 Baskets and snare (image provided by Olympus Europe, Hamburg, Germany).
With sharp objects, the foreign body should be grasped in such a position that the
sharp or pointed end trails distally to the endoscope, thus lowering the risk of a
procedure-related perforation or mucosal damage during extraction. Long foreign bodies
must be grabbed at the very end of the object to allow retrograde removal through
the esophagus. Grasping the object near the center would turn the object so that its
length was radially across the lumen, preventing it from being pulled through the
sphincters and the esophagus.
Before endoscopy, it is useful to practice grasping an object similar in shape to
the ingested foreign body, using different accessories to determine the most appropriate
available retrieval device [2]
[3]
[4]
[5]
[6]
[7].
After successful and uncomplicated endoscopic removal of ingested foreign bodies,
ESGE suggests that the patient may be discharged. If foreign bodies are not or cannot
be removed, a case-by-case approach depending on the size and type of the foreign
body is suggested (weak recommendation, low quality evidence).
Most patients with foreign body ingestion or food bolus impaction can be treated as
outpatients after endoscopic therapy. Consideration should be given to admitting patients
for observation after technically difficult extraction, when there has been ingestion
of multiple objects or foreign bodies associated with a high risk for complications
(i. e., sharp-pointed objects, batteries, magnets, objects larger than 5 – 6 cm),
and when there is extensive mucosal injury due to the foreign body ingestion or endoscopic
treatment.
If the foreign body cannot be retrieved endoscopically, inpatient treatment and close
clinical observation is mandatory for sharp-pointed objects and batteries. Radiographic
follow-up examinations should be performed to assess the object’s passage through
the gastrointestinal tract. Daily radiographs are recommended for sharp-pointed objects.
For batteries beyond the duodenum, plain radiography every 3 – 4 days is adequate.
Surgery must be considered for removal of dangerous foreign bodies that have passed
the ligament of Treitz and fail to progress within 3 days after ingestion. Long objects
lodged in the duodenum need surgical therapy when endoscopic efforts fail [1]
[2]
[3]
[5]
[6]
[7]
[27].
ESGE Guidelines represent a consensus of best practice based on the available evidence
at the time of preparation. They might not apply in all situations and should be interpreted
in the light of specific clinical situations and resource availability. Further controlled
clinical studies may be needed to clarify aspects of these statements, and revision
may be necessary as new data appear. Clinical considerations may justify a course
of action at variance with these recommendations. ESGE Guidelines are intended to
be an educational device for providing information that may assist endoscopists in
providing care to patients. They are not rules and should not be construed as establishing
a legal standard of care or as encouraging, advocating, requiring, or discouraging
any particular treatment.
