Foreign object ingestion and esophageal food impaction: An update and review on endoscopic management

Modern endoscopist’s toolbox: Innovations in foreign body removal

Foreign body ingestion is a common gastrointestinal emergency, particularly in children, who account for 80% of cases. While most ingested objects pass spontaneously, around 20% require medical intervention. In adults, incidents often occur accidentally during meals, leading to impactions, especially in individuals with underlying esophageal conditions. Endoscopy remains the gold standard for foreign body retrieval, with a success rate exceeding 95%. The type, shape, and location of the foreign body determine the clinical presentation and management approach. Sharp objects, batteries, and large items pose the highest risk of complications, including perforation, obstruction, and chemical injury. Prompt endoscopic removal is guided by established protocols, with emergent intervention required for complete esophageal obstruction and high-risk objects. Various retrieval devices, including forceps, snares, baskets, and overtubes, are used based on the nature of the foreign body. Technological advancements, such as artificial intelligence-assisted imaging and endoscopic ultrasound, are improving diagnostic precision and procedural outcomes. Despite these advances, foreign body ingestion can still lead to severe complications if not managed in a timely manner. Public awareness, preventive measures, and rapid medical response are essential in reducing morbidity and mortality associated with foreign body ingestion.

Endoscopic Removal of a Magnet Retained in the Stomach for Two Years: A Case Report and Literature Review

Foreign body ingestion (FBI) is a common clinical presentation, with most cases occurring in children. While accidental FBI in adults is less frequent, it is often associated with psychiatric conditions or substance use disorders. Magnet ingestion is particularly concerning due to the risk of pressure necrosis, perforation, and fistula formation, yet reports of magnet retention in adults are exceedingly rare. We describe a 45-year-old male with a history of depression and substance use disorder who presented with a three-week history of progressive abdominal pain, nausea, bloating, and foul-smelling belching. Imaging revealed a radiopaque foreign body in the distal gastric antrum, later identified as a 2.5 cm metallic disc-shaped magnet. Notably, a prior CT scan performed two years earlier had documented the same object, which the patient had presumed to be a dental filling and expected to pass spontaneously. Esophagogastroduodenoscopy (EGD) successfully retrieved the magnet using a Roth net, with immediate symptom resolution. This case is unique due to the prolonged asymptomatic retention of a magnet for two years before the onset of gastric outlet obstruction symptoms. While most foreign bodies pass spontaneously, endoscopic retrieval is warranted for magnets to prevent potential complications. The prolonged retention without perforation or obstruction highlights the role of anatomic location and object characteristics in determining outcomes. To our knowledge, this is the first reported case of successful endoscopic removal of a long-retained magnet in an adult using a Roth net. This case underscores the importance of considering FBI in the differential diagnosis of unexplained gastrointestinal symptoms, particularly in high-risk patients. Early recognition and intervention are crucial to prevent severe complications. Endoscopic removal remains a safe and effective strategy even for delayed presentations, emphasizing the need for clinical vigilance in cases of unwitnessed FBI.

Diagnosing eosinophilic esophagitis in pediatric patients

INTRODUCTION

Eosinophilic esophagitis (EoE) is an increasingly common disease that can present in children with the symptoms of feeding dysfunction, abdominal pain, vomiting, reflux-like symptoms, dysphagia, or food impaction. Diagnostically, children must have symptoms, dense esophageal eosinophilia, and other potential causes of these findings ruled out. Diagnostic recognition is critical to avoid food impactions and potential esophageal stricture development.

AREAS COVERED

In this review, a PubMed search using the search terms eosinophilic esophagitis, pediatric, and diagnosis were used to cover the last 10 years (2013-2023) of literature.

EXPERT OPINION

Early detection of EoE in children depends on increased recognition of diagnostic clues by many specialties. As increasing efforts to publicize the importance of EoE in children continues, our understanding of the molecular underpinnings of EoE is making rapid advances. Increasing growth of this knowledge base will provide more personalized diagnostic approaches, targeted interventions, and innovative treatments.

Retention of a Swallowed Dental Tool in the Small Bowel: Unusual Lodgment and Prolonged Conservative Management

Accidental ingestion of foreign bodies during dental procedures is relatively common, with the potential for serious complications, including intestinal perforations and severe pulmonary disorders. Our case report describes the prolonged, asymptomatic retention of a swallowed hex driver in the small bowel of a 38-year-old male, managed conservatively over an extended period. The patient, with a significant medical history of depression, was undergoing a dental procedure involving implant-supported restorations when the incident occurred. Initial x-rays confirmed the presence of the hex driver in the gastrointestinal tract. Despite its stationary position for over a week, it passed naturally without requiring invasive intervention. This case highlights the importance of individualized patient care and deferring recommendations for intervention in certain instances. We recommend a more individualized approach to managing ingested foreign bodies in dental settings, emphasizing the need for tailored strategies based on the patient's specific circumstances and clinical stability.

Patients with cardinal symptoms of eosinophilic esophagitis. Prejudice affects clinical practice…

INTRODUCTION

Dysphagia and bolus impaction are the cardinal manifestations of eosinophilic esophagitis (EoE). Esophageal biopsy sampling is mandatory for EoE diagnosis, data though suggest that clinician do not always obtain biopsies from patients with cardinal EoE symptoms during upper gastrointestinal endoscopy even if no other entity than EoE can explain patients symptoms. We aimed to search for the esophageal biopsy procurement rate as also for factors that drive clinicians to obtain esophageal biopsies among patients with cardinal EoE symptoms.

METHODS

We retrospectively searched for patients with cardinal EoE symptoms submitted to upper gastrointestinal endoscopy between 1/2018 and 12/2023 in our department. Epidemiologic, clinical, endoscopic, and histological data were analyzed.

RESULTS

In total 163 patients with cardinal EoE symptoms (dysphagia: 63 and bolus impaction: 100) were included in the study (M/F: 100/63, mean age: 54 ± 22 years). Biopsy sampling was obtained in 77/163 (47.2%) patients and sampling rates did not differ between patients with bolus impaction or dysphagia (47/100, 47% vs 30/63, 47.6%, P  = 0.553). Higher rates of sampling were observed in males ( P  = 0.045), those younger than 65 years old ( P  < 0.001) and patients with endoscopic EoE signs ( P  = 0.004). Age and endoscopic findings compatible to EoE were independently correlated to biopsy sampling. EoE was diagnosed in 35/74 patients (47.3%); the majority of patients were male, with a bolus impaction episode, compatible endoscopic findings and all were younger than 65 years old.

CONCLUSION

Clinicians take esophageal biopsies in half of patients with cardinal EoE. Age and supportive endoscopic evidence drive clinicians' decision to obtain esophageal biopsies.

Timing of Endoscopic Intervention for Esophageal Food Impaction and Its Impact on Patient Outcomes

INTRODUCTION

Esophageal food impaction (EFI) is a common complaint of patients presenting to the emergency department. EFI requires urgent evaluation by the gastroenterology service and often necessitates esophagogastroduodenoscopy (EGD) for management. Timing of EGD in patients with EFI that does not improve with medical management remains a point of contention. We aim to evaluate outcomes of EFI in the context of time to intervention.

METHODS

A retrospective cohort study was performed among patients who presented to a multicenter health system with EFI between 2018 and 2022. Patients with EFI that did not resolve after medical management and required EGD were included. Outcome analysis evaluated rates of complications and hospitalizations.

RESULTS

Two hundred eighty sis unique patient presentations were included. 175 (61.2%) of patients underwent EGD within six hours of presentation, 59 (20.6%) underwent EGD six to twelve hours after presentation, and 52 (18.2%) underwent EGD beyond twelve hours after presentation. Complication rates did not differ between patients depending on timing of EGD (p = 1.000). Admission rates were higher among patients in whom EGD was performed longer after presentation (p = 0.003). Complication rates were higher among patients with advanced age (p = 0.037), prior impaction (p = 0.004), and those who have not received glucagon (p = 0.007).

CONCLUSION

Timing of EGD after presentation in patients with EFI was not associated with a difference in complication rates. Delayed intervention was associated with a higher rate of hospitalization which should be taken into consideration when assessing the cost of EFI to the healthcare system.

Epidemiological and clinical characteristics of hospitalized unintentional injuries among children in central China from 2017-2023

Objectives

To examine the epidemiological and clinical characteristics of hospitalized unintentional injuries among children in Central China and theoretically propose preventive and control measures.

Methods

We conducted a retrospective study of children aged 0-18 years with unintentional injuries who were admitted to a tertiary hospital in Central China from January 2017 to December 2023. We examined various aspects of the unintentional injuries, including age, gender, urban-rural distribution, external causes, trends, location of injury, cost, and length of stay.

Results

A total of 20,166 children with hospitalized unintentional injuries were enrolled. The median age with IQR was 2.8 (1.6, 5.1) years, with majority of the patients (57.0%) were aged 1-3 years, while the fewest were aged 11-18 years. The male-to-female ratio was 1.8:1, and the urban-to-rural ratio was 1.1:1. The most common external causes were foreign bodies (41.7%), exposure to inanimate mechanical forces (25.1%), and falls (22.1%). The most frequently injured body parts were head (72.5%). The total number of unintentional injuries exhibited an increasing trend from 2017-2022, and a decreasing trend from 2022-2023. The urban-rural distribution reversed after 2020. The overall hospitalization cost was 20,810,870.4 USD, with an median cost of 758.7 (556.4, 1,186.2) USD per person.

Conclusion

Unintentional injuries imposed a heavy burden on society and families. However, the number of cases and the urban-rural distribution showed significant trend changes from 2017-2023. The external causes varied by age group, gender, and region, while prevention and control measures should be developed accordingly.

Unusual Case of Esophageal Foreign Body: A Whole Mantis Shrimp

Esophageal foreign bodies (FBs) are one of the common emergencies in otolaryngology, usually involving objects accidentally swallowed, and generally do not result in severe respiratory distress. This article presents an extremely rare case of an esophageal FB, where a 44-year-old man accidentally ingested an entire mantis shrimp while sucking its flavored tail, and was sent to the emergency department for severe throat pain and difficulty breathing. We immediately performed a laryngoscopy that revealed the FB that obstructs the entrance of the esophagus, obstructing the glottis due to the long shape of the shrimp. The mantis shrimp had barbs on its shell and trying to remove it intact would cause significant damage to the pharyngeal mucosa. Therefore, we extracted the mantis shrimp in segments under general anesthesia and applied electrocoagulation to stop bleeding from the damaged and bleeding posterior pharyngeal mucosa. As an esophagography was performed the following day, there were no signs of esophageal perforation. Through the detailed description and analysis of this case, our aim is to raise clinical awareness among physicians of such rare occurrences. Most important, appropriate examination and procedures of FBs should be performed based on the type, shape, and location of the FB.

Endoscopic Management of a Long-Duration Esophageal Food Impaction: A Case Report

Foreign object ingestion (FOI) is a potentially life-threatening pathology that affects all ages, from children to older adults. The classification includes true FOI and esophageal food impaction (EFI), and each presents unique challenges. Endoscopic intervention is often required to prevent complications. Flexible endoscopes are the preferred management tool, ensuring a high success rate and safety. The following text presents a case of a 48-year-old male with a 5-day undiagnosed esophageal food impaction and the approach taken.

Predicting Factors of Clinical Outcomes in Patients Hospitalized after Esophageal Foreign Body or Caustic Injuries: The Experience of a Tertiary Center

Ingestion of foreign bodies (IFB) and ingestion of caustic agents are frequent non-hemorrhagic causes of endoscopic urgencies, with the potential for severe complications. This study aimed to evaluate the predicting factors of the clinical outcomes of patients hospitalized as a result of IFB or ingestion of caustics (IC). This was a retrospective single-center study of patients admitted for IFB or IC between 2000 and 2019 at a tertiary center. Demographic and clinical data, as well as preliminary exams, were evaluated. Also, variables of the clinical outcomes, including the length of stay (LS) and other inpatient complications, were assessed. Sixty-six patients were included (44 IFB and 22 IC). The median LS was 7 days, with no differences between the groups (p = 0.07). The values of C-reactive protein (CRP) upon admission correlated with the LS in the IFB group (p < 0.01) but not with that of those admitted after IC. In the IFB patients, a diagnosis of perforation on both an endoscopy (p = 0.02) and CT scan (p < 0.01) was correlated with the LS. The Zargar classification was not correlated with the LS in the IC patients (p = 0.36). However, it was correlated with antibiotics, nosocomial pneumonia and an increased need for intensive care treatment. CT assessment of the severity of the caustic lesions did not correlate with the LS. In patients admitted for IFB, CRP values may help stratify the probability of complications. In patients admitted due to IC, the Zargar classification may help to predict inpatient complications, but it does not correlate with the LS.

Effect of Delayed Endoscopy Protocol on Timing and Safety of Endoscopy for Foreign Body Ingestion and Esophageal Food Impaction

BACKGROUND AND AIMS

Endoscopic procedures for foreign body ingestion (FBI) and esophageal food impactions (EFI) performed during on-call hours are associated with increased stress, risk, and cost. We implemented a Foreign Body Algorithm (FBA) designed to delay all but the most urgent endoscopy for EFI and FBI until regular working hours.

METHODS

Using endoscopy records from multiple academic and community hospitals within a large integrated health system in the United states, we identified esophagogastroduodenoscopy (EGD) performed for food impactions and foreign body ingestions occurring between May 2011 and February 2021.

RESULTS

We identified 479 EGDs performed for FBI and EFI. The introduction of the FBA was associated with a shorter length of stay (LOS) for overall cases (0.35 vs. 0.8 d P <0.001), day cases (0.16 vs. 1.0 d P <0.001), and night cases (0.40 vs. 0.6 d P =0.03). The introduction of the FBA did not change the rate of overall adverse events (AE) or night AE. AE from the entire cohort was rare (3%; 16 total). Of the AE, most were sedation related. The introduction of the FBA did not affect the overall rate of night cases or AE, but the rate of after-hours endoscopy for intentional ingestions decreased from 17.2% to 3.1% ( P =0.01).

CONCLUSION

This is one of the largest studies of esophageal impactions and foreign bodies in adults in the United States, and the first to examine the effects of a protocol designed to avoid after-hours endoscopy. These results suggest that postponing after-hours EGD until the daytime is not associated with adverse safety outcomes or increased LOS.

First Reported Case of Lesser Sac Empyema Secondary to Foreign Body Perforation

This is the first reported case of lesser sac empyema secondary to a foreign body perforation in the posterior stomach. Although PubMed and Google Scholar search reports cases of lesser sac empyema alone and foreign body penetrations, there are currently no reported cases of a lesser sac abscess secondary to a foreign body. Patients with a lesser sac empyema present atypically with an insidious onset. The lesser sac should be examined in patients with peritonitis without a clear source. A 48-year-old female presented to the emergency department with acute onset epigastric pain. The patient was tender in the epigastrium and left upper quadrant with associated guarding. The patient had elevated white cell count and C-reactive protein, with a computed tomography scan identifying a foreign body posterior gastric wall perforation. The patient was managed with endoscopic drainage of the lesser sac empyema and surgical washout of the abdomen. Foreign bodies are investigated using different imaging modalities, with computed tomography being able to further evaluate the size, shape, and complications. Intra-abdominal collections can be managed through three different methods: percutaneous drainage, endoscopic drainage, and surgery. Patients with peritonitis would require a laparoscopic or open surgical washout of the abdomen and inspection of the lesser sac would be necessary if no obvious source is identified. Foreign body ingestion requires careful history taking and assessment. Patients with lesser sac empyema present atypically, and this can lead to delayed surgical referral and management. Contained intra-abdominal collections can be drained percutaneously or endoscopically.

Endoscopic failure for foreign body ingestion and food bolus impaction in the upper gastrointestinal tract: an updated analysis in a European tertiary care hospital

OBJECTIVE

Harmfulness of foreign body ingestion and food bolus impaction (FBIs) varies according to geographical area, population, habits, and diet. Therefore, studies may not draw generalizable conclusions. Furthermore, data regarding FBIs management in Europe are limited and outdated. This study aimed to analyze the endoscopic management and outcomes of FBIs in an Italian tertiary care hospital to identify risk factors for endoscopic failure.

METHODS

We retrospectively reviewed patients who underwent upper gastrointestinal endoscopy for FBIs between 2007 and 2017. Baseline, clinical, FBIs, and endoscopic characteristics and outcomes were collected and reported using descriptive statistics and logistic regression analyses.

RESULTS

Of the 381 endoscopies for FBIs, 288 (75.5%) were emergent endoscopy and 135 (35,4%) included underlying upper gastrointestinal conditions. The study population included 44 pediatric patients (11.5%), 54 prisoners (15.8%), and 283 adults (74.2%). The most common type and location of FBIs were food boluses (52.9%) and upper esophagus (36.5%), respectively. While eight patients (2.1%) developed major adverse events requiring hospital admission, the remainder (97.9%) were discharged after observation. No mortality occurred. Endoscopic success was achieved in 263 of 286 (91.9%) verified FBIs endoscopies. Endoscopic failure (8.04%) was associated with age, bone, disk battery, intentional ingestion, razor blade, prisoners, and stomach in the univariate analysis. Multivariate logistic regression revealed that intentional ingestion was associated with endoscopic failure (odds ratio: 7.31; 95% confidence interval = 2.06-25.99; P  = 0.002).

CONCLUSION

Endoscopy for FBIs is safe and successful, with low hospital admission rate in children, prisoners, and adults. Intentional ingestion is a risk factor of endoscopic failure.

Accidental Sewing Pin Ingestion by a Tailor: A Case Report and Literature Review

Foreign body ingestion is a frequently encountered emergency in healthcare institutions. It mostly affects pediatric populations, although it can also affect adults with developmental delays, those with psychiatric diseases, drug abusers, and prisoners. Endoscopy is a diagnostic and treatment method for suspected foreign body ingestion. In this article, we discuss a 45-year-old tailor who swallowed a sewing pin while at work. The abdominal X-ray showed a needle-shaped metal shadow in the stomach region. During an upper endoscopy, it was discovered that a sewing pin with a sharp edge was stuck in the pylorus. The sewing pin was extracted endoscopically, and the patient was discharged the same day in good condition. Since the estimated risk of complications of foreign body ingestion in the adult population is about 35%, and the most common complications include impaction, laceration, bleeding, or perforation of the gastrointestinal wall, endoscopic or surgical removal is necessary. This also emphasizes the importance of a careful endoscopic evaluation of some at-risk occupations for foreign body ingestion with or without gastrointestinal complaints.

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.

Navigating the Esophagus: Effective Strategies for Foreign Body Removal

Foreign body ingestion is a common medical emergency that can affect individuals of all ages and can be caused by various factors, including accidental ingestion, psychiatric disorders, intellectual disabilities, and substance abuse. The most common site for foreign body lodgment is the upper esophagus, followed by the middle esophagus, stomach, pharynx, lower esophagus, and duodenum. This article provides a case report of a 43-year-old male patient with a history of schizoaffective disorder and an indwelling suprapubic catheter who presented to the hospital due to foreign body ingestion. After examination, a metal clip from his Foley catheter was found lodged in his esophagus. The patient was intubated for the procedure, and an emergent endoscopic removal was performed to remove the metallic Foley component. No postoperative complications were observed, and the patient was successfully discharged. This case highlights the importance of considering foreign body ingestion in patients with chest pain, dysphagia, and vomiting. Prompt diagnosis and treatment are crucial to prevent potential complications such as perforation or gastrointestinal tract obstruction. The article also emphasizes the need for healthcare providers to know the different risk factors, variations, and common sites for foreign body lodgment to optimize patient care. Furthermore, the article highlights the importance of multidisciplinary care involving psychiatry and surgery to provide comprehensive care to patients with psychiatric disorders who may be at higher risk for foreign body ingestion. In conclusion, foreign body ingestion is a typical medical emergency that requires prompt diagnosis and treatment to prevent complications. This case report highlights the successful management of a patient with foreign body ingestion and emphasizes the importance of multidisciplinary care to optimize patient outcomes.

A Case Report of Non-intentional Foreign Body Ingestion in an Elderly Patient

Foreign body ingestion is a common problem that can result in severe consequences. It occurs commonly in children and rarely in adults. High-risk adults include illicit drug users, prisoners, edentulous adults, alcoholics, psychiatric patients, adults with mental retardation, or those with decreased oral tactile sensation. In adults, most foreign body impactions are seen in patients with pre-existing pathologies, such as malignancy, achalasia, strictures, and esophageal rings. Complications that foreign bodies may cause in some cases are tracheoesophageal fistula, aorto-esophageal fistula, and intramural perforation. This case illustrates the importance of including foreign body ingestion in the differential diagnosis of dysphagia in high-risk groups, even when no clear history suggests this as a cause, which may decrease the complications.

CT Evaluation of the Esophagus: The Role of CT Imaging and CT Imaging Findings in Diagnosing Esophageal Abnormalities

Esophageal disorders are commonly encountered by radiologists on computed tomography. Characteristic computed tomography findings of various esophageal pathologies have been extensively described and are important for the radiologist to know to facilitate accurate and timely diagnosis. Esophageal disorders can be broadly classified as infectious and inflammatory, congenital/structural, or neoplastic. This paper reviews the most common presentations of various esophageal pathologies within each classification.

Impacted esophageal foreign bodies in children

PURPOSE

Foreign body (FB) ingestion in children has varied presentation. When unwitnessed, it poses therapeutic and diagnostic challenges especially in the presence of pre-existing anatomical pathology. We aim to analyze the clinical course, management, and outcome of children with impacted esophageal FBs.

METHODS

Retrospective chart review (Jan 2000-Feb 2018) recruiting children with impacted esophageal FBs. FBs in cricopharynx and those that moved to stomach were excluded. Investigations/management were based on underlying anatomical pathology, duration of impaction, and difficult FBs. Clinical details, management, and outcomes were collated.

RESULTS

Of 86 children, N1 = 31 had identifiable predisposing anatomic pathology and N2 = 55 had impactions in normal esophagus or difficult FBs. N1 group presented early (42 months), had recurrent impactions (1-6), and needed multiple dilatations (0-8) and longer follow-up (avg 35 months). Food matter was commonest impaction. Many had persistent symptoms. N2 group had commonly coin impactions and strictures developed in long standing or corrosive FBs. Most were asymptomatic.

CONCLUSION

Abnormal esophageal anatomy predisposes to impaction with organic food bolus. Age of presentation is earlier with recurrent impactions requiring multiple dilatations/surgery and longer follow-up. Metallic FBs commonly impact in normal esophagus and are often innocuous. Atypical/multiple FBs may mirror an underlying psychiatric illness.

Esophageal Food Impaction

Esophageal foreign body impaction requires urgent or emergent removal depending on clinical symptoms. Radiographic evaluation is extremely valuable in guiding management, although not required. The case presented herein describes a 66-year-old male presenting with epigastric pain and globus sensation for three days, inability to tolerate both foods and liquids, and regurgitation. Fluoroscopic evaluation revealed a food impaction in the distal esophagus. Urgent endoscopy confirmed the diagnosis and revealed a peptic stricture secondary to Barrett's esophagus. Although computed tomography has largely replaced the fluoroscopic examination, it can still provide a definitive diagnosis in many cases.

A Rare Case of an Exploratory Laparotomy to Treat a Liver Abscess Secondary to Foreign Body Ingestion

A 49-year-old female presented to the hospital with complaints of generalized weakness, subjective fevers, and chills. In the emergency department (ED), she was found to be hypotensive and tachycardic and met the sepsis criteria. A CT scan of the abdomen and pelvis (CT A/P) with contrast revealed a liver abscess and a foreign body (FB) that was suspected to be the cause of the liver abscess. Of note, the patient had undergone a recent dental procedure due to an infected root canal, which had involved a dental screw. The patient was uncertain whether the dental screw had been removed, but she felt as though it was no longer there. At this time, the clinical suspicion was high for FB secondary to this dental procedure. The patient underwent interventional radiology (IR)-guided liver abscess drainage and magnetic resonance cholangiopancreatography (MRCP) for the evaluation of the FB. An esophagogastroduodenoscopy (EGD) was performed, but no evidence of the FB was found. This warranted an exploratory laparotomy (EL) to ensure the successful removal of the FB. Upon gross visualization by surgery, the FB was revealed to be a bone that the patient did not recall ingesting. However, surgical pathology evaluation revealed that the FB was actually a plastic stick. This rare case highlights the clinical approach to FB ingestion when complicated by liver abscess, as well as successful treatment with EL as opposed to laparoscopy which is the procedure of choice.

Small Bowel Perforation Secondary to Blister Pill Pack Ingestion: A Case Report

We present a case of accidental ingestion of a foreign body-blister pill pack (FB-BPP) causing small bowel perforation in a patient taking aspirin and clopidogrel due to past history of coronary artery disease. A 71-year-old male presented in the emergency department (ED) with a two-day history of abdominal discomfort and loss of consciousness. His relevant home medication included aspirin and clopidogrel secondary to a history of coronary artery stents. Initial workup with emergent CT scan of abdomen/pelvis with intravenous contrast showed a loop of the terminal ileum with thickened wall and perforation. Incidentally, he was also found to have type II myocardial infarction. Emergent laparoscopic ileocecectomy with primary anastomosis was done. The postoperative course was unremarkable. The pathology report of the small bowel was consistent with a FB-BPP associated perforation. FB-BPP ingestion with perforation is a rare occurrence. It occurs more often in the elderly with significant mortality. Our case of accidental ingestion of FB-BPP was confirmed retrospectively after histopathological evaluation, and complicated by type II myocardial infarction. Emergent laparoscopic bowel resection was done despite significant preoperative risks.

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.

Esophageal Dysphagia in Children: State of the Art and Proposal for a Symptom-Based Diagnostic Approach

Pediatric esophageal dysphagia (PED) is an infrequent condition that can be determined by a large number of disorders. The etiologic diagnosis is challenging due to overlapping clinical phenotypes and to the absence of pediatric diagnostic guidelines. This review aims to summarize the most relevant causes of ED during childhood, highlight the clinical scenarios of PED presentation and discuss the indications of available diagnostic tools. Available information supports that PED should always be investigated as it can underlie life-threatening conditions (e.g., foreign body ingestion, mediastinal tumors), represent the complication of benign disorders (e.g., peptic stenosis) or constitute the manifestation of organic diseases (e.g., eosinophilic esophagitis, achalasia). Therefore, the diagnosis of functional PED should be made only after excluding mucosal, structural, or motility esophageal abnormalities. Several clinical features may contribute to the diagnosis of PED. Among the latter, we identified several clinical key elements, relevant complementary-symptoms and predisposing factors, and organized them in a multi-level, hierarchical, circle diagram able to guide the clinician through the diagnostic work-up of PED. The most appropriate investigational method(s) should be chosen based on the diagnostic hypothesis: esophagogastroduodenoscopy has highest diagnostic yield for mucosal disorders, barium swallow has greater sensitivity in detecting achalasia and structural abnormalities, chest CT/MR inform on the mediastinum, manometry is most sensitive in detecting motility disorders, while pH-MII measures gastroesophageal reflux. Further studies are needed to define the epidemiology of PED, determine the prevalence of individual underlying etiologies, and assess the diagnostic value of investigational methods as to develop a reliable diagnostic algorithm.

Foreign body ingestion and associated factors in pediatric patients at a tertiary care center

INTRODUCTION AND AIMS

Foreign body (FB) ingestion is a common problem in children under 5 years of age and is one of the main indications for endoscopy. The aim of the present study was to describe the clinical, radiographic, and endoscopic characteristics of patients with FB ingestion, as well as the factors associated with the anatomic location and the type of object ingested.

MATERIALS AND METHODS

An analytic cross-sectional study was conducted on all patients with FB ingestion seen at the gastroenterology service from January 2013 to December 2018. The data were analyzed using the SPSS program, obtaining frequencies, percentages, medians, and interquartile ranges. Associations were assessed through the chi-square test.

RESULTS

Eighty-five patients (52 males and 33 females) were included, with a median age of 4 years. The most common symptom was vomiting (29.4%). Two radiographic projections were carried out in 72.9% of the cases and the stomach was the site where the FB was most frequently visualized (32.9%). The objects most commonly ingested were coins (36%), with esophageal location (p<0.05), as well as objects with a diameter larger than 2cm (p<0.05). An endoscopic procedure was performed on 76 patients (89.4%) for FB extraction, with findings of erythema (28.9%), erosion (48.6%), ulcer (10.5%) and perforation (1.3%).

CONCLUSIONS

Numerous factors should be taken into account in the approach to FB ingestion in pediatric patients, including type and size of the FB, time interval from ingestion to hospital arrival, and patient clinical status and age.

Drugs of Abuse: Sympathomimetics

Sympathomimetic drugs comprise a broad category of substances including both illicit and prescribed drugs that have deleterious effects when ingested or abused. The clinical syndromes that result from overstimulation of the sympathetic nervous system by reuptake inhibition of biogenic amines, such as norepinephrine and dopamine, carry significant morbidity. Recognition and awareness of the appropriate supportive measures are required to mitigate life-threatening complications of multiple organ systems. The sympathomimetic toxidrome is recognized by a constellation of symptoms including agitation, hyperthermia, tachycardia, and hypertension, and the primary treatment involves supportive care, including the liberal use of benzodiazepines.

Foreign bodies of body orifices: A pictorial review

INTRODUCTION

Ingestion, inhalation, and insertion of foreign bodies (FB) are commonly encountered problems in the emergency departments (ED). Radiologists pay a key role in their diagnosis and management. Selecting an appropriate imaging modality is important depending on the route of entry and reported type of FB. Diagnosing FB is time sensitive and requires radiologists to be astute and familiar with varied imaging appearances of FB. In this article, we review imaging features of most common FB seen in clinical practice and their complications.

TEACHING POINTS

SUMMARY: FB in body orifices are frequently seen in the ED. Imaging plays a pivotal role in the management in majority of the cases. In this article, we present several cases of commonly encountered FB.

Foreign body ingestion and associated factors in pediatric patients at a tertiary care center

INTRODUCTION AND AIMS

Foreign body (FB) ingestion is a common problem in children under 5 years of age and is one of the main indications for endoscopy. The aim of the present study was to describe the clinical, radiographic, and endoscopic characteristics of patients with FB ingestion, as well as the factors associated with the anatomic location and the type of object ingested.

MATERIALS AND METHODS

An analytic cross-sectional study was conducted on all patients with FB ingestion seen at the gastroenterology service from January 2013 to December 2018. The data were analyzed using the SPSS program, obtaining frequencies, percentages, medians, and interquartile ranges. Associations were assessed through the chi-square test.

RESULTS

Eighty-five patients (52 males and 33 females) were included, with a median age of 4 years. The most common symptom was vomiting (29.4%). Two radiographic projections were carried out in 72.9% of the cases and the stomach was the site where the FB was most frequently visualized (32.9%). The objects most commonly ingested were coins (36%), with esophageal location (p <0.05), as well as objects with a diameter larger than 2cm (p <0.05). An endoscopic procedure was performed on 76 patients (89.4%) for FB extraction, with findings of erythema (28.9%), erosion (48.6%), ulcer (10.5%) and perforation (1.3%).

CONCLUSIONS

Numerous factors should be taken into account in the approach to FB ingestion in pediatric patients, including type and size of the FB, time interval from ingestion to hospital arrival, and patient clinical status and age.

Successful endoscopic removal of a swallowed toothbrush, a therapeutic challenge. A case report

Introduction: Toothbrush swallowing, whether voluntary or accidental, is a rare event and must be handled as an emergency, because these foreign bodies, due to their length and hardness, are not expected to pass completely through the digestive tract and may cause serious complications. Case presentation: A 22-year-old woman with an eating disorder (bulimia nervosa) involuntarily swallowed a toothbrush while inducing vomiting. Unfortunately, after the initial assessment in the emergency department, and due to the lack of symptoms, her psychiatric history, and the fact the toothbrush was not observed in imaging studies, she was discharged. Due to the patient's insistence that she was telling the truth, she was referred to a secondary healthcare institution by her treating physician, where the successful endoscopic extraction of the toothbrush was performed 36 hours after it was swallowed. The procedure was carried out with the patient under sedation and by experts in digestive extraction who used an overtube, foreign body forceps, and polypectomy loops. Conclusion: Cases of toothbrush swallowing are rarely reported and occur mainly in people with mental illnesses, such as eating disorders involving self-induced vomiting. Therefore, in these cases, physicians should always believe what these patients say, even in the absence of symptoms and imaging findings, as this enables their timely referral to a digestive service to confirm whether the toothbrush was swallowed or not and to perform the endoscopic extraction as soon as possible, since it can cause serious complications due to its characteristics.

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.

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.

[Diagnostic and treatment of foreign bodies of the upper digestive tract]

OBJECTIVE

To evaluate the results of diagnosis and treatment of foreign bodies of the upper gastrointestinal tract.

MATERIAL AND METHODS

There were 1187 patients aged 15-99 years with suspected foreign body of the upper gastrointestinal tract. In 536 patients (266 men, 270 women), foreign bodies were detected. Ingestion of a foreign body was more common in patients aged 46-65 years. In 516 patients, foreign bodies were detected in the esophagus (pharyngo-esophageal junction - 25, upper third of the esophagus - 426, middle third of the esophagus - 34, lower third of the esophagus - 21, esophageal-gastric junction - 10). Four patients admitted with esophageal wall perforation. In 3 cases, foreign bodies were localized in the throat, 15 patients - in the stomach, 2 patients - in the duodenum.

RESULTS

In most cases, foreign bodies were organic (n=506). Removal was successful in 530 cases. In 4 patients with esophageal wall perforation and mediastinitis, removal was performed intraoperatively. Flexible endoscope was used in 500 cases. In 86 patients, foreign bode was displaced in the stomach using flexible endoscopy. Foreign body removing wasn't successful in 4 cases. In 2 patients, extraction was followed by esophageal wall damage. In 4 patients, esophagotomy was applied to extract foreign body. Suturing the esophageal wall defect was carried out in 2 cases. Abrasion and erosive esophagitis were the most common injuries of esophageal mucosa. Esophageal diseases were detected in 75 cases after foreign body removal (67 cases - benign esophageal diseases). One patient died from bedsore of innominate artery complicated by acute hemorrhage.

CONCLUSION

Foreign bodies of the upper gastrointestinal tract are observed in 45% of patients at admission. Neck and chest X-ray examination is obligatory before endoscopy. Flexible endoscopy is a gold standard for diagnosis and extraction of foreign bodies. Repeated endoscopy after foreign body extraction should be mandatory. It is necessary to visualize complications associated with foreign body and identify esophageal diseases.

Use of an intraocular handpiece for the removal of magnets from the oropharynx of a pediatric patient

With the increasing availability of magnets within household objects and toys, otolaryngologists must be aware of the propensity of ingestions or impaction of magnets within the upper aerodigestive tract of pediatric patients. We describe a case of a 21-month old male who presented with throat pain after swallowing ten 0.5-inch magnetic balls, after which evaluation revealed the adherence the the of three magnets within the posterior oropharynx and an additional seven magnets in the small intestine. After an initial failed attempt to remove the pharyngeal magnets with forceps, the magnets were successfully removed using an ophthalmic intraocular magnet handpiece designed for ophthalmologic procedures. Use of this device should be taken into consideration for similar cases.

Foreign body and caustic ingestions in children: A clinical practice guideline

Foreign body and caustic ingestions in children are usually the most common clinical challenges for emergency physicians, general pediatricians and pediatric gastroenterologists. Management of these conditions often requires different levels of expertise and competence. Endoscopy is often necessary but there is a high risk of misusing this tool with incorrect timing and indications. The imprecise clinical history frequently leaves clinicians uncertain about timing and nature of the ingestion. Few clinical guidelines regarding management of these ingestions in children have been published, none of which from the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP). An expert panel of Italian endoscopists was convened by the SIGENP Endoscopy Working Group to produce the present article that outlines practical clinical approaches to the pediatric patient with a variety of foreign body and caustic ingestions. The Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) has also endorsed the project since many adult endoscopists usually manage children with these conditions. Differently from the other published guidelines, the proposed one focuses on the role of the endoscopists (regardless of whether they are adult or pediatric gastroenterologists) in the diagnostic process of children with foreign body and caustic ingestions.

Endoscopic Retrieval of Ingested Bags Following a Multidisciplinary Approach

Foreign body ingestion encompasses a broad variety of ingested objects, clinical presentations, and treatment approaches, with a wide spectrum of severity and urgency. Herein, we describe the case of a 29-year-old man presenting with abdominal pain following the ingestion of empty plastic bags. Monitoring with serial imaging demonstrated the bags in the stomach 18 hours post-ingestion. Given this finding and worsening pain, a multidisciplinary decision was made to pursue endoscopic retrieval. This case uniquely demonstrates the benefit of rapid multidisciplinary meetings in an emergency room setting leading to the successful removal of ingested bags from the gastric body. While the phenomenon of “body stuffing,” or hasty ingestion of bagged drugs to evade law enforcement has become common, there are few reports of endoscopic removal for such cases or those involving empty bag ingestion. This case highlights the importance of repeat abdominal imaging and early endoscopic intervention for foreign objects such as bags as they may be difficult to visualize on imaging, making it unreliable to track their progress. Dynamic imaging should be obtained, with computed tomography (CT) being the gold standard. This report represents the first case of empty bag ingestion, highlighting tenets of timely multidisciplinary management and considerations in endoscopic retrieval as a minimally invasive technique when a patient presents in the emergency department following bag ingestion.

Removal of a Large Stone in the Upper Thoracic Esophagus

Ingestion of a foreign body is a common occurrence. Flexible endoscopy is most commonly used for treatment, but certain large foreign bodies are more easily retrieved with rigid endoscopy. We present a technically challenging case of intentional ingestion of a large stone that required retrieval from the upper thoracic esophagus using rigid endoscopy. This case highlights the importance of alternative methods to manage large foreign bodies and of collaboration of medical subspecialties.

Pediatric Endoscopy, Update 2020

Optimal management of pediatric endoscopy requires a multidisciplinary approach. In most hospitals, endoscopy in pediatric patients is performed by conventional gastroenterologists and only a few centers have specialized pediatric gastroenterologists. This is due to the fact that the number of pediatric gastroenterologists is limited and not all of them are experienced in endoscopic techniques. However, there are also some pediatric centers offering a high-quality and high-volume endoscopy service provided by very experienced pediatric gastroenterologists. Up to now, the literature on pediatric endoscopy is rather sparse. In this article, we describe current knowledge and practice of endoscopic procedures in pediatric patients, which should be relevant for both the adult and pediatric gastroenterologists.