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

Endoscopic removal of esophageal foreign body and endoscopic closure of its associated perforation with early mediastinitis

A 55-year-old male swallowed fish bone accidentally and subsequently developed retrosternal pain. He underwent chest computed tomography at his local hospital on October 23, 2023, showing esophageal foreign body with suspected esophageal rupture. One day later, he underwent endoscopy at our department, showing a fish bone penetrated into the esophageal wall. After consultation with cardiothoracic surgeons, endoscopy-guided removal of this foreign body was performed under anesthesia. An esophageal ulcer with a length of 2cm was left with overflowing air bubbles, and was closed by three metal clips. Two days later, retrosternal pain disappeared. A tube was intubated to duodenal distal segment under endoscopy, via which enteral nutritional suspension was given. Then, he was discharged.

Postendoscopy Care for Patients Presenting With Esophageal Food Bolus Impaction: A Population-Based Multicenter Cohort Study

INTRODUCTION

Esophageal food bolus impactions (FBI) are a common gastrointestinal emergency. Appropriate management includes not only index endoscopy for disimpaction but also medical follow-up and treatment for the underlying esophageal pathology. We evaluated the appropriateness of postendoscopy care for patients with FBI and assessed patient-related, physician-related, and system-related factors that may contribute to loss to follow-up.

METHODS

We conducted a retrospective, population-based, multicenter cohort study of all adult patients undergoing endoscopy for FBI in the Calgary Health Zone, Canada, from 2016 to 2018. Appropriate postendoscopy care was defined by a composite of a clinical or endoscopic follow-up visit, appropriate investigations (e.g., manometry), or therapy (e.g., proton-pump inhibitors or endoscopic dilation). Predictors of inappropriate care were assessed using multivariable logistic regression.

RESULTS

A total of 519 patients underwent endoscopy for FBI: 25.2% (131/519) did not receive appropriate postendoscopy care. Half of the patients (55.3%, 287/519) underwent follow-up endoscopy or attended clinic, and among this group, 22.3% (64/287) had a change in their initial diagnosis after follow-up, including 3 new cases of esophageal cancer. Patients in whom a suspected underlying esophageal pathology was not identified at the index endoscopy were 7-fold (adjusted odds ratio 7.28, 95% confidence interval 4.49-11.78, P < 0.001) more likely to receive inappropriate postendoscopy follow-up and treatment, even after adjusting for age, sex, rural residence, timing of endoscopy, weekend presentation, and endoscopic interventions.

DISCUSSION

One-quarter of patients presenting with an FBI do not receive appropriate postendoscopy care. This is strongly associated with failure to identify a potential underlying pathology at index presentation.

An unusual etiology of acute intestinal occlusion: The swallowed missing dentures a case reports and literature review

INTRODUCTION

Denture swallowing is an uncommon incident. However, it should be suspected in edentulous elderly patients who wear removable dentures which are poorly cared for and maintain. The existence of neuro-psychiatric disorders may contribute to the occurrence of this adverse event.

CASE PRESENTATION

We report the case of an 85-years-old woman admitted to emergency with acute intestinal occlusion. The investigations concluded that the bowel was obstructed by a foreign body blocked in the terminal ileum. There was a high suspicion that his dental prosthesis had been swallowed. Removal of the dental prosthesis was achieved surgically after laparotomy.

DISCUSSION

Foreign bodies in the esophagus could be responsible of a variety of symptoms, including dysphagia, airway obstruction and even perforation. In the gastrointestinal tract foreign bodies may be responsible of fewer specific symptoms, including abdominal pain, melena or perforation. The blockage will occur in anatomical strictures. At the most appropriate situations, removal should be performed through endoscopy, although in case of failure of procedure or complication, surgery will be unavoidable.

CONCLUSION

Ingestion of a dental or other foreign object is a clinical condition that is more common in pediatric populations, but is very rare in healthy individuals. Denture swallowing is insidious in itself and may lead to a complicated course, if not properly managed. Although most of these can be conservative, careful monitoring is necessary to avoid such adverse event.

Comparable Efficacy for Push Versus Pull Technique in Esophageal Food Impaction: Systematic Review with Meta-Analysis

BACKGROUND

Esophageal food impaction (EFI) is a common GI emergency. Push and pull methods are used currently for EFI retrieval. We aim to review current available literature to compare success rates and evaluate adverse event rates of the two techniques.

METHODS

A comprehensive literature search was performed using MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science Core Collection, KCI-Korean Journal Index, SciELO and Global Index Medicus. Odds ratio (OR) with 95% confidence interval (CI) was calculated when comparing the dichotomous variables. We aimed to evaluate technical success and adverse events for EFI comparing push and pull technique on single arm and comparator analysis.

RESULTS

The search strategy yielded a total of 126 articles. 18 studies with 3528 participants were included. The technical success rate was 97.5% (CI 96.6-99.2%) in the push and 88.4% (CI 72.8-98.7%) in the pull technique with no statistical difference on comparator analysis. Overall rate of adverse events was 4.03% (CI 0.9-5.0%) in the push technique and 2.22% (CI 0-2.9%) in the pull technique with no statistical difference on comparator analysis (OR 95% CI 0.464-2.782, p = 0.78, I² = 31.54%). There was no statistical difference between rate of lacerations and perforations either between the two techniques.

CONCLUSION

Both techniques have acceptable clinical outcomes which appear within standard of care. Operator experience and individual clinical scenarios should guide decision-making regarding technique selection.

Decision-To-Scope Score: A novel tool with excellent accuracy in predicting foreign bodies in the esophagus

INTRODUCTION

Foreign body (FB) ingestion is a common indication for urgent esophagogastroduodenoscopy (EGD). Nevertheless, most pass spontaneously through the gastrointestinal (GI) tract. Differently from GI bleeding, there is no validated score aiming to identify "low-risk" patients in suspected FB ingestion. We aimed to create a score able to discriminate patients who are candidates to emergent EGD in this scenario.

METHODS

Retrospective study of consecutive patients admitted for suspected FB in the upper GI tract between 2016 and 2021. The evaluated outcome was endoscopic confirmation of FB in the esophagus. Variables significantly associated with the outcome on multivariate analysis were computed into a score predicting endoscopic confirmation.

RESULTS

We included 228 patients. From these, 97 (42.5%) had a confirmed FB in EGD. Time since ingestion <6 h (OR = 4.0; P = 0.042), absence of any meal after FB ingestion (OR = 7.1; P = 0.005), dysphagia (OR = 11.8; P < 0.001), odynophagia (OR = 4.6; P = 0.004), and drooling (OR = 15.1; P < 0.001) were independent predictors of confirmed FB. These variables were used to compute a FB predicting score-the Decision-To-Scope (DTS) Score: time since ingestion <6 h (+1 point), absence of meals (+2 points), dysphagia (+3 points), odynophagia (+1 point), and drooling (+4 points). DTS-Score had excellent accuracy to predict the outcome (AUC = 0.953; 95%CI = 0.928-0.977; P < 0.001). The optimal cutoff to identify low-risk patients was a score ≤5 (sensitivity 85.0% and specificity 94.7%).

CONCLUSIONS

More than half of the suspected FB were not confirmed by EGD. The DTS-Score presented excellent accuracy at stratifying patients' risk and may contribute to the decision to perform emergent EGD in suspected FB ingestion.

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.

Colonic Perforation: A Case Report of a Rare Delayed Complication Due to Accidental Swallowing of Denture

Removable partial dentures are the most common object found in elderly patients presenting with a history of foreign body ingestion. These patients will usually present within a week with complications if the foreign body gets impacted in the gastrointestinal tract. In this case report, we present a rare delayed complication in the form of colonic perforation that presented three years after swallowing a denture, with the emphasis on how to suspect and manage these patients.

Accidentally Swallowing a Toothbrush in a Patient during a Vomiting Attempt: Literature Review and Case Report

Swallowing a whole toothbrush is a rare event. As of today, no case described has documented that the foreign body has passed through the entire gastrointestinal tract and has been spontaneously eliminated. Places where it is most frequently retained have been described. Only in one single case described did the foreign body reach the colon. We describe the main injuries caused by this foreign body, and the most common correct therapeutic approach for solving the problem. The third case in the literature is presented, with diagnosis and treatment of a woman who, in an attempt to induce vomiting, swallowed a toothbrush which became lodged in her stomach. The patient, at the time of the examination, only showed abdominal pain and anxiety.

Endoscopic Retrieval of Ingested Foreign Bodies: A Single Surgeon Experience

Introduction

Foreign body (FB) ingestion either accidental or intentional is a common clinical scenario encountered by general surgeons. This article reports a single surgeon's experience of endoscopic retrieval of foreign bodies from the upper gastrointestinal (UGI) tract.

Methods

A retrospective analysis of data of all the patients who underwent endoscopic management for foreign body removal by a single surgeon in a tertiary care hospital in southern India between 2015 and 2020 was conducted. Patient variables in terms of age, sex, type of foreign body, its location in the gastrointestinal (GI) tract, the time between ingestion and presentation, the time between presentation and endoscopy, treatment outcomes were reviewed.

Results

A total of 97 patients were studied. The age range of the patients studied was one month to 71 years. Males were predominant (n=64, 65.97%). The most common retrieved foreign body were coins (n=31, 31.9%). The most common site of foreign body lodgment was the esophagus (n=75, 77.31%), with the upper third esophagus (n=38; 39.37%) being the predominant site. The success rate of endoscopic retrieval in our study was 97%. No procedure-related complications were encountered in any patient. Endoscopic management failed in two patients who ultimately required surgical intervention.

Conclusion

Endoscopic retrieval of foreign bodies in the UGI tract is a safe and effective modality. Early endoscopy in such patients avoids surgical intervention and reduces morbidity.

A double-scope technique enabled a patient with an esophageal plastic fork foreign body to avoid surgery: a case report and review of the literature

Foreign body ingestion is a common problem, and endoscopic removal is often performed with ancillary equipment. However, long, sharp foreign bodies are much more difficult to remove endoscopically than other objects and require emergent surgery. A 68-year-old man with a history of distal gastrectomy accidentally swallowed a plastic fork. He complained of chest pain at the visit. The plastic fork was located between the thoracic esophagus and remnant stomach. Endoscopic removal of the plastic fork was considered difficult, and surgery was deemed necessary. However, we were able to avoid surgery to remove the object using two endoscopes with hoods and a polypectomy snare. The first endoscope covered the sharp edge with a hood, and the snare grasped the neck of the plastic fork. The second endoscope covered the remaining sharp tip. A single operator held the two endoscopes and the snare and pulled them out together. This new double-scope technique is simple and useful for removing long, sharp foreign bodies, such as forks, from the esophagus.

Complication rates in emergent endoscopy for foreign bodies under different sedation modalities: A large single-center retrospective review

BACKGROUND

Foreign object ingestion (FOI) and food bolus impaction (FBI) are common causes of emergent endoscopic intervention. The choice of sedation used is often dictated by physician experience. Many endoscopists frequently prefer to use monitored anesthesia care (MAC) and general anesthesia (GA) as opposed to conscious sedation (CS) due to the concern for inadequate airway protection. However, there is insufficient data examining the safety of different sedation modalities in emergent endoscopic management of FOI and FBI.

AIM

To investigate the complication rates of emergent endoscopic extraction performed under different sedation modalities.

METHODS

We conducted a retrospective chart review of patients presenting with acute FBI and FOI between 2010 and 2018 in two hospitals. A standardized questionnaire was utilized to collect data on demographics, endoscopic details, sedation practices, hospital stay and adverse events. Complications recognized during and within 24 h of the procedure were considered early, whereas patients presenting with a procedure-related adverse event within two weeks of the index event were considered delayed complications. Complication rates of patients who underwent emergent endoscopic retrieval were compared based on sedation types, namely CS, MAC and GA. Chi-square analysis and multiple logistic regression were used to compare complication rate based on sedation type.

RESULTS

Among the 929 procedures analyzed, 353 procedures (38.0%) were performed under CS, 278 procedures (29.9%) under MAC and the rest (32.1%) under GA. The median age of the subjects was 52 years old, with 57.4% being male. The majority of the procedures (64.3%) were FBI with the rest being FOI (35.7%). A total of 132 subjects (14.2%) had chronic comorbidities while 29.0% had psychiatric disorders. The most commonly observed early complications were mucosal laceration (3.8%) and bleeding (2.6%). The most common delayed complication was aspiration pneumonia (1.8%). A total of 20 patients (5.6%) could not adequately be sedated with CS and had to be converted to MAC or GA. Patient sedated with MAC and GA were more likely to require hospitalization, P < 0.0001. Analysis revealed no statistically significant difference in the complication rate between patients sedated under CS (14.7%), MAC (14.7%) and GA (19.5%), P = 0.19.

CONCLUSION

For patients who present with FOI or FBI and undergo emergent endoscopic treatment, there is no significant difference in adverse event rates between CS, MAC and GA.

Food bolus and oesophageal foreign body: a summary of the evidence and proposed management process

PURPOSE

Food bolus and oesophageal foreign bodies are a common presentation that may be managed by otolaryngologists, gastroenterologists, acute medicine physicians and accident and emergency. The condition is highly variable with presentations ranging from well patients whose obstruction spontaneously passes to peri-arrest with severe aspiration or impending airway compromise. Management of this condition is heterogeneous and often depends on the specialty the patient is originally admitted under. There exist European and American guidelines from the perspective of gastroenterology, but there are no UK-based guidelines and limited consideration of the role of the otolaryngologists and rigid oesophagoscopy.

METHODS

An extensive literature search was carried out to generate conclusions on key management questions for food bolus and oesophageal foreign bodies. This was then summarised into both a written summary of the evidence and a graphical decision tree.

RESULTS

This paper is a review article and presents conclusions regarding management options for food bolus and oesophageal foreign bodies.

CONCLUSION

This article considers the current evidence surrounding investigation and management of oesophageal food bolus and foreign body. It draws conclusions regarding presentation, investigation and subsequent operative treatment. As part of this process, we propose a graphical decision tree to assist in management decisions.

Individualized endoscopic management strategy for impacting jujube pits in the upper gastrointestinal tract: a 3-year single-center experience in northern China

Background

Impaction of jujube pits in the upper gastrointestinal (GI) tract is a special clinical condition in the northern Chinese population. Endoscopic removal is the preferred therapy, but there is no consensus on the management strategies. We reported our individualized endoscopic strategies on the jujube pits impacted in the upper GI tract.

Methods

In this retrospective study, we included 191 patients (male: 57; female: 134) who presented to our hospital with ingestion of jujube pits between January 2015 and December 2017. Demographic information, times of hospital visiting, locations of jujube pits, endoscopic procedures, post-extraction endoscopic characteristics were analyzed. Management strategies including sufficient suction, repeated irrigation, jejunal nutrition and gastrointestinal decompression were given based on post-extraction endoscopic characteristics and impacted locations.

Results

Peak incidence was in the second quarter of each year (85/191 cases, 44.5%). Among the 191 cases, 169 (88.5%) showed pits impaction in the esophagus, 20 (10.5%) in the prepyloric region and 2 (1.0%) in the duodenal bulb. A total of 185 patients (96.9%) had pits removed with alligator jaw forceps, and 6 (3.1%) underwent suction removal with transparent caps placed over the end of the endoscope to prevent injury on removal of these pits with two sharp painted edges. Post-extraction endoscopic manifestations included mucosal erosion (26.7%), mucosa laceration (24.6%), ulceration with a white coating (18.9%) and penetrating trauma with pus cavity formation (29.8%). All patients received individualized endoscopic and subsequent management strategies and showed good outcomes.

Conclusions

Individualized endoscopic management for impacted jujube pits in the upper GI tract based on post-extraction endoscopic characteristics and impacted locations was safe, effective, and minimally invasive.

The pressure effects of different commercially available beverages on food boluses in vitro

PURPOSE

Acute oesophageal food impaction is a common and potentially life-threatening condition. Effervescent agents have been used to manage these patients. To date, there have not been any studies comparing the differences in commercially available beverages in relieving food bolus impaction. The aim of this study was to design an in vitro system where the pressure changes generated by different commercially available beverages could be compared in the presence of different food items.

METHODS

A closed in vitro system was designed using a flask and manometer. Different food items [potato, beef, chicken, and no food item (control)] and different beverages (Coca-Cola®, lemonade, 7 Up Free, Prosecco and water) were inserted into this system in turn. For each food item and beverage, pressure changes (cmH₂O) were recorded over a 3-min period.

RESULTS

Comparing the different food items, the potato appeared to cause the greatest increases in pressure over most time points with all beverages except Coca-Cola® and water. Between the beverages, the lemonade and Prosecco seemed to generate the greatest pressure changes; lemonade generating higher (but non-significant) pressures than the Prosecco with the potato and control.

CONCLUSION

Our study demonstrates that, in vitro, amongst the beverages, lemonade and Prosecco generated the greatest increases in pressure, whilst potatoes generated a greater reaction than the other food items. These findings need to be studied in further detail and, if deemed clinically relevant, may prompt further investigation for their use in the clinical setting.

Duodenal obstruction due to accidental swallowing of a dental prosthesis: a case report and review of the literature

BACKGROUND

Artificial dentures are the most common object ingested by elderly patients and account for 4-18% of all foreign body ingestions. Denture impaction in the small bowel is a rare phenomenon. Surgery of the duodenum is difficult, so endoscopy should be the first choice in these patients. There are very rare case reports on denture ingestion-induced duodenal obstruction or perforation, so the aim of this publication was to show a rare case of accidental ingestion of a dental prosthesis with duodenal obstruction and also perforation that could not be treated with endoscopic management and was managed with duodenal kocherization and gastrostomy.

CASE PRESENTATION

A 47-year-old Iranian woman presented to our hospital with epigastric abdominal pain of 2 hours' duration after the accidental ingestion of a dental prosthesis 2 days before admission. The patient had severe epigastric tenderness. Radiographic examination revealed nothing. Upper gastrointestinal endoscopy showed a swallowed lodged denture in the second to third parts of the duodenum, and the attempt to extract the denture failed. The patient underwent laparotomy and duodenal kocherization, pushing the denture to the stomach, and gastrostomy, and the denture was brought out without any complications.

CONCLUSIONS

Patients with old and worn dentures should have their prosthesis reconstructed and redesigned periodically in order to prevent denture ingestion and its complications. Early surgical intervention is recommended in patients with failed endoscopic extraction of foreign bodies and in those with duodenal perforation.

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.

Cap-Assisted Technique versus Conventional Methods for Esophageal Food Bolus Extraction: A Comparative Study

BACKGROUND/AIMS

Food bolus impaction is the most common form of esophageal foreign body impaction observed in adults. Clinical guidelines recommend using the push technique or retrieval methods in such cases. The push technique can cause injuries in certain clinical situations. Notably, conventional retrieval methods are time and effort consuming. Cap-assisted endoscopic extraction of an impacted food bolus is an easy and effective technique; however, more data are needed for its validation. This study compared the capassisted extraction technique with conventional methods.

METHODS

This prospective observational multicenter study compared the success and en bloc removal rates, total procedure time, and adverse events in both techniques..

RESULTS

The study included 303 patients who underwent food bolus extraction. The push technique was used in 87 patients (28.7%) and a retrieval procedure in 216 patients (71.3%). Cap-assisted extraction was performed in 106 patients and retrieval using conventional methods in 110 patients. The cap-assisted technique was associated with a higher rate of en bloc removal (80.2% vs. 15%, p<0.01), shorter procedure time (6.9±3.5 min vs. 15.7±4.1 min, p<0.001), and fewer adverse events (0/106 vs. 9/110, p<0.001).

CONCLUSION

Cap-assisted extraction showed no adverse events, higher efficacy, and a shorter procedure time compared with conventional retrieval procedures.

Esophageal Foreign Bodies and Obstruction in the Emergency Department Setting: An Evidence-Based Review

BACKGROUND

Patients with esophageal foreign bodies or food bolus impaction may present to the emergency department with symptoms ranging from mild discomfort to severe distress. There is a dearth of emergency medicine-focused literature concerning these conditions.

OBJECTIVE OF THE REVIEW

This narrative review provides evidence-based recommendations for the assessment and management of patients with esophageal foreign bodies and food bolus impactions.

DISCUSSION

Esophageal foreign bodies and food bolus impaction are common but typically pass spontaneously; however, complete obstruction can lead to inability to tolerate secretions, airway compromise, and death. Pediatric patients are the most common population affected, while in adults, edentulous patients are at greatest risk. Foreign body obstruction and food bolus impaction typically occur at sites of narrowing due to underlying esophageal pathology. Diagnosis is based on history and examination, with most patients presenting with choking/gagging, vomiting, and dysphagia/odynophagia. The preferred test is a plain chest radiograph, although this is not required if the clinician suspects non-bony food bolus with no suspicion of perforation. Computed tomography is recommended if radiograph is limited or there are concerns for perforation. Management requires initial assessment of the patient's airway. Medications evaluated include effervescent agents, glucagon, calcium channel blockers, benzodiazepines, nitrates, and others, but their efficacy is poor. Before administration, shared decision making with the patient is recommended. Endoscopy is the intervention of choice, and medications should not delay endoscopy. Early endoscopy for complete obstruction is associated with improved outcomes.

CONCLUSIONS

This review provides evidence-based recommendations concerning these conditions, focusing on evaluation and management.

Foreign Body Removal in Children Using Foley Catheter or Magnet Tube from Gastrointestinal Tract

Foreign body (FB) ingestion of children is a common pediatric emergency requiring medical attention. Pediatric emergency physicians and gastroenterologists often encounter nervous and distressed situations, because of children presenting with this condition in the common clinical practice. When determining the appropriate timing and indications for intervention, physicians should consider multiple patient- and FB-related factors. The utilization of a flexible endoscopy is considered safe and effective to use in these cases, with a high success rate, for the effective extraction of FBs from the gastrointestinal tract of a child. Additionally, a Foley catheter and a magnet-attached Levin tube have been used for decades in the case of FB removal. Although their use has decreased significantly in recent times, these instruments continue to be used for several indications. Using a Foley catheter for this purpose does not require special training and does not necessarily require sedation of the patient or fluoroscopy, which serve as advantages of utilizing this method for foreign object retrieval. An ingested magnet or iron-containing FB can be retrieved using a magnet-attached tube, and can be effective to retrieve an object from any section of the upper gastrointestinal tract that can be reached. Simple and inexpensive devices such as Foley catheters and magnet-attached tubes can be used in emergencies such as with the esophageal impaction of disk batteries if endoscopy cannot be performed immediately (e.g., in rural areas and/or in patients presenting at midnight in a facility, especially in those without access to endoscopes or emergency services, or in any situation that warrants urgent removal of a foreign object).

Unusual case of a fatal upper esophageal trauma caused by a toothpick

The authors report the case of the unexpected death of a fifty-year-old female found by her partner in the bathroom floor. External examination revealed some contusions dispersed by different corporal areas and an unusually placed green discoloration of the anterior cervical region. After neck dissection and opening the esophagus, a three and a half centimeter wooden toothpick fragment was found at the upper region, covered by a purulent substance associated with puncture wounds. Histopathological and microbiological studies revealed "acute bilateral cervical cellulitis" and Klebsiella Oxytoca, respectively. Further investigation revealed that during the five days prior to her death, the victim was observed twice in an emergency department with complains of throat discomfort after eating some bread with salami. X-Ray and a laryngoscopy were performed but did not reveal any significant findings. Due to the victim's medical history, she was evaluated by a psychiatrist that dismissed a non-somatic setting due to the type of complains and the elevation of blood inflammatory parameters. Rinopharyngitis was then assumed as the most likely diagnosis and was treated accordingly. The victim died the following day. This case reports an unusual fatal traumatic lesion to the upper esophagus that is a very important remainder, particularly for clinical practitioners, to maintain a high degree of suspicion, avoid diagnostic biases such as those related to psychiatric disorders and meticulously evaluate patients in order to deliver the most evidence-based diagnosis possible. To the best of the authors' knowledge there are no other cases described in the literature of a death caused by esophageal toothpick lesion.

Foreign body ingestion and food impaction in adults: better to scope than to wait

Background and objective

To assess clinical outcomes after foreign body ingestion and food impaction; to identify predictors of foreign body presence at the time of endoscopy.

Methods

A prospective study including consecutive adult patients with foreign body ingestion or suspected food impaction between May 2014 and August 2016.

Results

In total, 521 patients were included, 320 with foreign body ingestion and 201 with suspected food impaction. Food impaction patients were significantly older and more frequently had a history of oesophageal disease. The foreign body was encountered in the upper digestive tract in 43% of the patients with foreign body ingestion, and food impaction was confirmed in 87%. Older age (odds ratio (OR)_year 1.04, 95% confidence interval (CI) 1.02-1.06) and early presentation (OR_{first six hours} 4.41, 95% CI 2.24-8.66) were independent predictors of foreign body presence, while a history of psychiatric disease was an independent predictor of food impaction (OR 6.69, 95% CI 1.66-26.9). Successful endoscopic treatment was achieved in more than 90% of the cases, with adverse events occurring in fewer than 5%. Foreign body forceps was the preferred device in foreign body ingestion, while retrieval basket and mobilisation were preferred in food impaction. The need to use more than one instrument was significantly higher in food impaction.

Conclusion

Foreign bodies are encountered at endoscopy in almost half of the cases. Older age and earlier presentation are independent predictors of its presence. Given the high proportion of patients with foreign body at endoscopy and the low risk of complications, endoscopic evaluation is probably justified in the majority of cases.