Management and endoscopic techniques for digestive foreign body and food bolus impaction

The Biting Colon: An Unfortunate Nightmare for a Healthy but Anxious Patient

A 48-year-old female with no significant past medical history presented to the emergency department with an uncommon scenario after accidentally ingesting a three-unit dental bridge, leading to its impaction within the lower gastrointestinal tract. Despite initial conservative management with laxatives aimed at facilitating spontaneous passage, the foreign body remained lodged in the colon. Subsequently, the patient underwent endoscopic intervention via colonoscopy, during which the dental bridge was successfully extracted. This case highlights the complexity of managing foreign body ingestions, particularly when impaction occurs in uncommon locations, such as the colon. We emphasize the importance of individualized care strategies and recognize the potential of endoscopic procedures in resolving clinical scenarios involving foreign body ingestions.

Endoscopic management of duodenal perforation caused by foreign bodies in adults: A retrospective study

BACKGROUND AND AIMS

Duodenal perforation caused by foreign bodies (FBs) is very rare but is an urgent emergency that traditionally requires surgical intervention. Several case reports have reported the successful endoscopic removal of duodenal perforating FBs. Here we aimed to evaluate the safety and efficacy of endoscopic management of duodenal perforating FBs in adults.

METHODS

Between October 2004 and October 2022, 12,851 patients with endoscopically diagnosed gastrointestinal FBs from four tertiary hospitals in China were retrospectively reviewed. Patients were enrolled if they were endoscopically and/or radiographically diagnosed with duodenal perforating FBs.

RESULTS

The incidence of duodenal total FBs and perforating FBs was 1.9% and 0.3%, respectively. Thirty-four patients were enrolled. Endoscopic removal was achieved in 25 patients (73.5%), and nine patients (26.5%) received surgery. For the endoscopic group, most perforating FBs were located in the duodenal bulb (36.0%) and descending part (28.0%). The adverse events included 3 mucosal injuries and 1 localized peritonitis. All patients were cured after conventional treatment. In the surgical group, most FBs were lodged in the descending part (55.6%). One patient developed localized peritonitis and one patient died of multiple organ failure. The significant features of FBs requiring surgery included FB over 10 cm, both sides perforation, multiple perforating FBs and massive pus overflow.

CONCLUSION

Endoscopic removal of duodenal perforating FBs is safe and effective, and can be the first choice of treatment for experienced endoscopists. Surgical intervention may be required for patients with FBs over 10 cm, both sides perforation, multiple perforating FBs, or severe infections.

Ingestion of a row of artificial dentures in an adult: A case report and review of the literature

RATIONALE

Foreign body (FB) ingestion is a common clinical emergency, although in most cases, the FB can pass safely through the entire gastrointestinal tract without causing any damage. However, ingestion of large dentures is very rare and alarming, as it can threaten the intestinal mucosa and cause perforation of the gastrointestinal tract, among other complications.

PATIENT CONCERNS

A 64-year-old Chinese male was referred to our hospital for removal of a FB, which was a large denture. Clinical symptoms included chest and upper abdominal pain. He had no cough or dyspnea. Medical history included a recent cerebral infarction, craniocerebral surgery, and being bedridden for a long term.

DIAGNOSES

We initially suspected a single and smooth denture, complicated by pharyngeal and esophageal mucosal injury. Radiographic examination however showed a 70-mm long opaque object located in the middle and upper esophagus, close to the trachea and aorta.

INTERVENTIONS

Multiple dentures and metal hooks were removed via endoscopy using a net, grasping forceps, and rubber jacket.

OUTCOMES

The patient recovered well and experienced no postoperative complications. The patient was discharged 5 days after endoscopic therapy.

LESSONS

Our case showed that endoscopy was effective for the retrieval of an esophageal FB. For sharp FBs, the use of a net and rubber jacket is a good choice. However, we advocate for appropriate surgery in patients in whom endoscopy is not possible after an accurate diagnosis or those with severe complications.

Foreign body in the gastrointestinal tract in children: A tertiary hospital experience

Background

Foreign body (FB) ingestion in the gastrointestinal tract (GIT) in children is common. Although most foreign bodies will pass spontaneously, surgical intervention is required when they fail to pass.

Aims and Objectives

The aim of this study was to evaluate our experience in the management of children who presented with FB in the GIT.

Materials and Methods

This was a retrospective study of children that underwent laparotomy for the removal of FB in the GIT at the paediatric surgery unit of Enugu State University Teaching Hospital, Enugu over a 10-year period.

Results

A total of 272 children presented with FB in the GIT during the study period, out of which 30 patients had laparotomy. This gave an operative incidence rate of 11%. There was a slight male predominance and the ages of the patients ranged from 6 months to 5 years (median 3 years). About half of the patients had no symptoms and all the patients were investigated with an abdominal radiograph. Only one-third of the patients had a predisposing factor that could have led to FB impaction. FB impaction was the most common indication for surgery, and enterotomy with FB removal was the most performed surgical procedure. The most common FB removed were tiny parts of toys, and the most common post-operative complication was surgical site infection. There was no mortality.

Conclusion

FB in GIT in children could be associated with complications that require surgical treatment. FB ingestion is preventable. Focus should be placed on caregivers preventing children from ingesting FB.

Cap-assisted endoscopy for esophageal foreign bodies: A meta-analysis

BACKGROUND

Esophageal foreign bodies are common around the world. Newer approaches, such as cap-assisted endoscopy, have been introduced as an alternative to conventional methods. Therefore, we performed a meta-analysis ono cap-assisted endoscopy versus conventional endoscopy for removal of esophageal foreign bodies.

AIM

To investigated the effectiveness of cap-assisted endoscopy with conventional endoscopy.

METHODS

An extensive literature search was performed (December 2021). For esophageal foreign body removal, cap-assisted endoscopy was compared to conventional endoscopy for procedure time, technical success of the procedure, time of foreign body retrieval, en bloc removal, and adverse event rate using odds ratio and mean difference.

RESULTS

Six studies met the inclusion criteria (n = 1305). Higher odds of technical success (P = 0.002) and en bloc removal (P < 0.01) and lower odds of adverse events (P = 0.02) and foreign body removal time (P < 0.01) were observed with cap-assisted endoscopy as compared to conventional techniques.

CONCLUSION

For esophageal foreign bodies, the technique of cap-assisted endoscopy demonstrated increased en bloc removal and technical success with decreased time and adverse events as compared to conventional techniques.

Transparent cap-assisted endoscopic retrieval of a sharp foreign body in the esophagus

We herein report an 80-year-old woman who accidentally ingested a sharp foreign body. Transparent cap-assisted endoscopy disclosed an impacted press-through package (PTP) in the upper esophagus. The PTP was grasped by the forceps, inserted into the cap, and removed carefully without complication. Ingestion of sharp-pointed foreign bodies has serious risks of gastrointestinal perforation and hemorrhage; therefore, emergent endoscopic removal has been recommended. Transparent cap-assisted endoscopy is a simple, safe, and effective method with a shorter procedure time and clearer visual field compared with conventional endoscopy. We wish to emphasize that this method has advantages and a potential to be used for endoscopic retrieval of small sharp foreign bodies.

Cap-assisted endoscopy for esophageal foreign bodies: A meta-analysis

BACKGROUND

Esophageal foreign bodies are common around the world. Newer approaches, such as cap-assisted endoscopy, have been introduced as an alternative to conventional methods. Therefore, we performed a meta-analysis ono cap-assisted endoscopy versus conventional endoscopy for removal of esophageal foreign bodies.

AIM

To investigated the effectiveness of cap-assisted endoscopy with conventional endoscopy.

METHODS

An extensive literature search was performed (December 2021). For esophageal foreign body removal, cap-assisted endoscopy was compared to conventional endoscopy for procedure time, technical success of the procedure, time of foreign body retrieval, en bloc removal, and adverse event rate using odds ratio and mean difference.

RESULTS

Six studies met the inclusion criteria (n = 1305). Higher odds of technical success (P = 0.002) and en bloc removal (P < 0.01) and lower odds of adverse events (P = 0.02) and foreign body removal time (P < 0.01) were observed with cap-assisted endoscopy as compared to conventional techniques.

CONCLUSION

For esophageal foreign bodies, the technique of cap-assisted endoscopy demonstrated increased en bloc removal and technical success with decreased time and adverse events as compared to conventional techniques.

A comparison of patients with neck abscesses caused by esophageal foreign body impaction vs. inflammatory disease: a retrospective study

OBJECTIVES

During clinical practice, we have detected a few cases of neck abscesses in patients diagnosed with esophageal foreign body impaction (EFB) but without the primary inflammatory disease. However, we do not know if neck abscesses caused by an inflammatory source are more like to be associated with a more severe progression or poorer prognosis. In this study, we aimed to identify differences between these two groups of patients by comparing progression and prognosis.

MATERIALS AND METHODS

We retrospectively reviewed all patients who underwent neck abscess incisions between January 2011 and March 2022 and divided these patients into two groups: an EFB group and an inflammation group. Data were described by percentages, means, and standard deviations (SDs). Fisher's precision probability test was used to compare differences between the EFB and inflammation groups. Categorical variables were analyzed by Pearson's Chi-squared test. In addition, three factors including hospital days, intensive care unit (ICU) stay, and drainage-tube removal time were used for multivariate analysis to identify independent correlations separately.

RESULTS

We enrolled a total of 33 patients with neck abscesses who received surgical incisions; the EFB group included 14 (42%) cases, while the inflammatory group included 19 (58%) cases. No significant differences were identified between the two groups in terms of surgery type (with or without mediastinotomy) and postoperative management (negative pressure drainage or postoperative irrigation). There were no significant differences between the two groups in terms of hospital stay, the timing of drainage-tube removal, the risk of ICU admission, and the probability of receiving intubation and tracheotomy. The incidence rate of esophageal perforation differed significantly between the two groups (p < 0.001). However, there were no significant differences in terms of other preoperative or postoperative comorbidities. The multivariate analysis revealed that the application of mediastinotomy (HR = 0.216 [0.049, 0.963]; p = 0.044) was correlated with a longer stay in the hospital. The time from symptoms to surgery was associated with a longer drainage tube removal time (HR = 0.392 [0.159, 0.967]; P = 0.042) and longer ICU stay (OR = 79.754[1.513, 4203.182]; P = 0.03).

CONCLUSION

Patients with neck abscesses associated with EFB and inflammation received the same therapeutic management, and there were no significant differences between these two groups in terms of prognosis. Furthermore, esophageal perforation was found to be irrelevant to the aggravation of neck abscesses, and there was no need for additional surgery to repair a perforated esophagus in patients with neck abscesses.

LEVEL OF EVIDENCE

Retrospective cohort (2b).

Cap-Assisted Endoscopic Esophageal Foreign Body Removal Is Safe and Efficacious Compared to Conventional Methods

INTRODUCTION

Esophageal foreign body impaction (FBI) is a commonly encountered gastrointestinal emergency requiring immediate intervention. Foreign bodies can be composed of food, commonly referred to as a "food bolus" (FB), or other matter (non-food). We aim to conduct systematic review and meta-analysis to compare cap-assisted and conventional endoscopic techniques for removal of esophageal FBI.

METHODS

A comprehensive search technique was utilized to identify studies that used capped endoscopic devices to remove FB or other esophageal foreign bodies. The primary outcomes were the technical success rate, rate of en bloc retrieval, and procedure time. Secondary outcomes were overall adverse events, bleeding, mucosal tears, and perforation.

RESULTS

Seven studies with a total of 1407 patients were included. The mean patient age was 55.3 (SD ± 7.2) years and 44.8% of patients were male. There were two RCTs and five observational studies among the included studies. The technical success rate was significantly higher in the cap-assisted group compared to the conventional group (OR 3.47, CI 1.68-7.168, I² = 0%, p =  < 0.001), as well as the en bloc retrieval rate (OR 26.90, CI 17.82-40.60, I² = 0%, p = 0.001). There was a trend towards lower procedural time for the cap-assisted group compared to the conventional group, although the difference did not reach statistical significance (MD - 10.997, CI - 22.78-0.786, I² = 99.9%, p = 0.06). The overall adverse events were significantly lower in the cap-assisted group compared to the conventional group (OR 0.118, CI 0.018-0.792, I² = 81.79%, p = 0.02).

CONCLUSION

The cap-assisted technique has improved efficacy and safety. To confirm these results, larger randomized trials are warranted.

Delayed Endoscopic Management of Esophageal Sharp-Pointed Food Impaction: An Analysis of 829 Cases in China

BACKGROUND

Esophageal foreign body impaction is the most common cause of endoscopic emergency. However, there are limited available data on delayed endoscopic management of esophageal sharp-pointed food impaction.

AIMS

To investigate cases of esophageal sharp-pointed food impaction with endoscopic removal findings.

METHODS

This single-center retrospective study collected medical records to identify patients with esophageal sharp-pointed food impaction who underwent endoscopic removal between April 2018 and April 2020. The patients were divided into the early (endoscopic removal <12 h) and delayed intervention (>12 h) cohorts.

RESULTS

Overall, 133 and 696 patients received early and delayed intervention, respectively. The success rate of endoscopic foreign body removal was 96.45%. The most common foreign body was fish bone (66.90%), and the most common shape was "I" (56.26%). Patients from the delayed intervention cohort received general anesthesia with a higher risk for perforation, and no foreign body was identified. The duration of endoscopy, distance between the foreign body/wound and the incisor, and longest diameter of the foreign body were not different between the groups. In multivariate analysis, male sex (odds ratio = 1.792 [1.159, 2.771]; P = 0.009), longer duration of impaction (odds ratio = 2.212 [1.121, 4.365]; P = 0.022) and endoscopy (odds ratio = 1.502 [1.253, 1.800]; P < 0.001), and longest diameter of the foreign body (odds ratio = 1.632 [1.329, 2.003]; P < 0.001) were associated with a higher incidence of perforation in patients with foreign body impaction.

CONCLUSIONS

Endoscopic removal is a safe and effective treatment method for sharp-pointed food impaction. Delayed endoscopic removal can increase the risk of esophageal perforation.

Zenker’s diverticulitis: a bitter pill to swallow

Acute oesophageal obstruction from food bolus impaction is often triggered by underlying oesophageal pathology, both benign and malignant. These can be readily detected with standard investigations such as oesophagoscopy or computed tomography. Zenker’s diverticulum (ZD) is a benign condition frequently presenting with chronic dysphagia or may be asymptomatic. We report the case of an 81-year-old man with a previously undiagnosed 1-cm ZD causing complete oesophageal obstruction secondary to localized oedema from an impacted ibuprofen tablet. Although initial clinical, endoscopic and radiological findings were equivocal and suspicious for upper oesophageal malignancy, symptoms rapidly settled in response to systemic corticosteroids. The diagnosis was later confirmed on barium swallow with no other clinical, radiological or histopathological abnormalities identified. In conclusion, ZD is an uncommon cause of acute oesophageal obstruction which may occur in diverticula of all sizes. Surgery should be performed in patients with recurrent symptoms or large diverticula.

Comparison of Cap-Assisted vs Conventional Endoscopic Technique for Management of Food Bolus Impaction in the Esophagus: Results of a Multicenter Randomized Controlled Trial

INTRODUCTION

"Push" or "pull" techniques with the use of snares, forceps, baskets, and grasping devices are conventionally used to manage esophageal food bolus impaction (FBI). A novel cap-assisted technique has recently been advocated to reduce time taken for food bolus (FB) removal. This study aimed to compare the effectiveness of the cap-assisted technique against conventional methods of esophageal FB removal in a randomized controlled trial.

METHODS

Consecutive patients with esophageal FBI requiring endoscopic removal, from 3 Australian tertiary hospitals between 2017 and 2019, were randomized to either the cap-assisted technique or the conventional technique. Primary outcomes were technical success and FB retrieval time. Secondary outcomes were technical success rate, en bloc removal rate, procedure-related complication, length of hospital stay, and cost of consumables.

RESULTS

Over 24 months, 342 patients with esophageal FBI were randomized to a cap-assisted (n = 171) or conventional (n = 171) technique. Compared with the conventional approach, the cap-assisted technique was associated with (i) shorter FB retrieval time (4.5 ± 0.5 minutes vs 21.7 ± 0.9 minutes, P < 0.001), (ii) shorter total procedure time (23.0 ± 0.6 minutes vs 47.0 ± 1.3 minutes, P < 0.0001), (iii) higher technical success rate (170/171 vs 160/171, P < 0.001), (iv) higher rate of en bloc removal (159/171 vs 48/171, P < 0.001), and (v) lower rate of procedure-related mucosal tear and bleeding (0/171 vs 13/171, P < 0.001). There were no major adverse events or deaths within 30 days in either group. The total cost of consumables was higher in the conventional group (A$19,644.90 vs A$6,239.90).

DISCUSSION

This multicenter randomized controlled trial confirmed that the cap-assisted technique is more effective and less costly than the conventional approach and should be first-line treatment for esophageal FBI.

Anorectal emergencies: WSES-AAST guidelines

Anorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome. This paper aims to improve the knowledge and the awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies.The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the WSES-AAST-WJES Consensus Conference on Anorectal Emergencies, and for each statement, a consensus among the WSES-AAST panel of experts was reached. We structured our work into seven main topics to cover the entire management of patients with anorectal emergencies and to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.

Retrospective observational analysis of esophageal foreign bodies: a novel characterization based on shape

This single-center retrospective study aims to investigate the clinical features of esophageal foreign bodies (EFBs) and determine the influence of EFB shapes on management and prognosis. A total of 427 patients aged 13 to 95 years with suspected EFB ingestion were enrolled between January 2013 and June 2018, 183 of whom were male. EFBs were divided into six shapes: pin (n = 161), sheet (n = 97), trident (n = 51), spindle (n = 66), irregular (n = 46), and sphere (n = 6). Spindle-shaped EFBs correlated with a significantly higher rate of perforation and severe complications (P < 0.001 and P = 0.021, respectively) than any other EFB shape, while sheet-shaped EFBs were linked to less severe complications (P = 0.006). The number of pressure points was provided to stratify the risk of poor prognosis for each shape. EFBs with only two pressure points (pin and spindle EFBs) required more advanced management strategies and were correlated with a higher number of patients suffering esophageal perforation (27.11%) and severe complications (12.44%) when compared with other shapes (χ² = 11.149 and P = 0.001; χ² = 5.901 and P = 0.015, respectively). Spindle shape was an independent risk factor for poor prognosis, and contributed a more clinical risk than the pin shape. In conclusion, clinical features, management, perforation rate, and severe complications differed based on EFB shape. The EFBs with two pressure points, especially the spindle-shaped EFBs, were more dangerous compared with those with more pressure points.

Role of endoscopic transparent cap in managing pediatric foreign bodies in the entrance of the esophagus in a waking state

Background

This study aims to investigate the effect and safety of a gastroscope plus transparent cap in treating pediatric foreign bodies in the entrance of the esophagus in a waking state.

Methods

A total of 47 pediatric cases with foreign bodies were randomly divided into two groups: transparent cap group (24 cases), and the control group (23 cases). In the former group, one transparent cap was first installed on top of the gastroscope. Then, the foreign body was extracted using the gastroscope with a transparent cap in a waking state. In the other group, the foreign body was extracted using a gastroscope without a transparent cap in a waking state. Then, the time of extracting the foreign body, the success rate of extracting the foreign body and complication rate were compared between these two groups.

Results

The time of extraction in the transparent cap group was 6.78±1.76 min, which was obviously shorter than that of the control group (11.41±4.12 min, P<0.05). In addition, the success rate of extraction in the former group (23/24, 95.8%) was higher than that of the latter group (17/23, 73.9%) (P<0.05), and local mucosal bleeding correlated with the endoscopic operation in the former group was lower than that of the latter group (P<0.05).

Conclusions

The use of a transparent cap could shorten the time of extraction and improve the success rate of extraction through a gastroscope in treating pediatric foreign bodies in the entrance of the esophagus in a waking state. This is an effective and safe treatment approach for pediatric foreign bodies in the entrance of the esophagus.

The evolution of treatment and complications of esophageal food impaction

Background

Esophageal food impaction is relatively common and increasing over time. Treatment ranges from medications to invasive endoscopic therapies. The endoscopic push technique has been advised against in favor of endoscopic retrieval for safety concerns. We sought to assess use patterns and safety of treatments for food impaction in a population-based retrospective review.

Methods

A database of recorded esophageal food impactions in Olmsted County, MN, USA, from 1975-2011 was reviewed for patient demographics, treatment, and complications.

Results

A total of 645 impactions occurred, with increasing incidence over time, peaking at 23.2 per year (2000-2004). Medications (almost exclusively glucagon) were successful in relieving impactions 34.5% of the time when trialed. Urgent endoscopy was common (74.0%), as was the need for endoscopic therapy (67.1%). Endoscopic therapy increased over time, with the endoscopic push technique becoming most common. Esophageal complications (deep mucosal injury or perforation) increased over time but remained rare (peak 11%). There was no difference in complications between push and retrieval techniques.

Conclusions

The endoscopic push technique is safe in comparison to endoscopic retrieval in esophageal food impactions. While complications surrounding impaction have increased, they remain rare. Medication trials are reasonable, as long as they do not delay endoscopy, and may prevent the need for emergent endoscopy in one-third of cases.

Esophageal Food Impaction: Causes, Elective Intubation, and Associated Adverse Events

GOALS

The goal of this study is to examine the causes, type of adverse events (AE), and effects of elective intubation in outcomes associated with esophageal food impaction (EFI).

BACKGROUND

EFI is a gastrointestinal emergency requiring immediate medical attention.

STUDY

Retrospective review of all EFI cases presenting at 3 large tertiary centers from October 1, 2011 to October 31, 2014 and all cases registered in the Clinical Outcome Research Initiative (CORI) database from January 1, 2000 to December 31, 2012. Statistical analysis compared health care utilization, AEs, and outcomes in patients with or without elective intubation.

RESULTS

A total of 214 cases presenting with EFI at our 3 referral hospitals and 4950 cases in the CORI database met inclusion criteria. Prevalence of structural disorders was similar in the Mayo Clinic and CORI datasets: 24.3% and 27.7% had strictures, and 3.8% and 2.5% had a tumor, respectively. AEs in the nonintubation group were 14.7% compared with 33.3% in the elective intubation group (P=0.003); however, 71.0% of these events were associated with EFI itself and not therapeutic procedure. Esophageal AEs were common (15.0%), followed by pulmonary and cardiovascular events with 3.0% and 1.4%, respectively. Severity of the AEs was influenced by the impaction-to-endoscopy time.

CONCLUSIONS

Prevalence of structural esophageal disorders was similar to previous smaller studies. Elective intubation was associated with increased AEs; however, this is felt to be because of the nature of EFI itself and not by therapeutic endoscopy. Prolonged impaction-to-endoscopy time was associated with severe AEs.

Early referral for endoscopy is the most appropriate management strategy in cases of food bolus obstruction

OBJECTIVE

To investigate the characteristics of patients presenting with oesophageal food bolus obstruction (FBO) who achieve early resolution of symptoms, and to assess the impact of medical therapies on the overall time course of FBO.

METHODS

A retrospective observational study was performed in a university teaching hospital with regional acute endoscopy services. Patients presenting with symptoms of FBO were identified through clinical coding and demographic, clinical and endoscopic data extracted from the electronic medical record. The primary outcome was the time to resolution defined as the earliest of symptom resolution, endoscopic or surgical intervention or discharge.

RESULTS

A total of 116 patients presented with symptoms of FBO. Twenty-seven (23.3%) had early resolution of symptoms and were discharged from the ED without acute endoscopy, the remainder were admitted for further management. Patients discharged from the ED presented to hospital sooner after the onset of symptoms (137 vs 288 min, P < 0.05), but did not differ from those admitted in any other characteristic. Seventy-one (61.2%) patients received medical therapy. There was no statistical difference in the time to resolution between those who received medical therapy and those who did not. Furthermore, the use of medical therapy was associated with a delay in referral for endoscopy (140 vs 100 min, P < 0.05).

CONCLUSIONS

Time from symptom onset to presentation is the only predictor of early resolution from FBO, while medical therapy is ineffective in relieving obstruction and may delay definitive therapy. We recommend the use of an institutional management plan to facilitate early access to endoscopy in cases of FBO.

Foreign body embedded in the lower esophageal wall located by endoscopic ultrasonography: A case report

RATIONALE

Ingested esophageal foreign bodies are commonly seen in adult population. In very few instances, esophageal foreign body may pass through the mucosal surface, re-epithelialize or migrate into surrounding soft tissues.

PATIENT CONCERNS

A 55-year-old Chinese male was admitted to our hospital with a 10-day history chest and upper abdominal pain without dysphasia, cough or other symptoms.

DIAGNOSES

We initially suspected chronic gastritis, and thoracic computed tomography and endoscopy ultrasonography (EUS) were used to identify a fish bone completely embedded within the lower esophageal wall.

INTERVENTIONS

Under the EUS-guidance, we marked the foreign body using methylene blue with saline solution, which was followed by successful thoracoscopy and surgical removed of the foreign body.

OUTCOMES

The patient recovered well and was discharged 1 week postoperatively. One month postoperatively, the patient was symptom free and the chest wound was complete healed.

LESSONS

Our case showed that computed tomography is necessary to diagnose the esophageal foreign body, and EUS may help confirm the position of foreign body, especially those embedded in the esophageal submucosa. We advocate necessary surgery at the first accurate diagnosis in patient with esophageal foreign body when endoscopy is not possible.

Safety and Efficacy of the Push Endoscopic Technique in the Management of Esophageal Food Bolus Impactions in Children

OBJECTIVES

Adult-based guidelines support the use of the pull (extraction) endoscopic technique in managing esophageal food bolus impactions (FBIs) but allow the consideration of the push (advancement) technique with caution based on available published literature. The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition guidelines mention the use of gentle endoscopic pushing for disimpaction but elaborate that this technique has not been studied in children. Our study aimed at assessing the safety and efficacy of the push technique in managing pediatric esophageal FBIs.

METHODS

This was a retrospective cohort study of all pediatric patients presenting with esophageal FBIs to a pediatric tertiary care center from 2003 to 2016.

RESULTS

Two hundred forty-two procedures for esophageal foreign body removal were reviewed. Thirty-nine procedures for managing esophageal FBIs were included in a total of 23 patients (1-4 procedures per patient). The most common underlying diagnoses were eosinophilic esophagitis and repaired tracheoesophageal fistula. The cohort had a median age of 8 years and median weight of 34.4 kg. Initial endoscopic disimpaction methods included 20 push and 19 pull technique attempts with success rates of 65% and 68%, respectively (P = 1.0). Unsuccessful attempts using 1 technique were successfully accomplished using the other technique. Patients initially managed by either of the 2 disimpaction techniques did not differ in age, weight, sex, or underlying diagnoses. No procedure-related complications were reported at our center.

CONCLUSION

The present study shows that the push technique is as safe and effective as the pull technique in managing esophageal FBIs in pediatric patients.

Esophageal foreign body ingestion in adults on weekdays and holidays: A retrospective study of 1058 patients

The purpose of this study is to compare the clinicopathological characteristics and outcomes of esophageal foreign body (FB) ingestion in adults between weekdays and holidays. This is a retrospective study including 1058 patients with esophageal FB ingestion from 2012 to 2016. Patient characteristics, the types and locations of FB, and clinical outcomes were compared between patients on weekdays and holidays. Furthermore, independent risk factors of complication on weekdays and holidays respectively were evaluated. The locations of FB, underlying diseases, and complications significantly differed between weekdays and holidays groups, while no difference was found in the types of FB. Patients got higher percentage of erosion complication on holidays than that on weekdays (60.8% vs 47.6%, P < .0001). Multivariate logistic regression analysis revealed that jujube shell was a significant predictor of complication on weekdays (P < .001). However, complication was significantly associated with nonfood bolus FB ingestion on holidays (P < .001). Our data suggest that there were different clinicopathological characteristics of FB ingestion between weekdays and holidays, and more patients got complications on holidays. On holidays, a latex protector hood or an overtube should be applied to patients who swallowed nonfood bolus in order to reduce esophageal mucosal damage.

Two Cases of Colonoscopic Retrieval of a Foreign Body in Children: A Button Battery and an Open Safety Pin

Ingestion of foreign body in children is a relatively common problem among paediatric population. The foreign bodies mostly pass spontaneously through the gastrointestinal tract. However, complications can occur according to its anatomical location, the characteristics of the foreign body, and delays in management. Although the cases of ingested button batteries or sharp objects impacted at the gastrointestinal tract can be very serious, there have been very only a few cases have reported colonoscopic removal of these dangerous foreign bodies in adults, and there have been no case reports in children. We report one case of a button battery and one case of an open safety pin, both impacted in the terminal ileum that had moved from the stomach within a few hours of ingestion and were eventually managed by colonoscopy without any complications.

Diagnosis and Management of a Postpyloric Foreign Body Causing Small Bowel Obstruction in an Infant

Foreign body ingestion is a common occurrence in the pediatric population and most ingestions resolve with little morbidity. Although radiopaque objects are easily identified on biplane radiographs, radiolucent objects may elude detection, delaying diagnosis. We report a case of a healthy 10-month-old infant who presented with a 5-day history of postprandial vomiting and imaging consistent with small bowel obstruction. On exploratory laparotomy, she was discovered to have a postpyloric foreign body requiring removal through an enterotomy.

A dental nightmare, resolved: what a radiologist needs to know when consulted about ingestion of dental foreign body material

Ingestion of dental foreign bodies, while relatively rare, may cause serious, and occasionally fatal, injuries to the airways and gastrointestinal tract. Numerous case reports are available describing the clinical course of such ingestions. The aim of this paper is to develop concise, practical recommendations to aid radiologists in providing clinically relevant diagnostic information, thereby accelerating detection and management of acute ingestion of dental material.

Prevalence of eosinophilic oesophagitis in adults presenting with oesophageal food bolus obstruction

AIM: To look at the relationship between eosinophilic oesophagitis (EO) and food bolus impaction in adults.

METHODS: We retrospectively analysed medical records of 100 consecutive patients who presented to our hospital with oesophageal food bolus obstruction (FBO) between 2012 and 2014. In this cohort, 96 were adults (64% male), and 4 paediatric patients were excluded from the analysis as our centre did not have paediatric gastroenterologists. Eighty-five adult patients underwent emergency gastroscopy. The food bolus was either advanced into the stomach using the push technique or retrieved using a standard retrieval net. Biopsies were obtained in 51 patients from the proximal and distal parts of the oesophagus at initial gastroscopy. All biopsy specimens were assessed and reviewed by dedicated gastrointestinal pathologists at the Department of Pathology, University Hospital Geelong. The diagnosis of EO was defined and established by the presence of the following histological features: (1) peak eosinophil counts > 20/hpf; (2) eosinophil microabscess; (3) superficial layering of eosinophils; (4) extracellular eosinophil granules; (5) basal cell hyperplasia; (6) dilated intercellular spaces; and (7) subepithelial or lamina propria fibrosis. The histology results of the biopsy specimens were accessed from the pathology database of the hospital and recorded for analysis.

RESULTS: Our cohort had a median age of 60. Seventeen/51 (33%) patients had evidence of EO on biopsy findings. The majority of patients with EO were male (71%). Classical endoscopic features of oesophageal rings, furrows or white plaques and exudates were found in 59% of patients with EO. Previous episodes of FBO were present in 12/17 patients and 41% had a history of eczema, hay fever or asthma. Reflux oesophagitis and benign strictures were found in 20/34 patients who did not have biopsies.

CONCLUSION: EO is present in approximately one third of patients who are admitted with FBO. Biopsies should be performed routinely at index endoscopy in order to pursue this treatable cause of long term morbidity.

Endoscopic Management of Foreign Bodies in the Upper Gastrointestinal Tract: An Evidence-Based Review Article

Gastrointestinal foreign bodies (FB) are comprised of food bolus impaction and intentionally or unintentionally ingested or inserted true FB. Food bolus impaction and true FB ingestion represent a recurrent problem and a true challenge in gastrointestinal endoscopy. More than 80-90% of the ingested true FB will pass spontaneously through the gastrointestinal tract without complications. However, in 10-20% of the cases an endoscopic intervention is deemed necessary. True FB ingestion has its greatest incidence in children, psychiatric patients and prisoners. On the other hand, food bolus impaction typically occurs in the elderly population with an underlying esophageal pathology. The most serious situations, with higher rates of complications, are associated with prolonged esophageal impaction, ingestion of sharp and long objects, button batteries and magnets. Physicians should recognize early alarm symptoms, such as complete dysphagia, distressed patients not able to manage secretions, or clinical signs of perforation. Although many papers are yearly published regarding this subject, our knowledge is mainly based on case-reports and retrospective series. Herein, the authors summarize the existing evidence and propose an algorithm for the best approach to FB ingestion.

Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee

Foreign body ingestions in children are some of the most challenging clinical scenarios facing pediatric gastroenterologists. Determining the indications and timing for intervention requires assessment of patient size, type of object ingested, location, clinical symptoms, time since ingestion, and myriad other factors. Often the easiest and least anxiety-producing decision is the one to proceed to endoscopic removal, instead of observation alone. Because of variability in pediatric patient size, there are less firm guidelines available to determine which type of object will safely pass, as opposed to the clearer guidelines in the adult population. In addition, the imprecise nature of the histories often leaves the clinician to question the timing and nature of the ingestion. Furthermore, changes in the types of ingestions encountered, specifically button batteries and high-powered magnet ingestions, create an even greater potential for severe morbidity and mortality among children. As a result, clinical guidelines regarding management of these ingestions in children remain varied and sporadic, with little in the way of prospective data to guide their development. An expert panel of pediatric endoscopists was convened and produced the present article that outlines practical clinical approaches to the pediatric patient with a variety of foreign body ingestions. This guideline is intended as an educational tool that may help inform pediatric endoscopists in managing foreign body ingestions in children. Medical decision making, however, remains a complex process requiring integration of clinical data beyond the scope of these guidelines. These guidelines should therefore not be considered to be a rule or to be establishing a legal standard of care. Caregivers may well choose a course of action outside of those represented in these guidelines because of specific patient circumstances. Furthermore, additional clinical studies may be necessary to clarify aspects based on expert opinion instead of published data. Thus, these guidelines may be revised as needed to account for new data, changes in clinical practice, or availability of new technology.

Endoscopic foreign body removal in the upper gastrointestinal tract: risk factors predicting conversion to surgery

BACKGROUND/AIMS

Most foreign bodies of the upper gastrointestinal tract (UGIT) are successfully removed by endoscopic techniques without complications. However, some require conversion to surgery due to failure of endoscopic removal. The aim of this study was to analyze the risk factors predicting the need to convert to surgery after inability to endoscopically remove the foreign body.

PATIENTS AND METHODS

The medical records of 885 patients treated between January 2006 and March 2014 for suspected foreign bodies in the UGIT were retrospectively reviewed. Patient characteristics, the type of foreign bodies, clinical outcomes, and risk factors predicting the conversion to surgery were analyzed.

RESULTS

While endoscopic removal was successful in 94.7% (665/702) of the patients, the remaining 5.3% (37/702) needed conversion to surgery. There were no procedure-related deaths. According to the multivariate logistic regression analyses, older age (>70 years, p = 0.004), location (upper esophagus, p = 0.001), larger size (maximal diameter > 30 mm, p = 0.005), and longer impaction time (>40 h, p < 0.001) were significant risk factors predicting conversion to surgery due to inability to remove the foreign body endoscopically.

CONCLUSIONS

Most of the foreign bodies in the UGIT were successfully removed by endoscopic techniques. However, surgical removal might need to be considered in patients with age >70 years, and those with foreign bodies in the upper esophagus, maximal diameter >30 mm, and impaction time >40 h, due to the possible high failure rate of endoscopic removal.

Foreign bodies and caustic lesions

Foreign body ingestions, food bolus impactions, and caustic agent injuries are frequent but specific situations. Although most foreign bodies will naturally pass through the digestive tract, practitioners should recognize specific situations were endoscopic management is required. In such cases, timing and adequate equipment are critical. Endoscopic treatment is successful in about 95% of patients. Severe complications (including oesophageal perforations) are rare. Underlying diseases (including eosinophilic oesophagitis) must be investigated after food bolus impaction. Accidental or suicidal ingestion of corrosive agents may result in severe upper gastrointestinal tract injuries requiring a multidisciplinary approach including gastroenterologists, surgeons, otorhynolaryngologists, anaesthesiologists and psychiatrists. Treatment includes conservative management of patients with mild injuries, while patients with severe injuries undergo emergency surgical exploration. At distance of the ingestion episode, oesophageal reconstruction is required in patients who underwent oesophageal resection and in patients who developed oesophageal strictures that failed dilatation.