Endoscopic management of foreign bodies in the upper gastrointestinal tract: A review

Cluster analysis of symptoms and assessment of caregiver reports in pediatric foreign bodies

Foreign body (FB) ingestion and aspiration are frequent causes of pediatric emergency room visits, with significant morbidity and mortality risks. This cross-sectional study analyzed 1,052 pediatric patients admitted for suspected FB events at a single institution between 2008 and 2015, including 886 cases of suspected ingestion and 166 cases of suspected aspiration. Cluster analysis identified three distinct clusters for both groups, with respiratory symptoms being predominant in clusters with worse outcomes. The respiratory clusters were associated with increased complication rates (13.0% for aspiration, 3.6% for ingestion) and all mortalities (three in aspiration and two in ingestion). In ingestion cases, Respiratory Cluster patients showed increased complications, prolonged hospital stays (mean 55.1 h), and accounted for all mortalities, a relationship not previously reported. Caregiver-reported certainty of event occurrence showed moderate sensitivity (72.5%) and low specificity (45.4%) for aspiration, and higher sensitivity (86.8%) with lower specificity (19.8%) for ingestion. Decision Curve Analysis revealed a net benefit in utilizing caregiver certainty for clinical decision-making. Confirmatory radiographic findings were commonly observed in ingestion cases (84.2%) than in aspiration cases (37.7%), likely due to the higher incidence of metal ingestions compared to mostly organic aspirations. Endoscopic management had high success rates (97.6%), and low mortality, highlighting its central role in FB treatment. These findings underscore the importance of assessing respiratory symptom severity within the broad clinical spectrum of FBs to identify patients at risk of worse clinical outcomes, which helps prioritize resources when necessary. Caregiver-reported information has been shown to be valuable in guiding diagnostic decisions.

Clinical Characteristics of Children With Foreign Bodies in the Digestive Tract and Analysis of Risk Factors for Serious Complications

Foreign bodies (FBs) in the digestive tract are common in children, we analyzed the clinical characteristics of children with FBs in the digestive tract and discuss the risk factors for serious complications. We retrospectively reviewed clinical data of 139 children with FBs in the digestive tract. Based on the severity of complications caused by FBs, the patients were divided into risk and general groups for analysis and comparison. Significant differences were observed in the retention sites of FBs, the diameter of FBs retained in the esophagus, FBs retention time exceeding 24 h, and the absence of witnesses between the 2 groups. Inadequate care, button batteries (BBs), ingested mmFBs, FBs retained in the esophagus, long-term retention, and giant gastric bezoars may cause serious complications. In addition to treating FBs and the complications, clinicians should emphasize the importance of childcare to prevent the ingestion of FBs.

Complications owing to oesophageal impaction of button batteries and risk factors in children in China: a review

BACKGROUND

Impaction of button batteries (BB) in children is not rare.

AIM

To conduct a systematic review of reports of oesophageal injury caused by impaction of BB in children in China.

METHODS

The databases of Wanfang, VIP, China National Knowledge Internet, the Chinese Medical Association Journal and PubMed were searched for reports by Chinese authors of BB impaction published between May 2005 and July 2023. The risk factors for complications were analysed by multiple unconditional logistic regression.

RESULTS

After excluding 95 articles which did not meet the criteria, 77 remained, with a total of 964 cases of BB impaction. Of 516 cases with complications, 402 were in children (77.9%). The most common complications were oesophageal erosions and ulceration (218/402, 54.2%), followed by oesophageal perforation (88/402, 21.1%), tracheo-oesophageal fistula (69/402, 17.2%), oesophageal stricture (38/402, 9.5%) and peri-oesophagitis (31/402, 7.7%). Regression analysis demonstrated that the duration and location of impaction were the risk factors for complications (OR 13.7 and 11.3, respectively; p < 0.05 for both).

CONCLUSION

BB impaction remains common and causes serious oesophageal complications in children. Widespread knowledge of the risks is essential for prevention.

Has the cat got your tongue, or is something obstructing your throat? A review of imaging of ingested and aspirated foreign bodies in the paediatric population

Children frequently swallow or inhale foreign objects, a situation that can be life-threatening. Radiographic imaging plays a lead role in the early identification and location of inhaled or swallowed objects is essential. Promptly identifying and locating inhaled or swallowed objects are essential, as some items require immediate removal. For example, button batteries in the throat can cause grave harm; magnets can attract each other through the gut and cause perforations; and other objects can obstruct the airway or intestinal tract. Radiologists must understand how these objects appear in images to assist doctors in treating patients effectively. Recognising signs of inhaled objects on radiographs is also crucial, as symptoms may not always be clear, and many inhaled objects are not visible on radiographs. Radiographs are the primary means of checking for swallowed or inhaled objects, although other tests like fluoroscopy and computed tomography may be used in complex cases. Doctors working with children should be acquainted with the appearance of these common objects on images and their clinical importance.

Inadvertent removal of a needle foreign body via endoscopic suctioning in a dog

A 6-month-old intact female English bulldog was presented following witnessed ingestion of a sewing needle. The dog underwent attempted endoscopic retrieval under general anesthesia. The needle foreign body was visualized but could not be removed due to orientation, and subsequent attempts at visualization were unsuccessful. Due to the unsuccessful removal, radiographs were obtained before intended surgical exploration, and no sewing needle was identified. The needle was subsequently identified in the working channel of the endoscope, and the dog recovered uneventfully. This is the first report to describe inadvertent endoscopic suctioning of a sharp, needle foreign body. Key clinical message: Endoscopy is a key tool in the management and treatment of sharp gastric foreign bodies. Complications are uncommon and typically patient-focused, including gastric perforation or irritation. However, this case report identifies an additional complication that should be considered when endoscopy is not successful.

Use of Endoscopy to Remove Fish Bone That Caused Sigmoid Colon Perforation

An 87-year-old man experiencing lower abdominal discomfort resulting from the ingestion of a fish bone underwent conservative management involving endoscopic extraction of the fish bone lodged in the sigmoid colon. Most patients with lower gastrointestinal tract perforations typically develop peritonitis or abscesses, necessitating surgical intervention. Notably, endoscopic management of lower gastrointestinal tract perforations is infrequently employed. Patients presenting with localized abdominal symptoms along with a stable overall health condition may benefit from conservative therapeutic approaches that utilize endoscopic methods. Notably, the transition from endoscopic procedures for foreign body removal to surgical intervention requires close collaboration with a surgeon and must be executed judiciously.

Endoscopic lavage for an infected pelvic hematoma in a patient with pelvic sepsis after anterior pelvic exenteration

Anastomotic leakage and subsequent pelvic sepsis are serious complications after surgery for pelvic malignancies, particularly challenging due to the large pelvic cavity dead space post-exenteration. We report a 47-year-old man treated for a severely infected pelvic hematoma and sepsis following anastomotic leakage after anterior pelvic exenteration. Post robot-assisted exenteration for locally advanced sigmoid colon cancer treated with neoadjuvant chemotherapy, a pelvic abscess from anastomotic dehiscence was identified. Initial CT-guided drainage and subsequent laparoscopic drainage were performed. On postoperative day 22, a bleeding left internal iliac pseudoaneurysm required embolization. Despite these efforts, the sepsis worsened due to an enlarged, infected hematoma. Endoscopic lavage, in collaboration with skilled endoscopists, successfully removed the hematoma, leading to an improved inflammatory response, and the patient was discharged. Endoscopic lavage proved to be the safest and most effective treatment for pelvic sepsis with an infected hematoma after various attempted interventions.

Fluoroscopic-Guided Removal of Jejunal Sharp Foreign Body: An Alternative Approach to Surgery

Introduction

Foreign body (FB) ingestion represents a frequently encountered scenario in clinical practice. Most ingested FBs typically pass spontaneously, requiring no intervention. Endoscopic removal stands out as the least invasive method, with only a minimal 1% needing surgical intervention. Case Presentation. We present a case of a 30-year-old male who ingested multiple FBs located in the stomach and small bowel. While successful removal of the stomach FB was achieved through endoscopy, the second FB in the small bowel proved challenging due to perforation concerns and limited expertise. Given a history of prior surgical intervention resulting in a large incisional hernia, surgical removal was discouraged. Consequently, a collaborative decision involving surgeon and interventional radiologist (IR) led to the adoption of a fluoroscopic-guided removal approach facilitated by IR techniques.

Conclusion

This case highlights the potential for a less invasive alternative in situations where both endoscopic and surgical interventions are deemed not feasible.

Evaluation of the Quality and Readability of Web-Based Information Regarding Foreign Bodies of the Ear, Nose, and Throat: Qualitative Content Analysis

BACKGROUND

Foreign body (FB) inhalation, ingestion, and insertion account for 11% of emergency admissions for ear, nose, and throat conditions. Children are disproportionately affected, and urgent intervention may be needed to maintain airway patency and prevent blood vessel occlusion. High-quality, readable online information could help reduce poor outcomes from FBs.

OBJECTIVE

We aim to evaluate the quality and readability of available online health information relating to FBs.

METHODS

In total, 6 search phrases were queried using the Google search engine. For each search term, the first 30 results were captured. Websites in the English language and displaying health information were included. The provider and country of origin were recorded. The modified 36-item Ensuring Quality Information for Patients tool was used to assess information quality. Readability was assessed using a combination of tools: Flesch Reading Ease score, Flesch-Kincaid Grade Level, Gunning-Fog Index, and Simple Measure of Gobbledygook.

RESULTS

After the removal of duplicates, 73 websites were assessed, with the majority originating from the United States (n=46, 63%). Overall, the quality of the content was of moderate quality, with a median Ensuring Quality Information for Patients score of 21 (IQR 18-25, maximum 29) out of a maximum possible score of 36. Precautionary measures were not mentioned on 41% (n=30) of websites and 30% (n=22) did not identify disk batteries as a risky FB. Red flags necessitating urgent care were identified on 95% (n=69) of websites, with 89% (n=65) advising patients to seek medical attention and 38% (n=28) advising on safe FB removal. Readability scores (Flesch Reading Ease score=12.4, Flesch-Kincaid Grade Level=6.2, Gunning-Fog Index=6.5, and Simple Measure of Gobbledygook=5.9 years) showed most websites (56%) were below the recommended sixth-grade level.

CONCLUSIONS

The current quality and readability of information regarding FBs is inadequate. More than half of the websites were above the recommended sixth-grade reading level, and important information regarding high-risk FBs such as disk batteries and magnets was frequently excluded. Strategies should be developed to improve access to high-quality information that informs patients and parents about risks and when to seek medical help. Strategies to promote high-quality websites in search results also have the potential to improve outcomes.

Coin-cidence? Have cashless payments reduced the incidence of upper aerodigestive foreign body insertion? A study of UK Hospital Episode Statistics

OBJECTIVES

Insertions of nasal and oral foreign bodies (FB) are common presentations in the emergency department, with coins frequently implicated among paediatric populations. Contactless payments were first introduced in the UK in 2007, and cash payments significantly declined from 2012. This study aims to explore the potential implications of increasing contactless payments on FB ingestion.

METHODS

UK Hospital Episode Statistics (HES) were reviewed between 2000 and 2022. All FB retrieval procedures involving the alimentary tract, respiratory tract and nasal cavity were included. Regression analysis was performed to assess trends in the incidence of FB ingestion before and following the transition to cashless payments in 2012.

RESULTS

Following the decline in cash payments in 2012, the frequency of alimentary tract FB removal procedures decreased significantly by 27.78 procedures per year (p < 0.001). Similarly, respiratory FB removal procedure decreased by 4.83 per year (p = 0.009) and nasal cavity FB removal procedures decreased by 52.82 per year (p < 0.001).

CONCLUSIONS

This study suggests a statistically significant decline in the number of procedures for removal of FB performed in the UK from 2012. Although this relationship is multifactorial, our data suggest an association between the introduction of contactless payments and a reduction in the number of FB retrieval procedures from the of upper aerodigestive tract.

Perforation of the Terminal Ileum Secondary to Mucosal Damage of Enteroaggregative Escherichia coli and a Toothpick

Enteroaggregative Escherichia coli (EAEC) is a common form of E. coli that causes gastroenteritis and diarrhea worldwide. Biofilm formation on the intestinal mucosa initiates an inflammatory cascade in the gastrointestinal tissue, which has significant destructive effects on the mucosa of the small and large intestines. Small bowel obstruction and perforation due to a foreign body are uncommon, but the risk increases with pre-existing conditions such as the presence of intestinal strictures, inflammation, and mucosal ulceration. We present a unique case of acute enteritis from EAEC with mucosal ulceration and perforation because of co-ingestion of foreign body and impaction with the presence of stricture in the terminal ileum. This was treated with small bowel resection and primary anastomosis. The patient was successfully discharged from the hospital. The clinical features and pathological findings of enteric EAEC infection are described. To our knowledge, intestinal perforation and secondary peritonitis related to EAEC enteric infection, with mucosal ulceration and perforation secondary to co-ingestion of a foreign body with intestinal stricture, have not been documented. In this case, EAEC was associated with terminal ileum mucosal ulceration and complicated by perforation secondary to foreign body impaction along with ileal stricture. These compounding effects likely explain gastrointestinal tract perforation and secondary peritonitis.

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.

Spontaneous passage of ingested sewing needle: A case report

Key Clinical Message

Sewing needle ingestion is a rare but potentially dangerous event that can affect people of all ages and backgrounds like this patient.Conservative management with serial abdominal examination and x-rays can be a reasonable option for patients who do not show signs of perforation or sepsis, as most foreign bodies will pass spontaneously without complications such as this case.

Abstract

Though rare, swallowing a sewing needle is a peculiar and potentially dangerous health risk. People of all ages and backgrounds can accidentally ingest sewing needles, with cases documented in both children and adults. Our case focuses on a 17-year-old Ethiopian girl who accidentally gulped down a needle while stitching her clothing. Subsequently, she had an episode of vomiting that was tinged with blood along with ingested matter. Remarkably, the patient underwent conservative management using repeated abdominal checkups and x-rays, successfully passing the broken needle without any surgical intervention. It is important to remember that while uncommon, ingesting sewing needles might lead to significant complications, necessitating immediate and appropriate care.

Non-surgical Management of a Malecot Tube Migrating From a Small Bowel Fistula

Foreign bodies are encountered relatively often within the practice of general surgery. We present a unique case of a rubber, self-retaining, radiopaque "mushroom-tip" Malecot tube placed for fistula drainage control due to an enterocutaneous fistula (ECF) that became a gastrointestinal foreign body.  A 24-year-old male presented in shock with gunshot wounds to his right chest and right upper abdomen to a Level I trauma center. He required a prolonged hospital stay with additional urological and thoracic procedures and an interventional radiology procedure for hepatic pseudoaneurysm and subsequently developed an ECF. The patient was discharged to a rehabilitation facility with a wound management system (WMS) for ECF drainage but returned to the clinic with chemical burns and skin excoriation due to poorly controlled output and suboptimal WMS fit. A better fitting WMS was employed and a 20-French Malecot catheter was placed to assist with drainage control. The patient later returned with abdominal pain reporting the Malecot advanced forward spontaneously and was not externally visible. CT scan revealed the Malecot across the prior ileocolic anastomosis. After considering potential treatment options, we initially proceeded with aggressive bowel stimulation, and saline enemas hoping the tube would pass through his colostomy. He was discharged and the catheter passed at home a few days later via the stoma. Gastroenterological literature recommends invasive management for sharp, corrosive, or elongated foreign bodies exceeding 6cm in length. This unusual case demonstrates a 30-centimeter (cm) blunt object passing through the small bowel and colon in the absence of an ileocecal valve.

See Something, Say Something: Global Positioning System Tracker Foreign Body Ingestion as a Unique Presentation of Human Trafficking

In 2021, there were about 17,000 victims of human trafficking in the United States. We present a case of a 28-year-old sex trafficking victim who was forced to swallow 2 global positioning system trackers by her perpetrator. The gastroenterology team performed an upper endoscopy and retrieved 2 global positioning system devices from her antrum. Most of these victims do not disclose any history of abuse because of fear of their perpetrators. Further training and research can help to allow for recognition of these victims and potentially help them.

A retrospective cohort study on oesophageal food bolus obstruction in the North Denmark region in 2021-two thirds were never diagnosed with a cause

BACKGROUND

Food bolus obstruction (FBO) leading to hospital treatment is often associated with eosinophilic oesophagitis (EoE), stenosis, or oesophageal cancer (1). Danish national guidelines recommend that patients with FBO undergo a diagnostic upper endoscopy within two weeks of presentation to exclude possible malignancy, and histological evaluation of eight biopsies (2, 3).

AIMS

The aims of this study were to (1) report the incidence and describe the causes and treatment of FBO in the North Denmark Region (NDR), (2) determine the proportion of patients who underwent upper endoscopy and biopsy according to regional and national guidelines, and (3) identify International Classification of Diseases 10th Revision (ICD-10) diagnosis and procedure codes applied to the hospital visits due to FBO in the NDR.

METHODS

Among all acute hospital visits in the NDR in 2021, all visits with ICD-10 codes possibly reflecting FBO, as well as a random sample of 14,400 visits with unspecific ICD-10 codes (R and Z codes), were screened manually for possible FBO. Diagnosis, follow-up, and treatment of all patients with FBO were recorded.

RESULTS

The median patient age was 66.0 (Q1-Q3: 49.8-81.0) years, and half of the patients had experienced FBO before. Two thirds of patients (66.0%) were never diagnosed with a cause of FBO, followed by 17.3% with EoE. 30% of patients did not undergo upper endoscopy within two weeks of the hospital visit, and 50.7% were never biopsied in the oesophagus. Of 1886 hospital visits with registry ICD-10 codes that possibly reflected FBO, 8.4% were due to FBO, while FBO was present in 0.028% of the random sample of unspecific ICD-10 codes.

CONCLUSIONS

Most hospitalized FBO patients in the NDR in 2021 were never diagnosed with a cause. In these patients there is a high risk of overlooked EoE or upper gastrointestinal cancers. The area needs immediate focus and changed routines to improve treatment and prevent new FBO.

Sigmoid Colon Perforation, Pelvic Collection, and Hydronephrosis Caused by an Ingested Chicken Wishbone

This case report presents an unusual and challenging case of an 82-year-old female patient who presented with constipation and abdominal pain and was diagnosed with bowel perforation and hydronephrosis caused by an ingested chicken wishbone. This patient was treated with emergency laparotomy and bowel sigmoid resection. She made a good recovery and was discharged home. The patient's clinical presentation, diagnostic challenges, and successful management are discussed.

The Gastric Obstruction Due to Orbeez Beads Ingestion: A Case Report With Esophagogastroduodenoscopy Findings

Ingestion of non-food entities poses a critical risk, particularly in children and young adults. Mostly foreign bodies can safely pass through the gastrointestinal tract if they traverse the pylorus; however, ingestion of Orbeez beads can present as a unique challenge. Orbeez beads have the potential to absorb water and can expand in the stomach and small intestine, and can result in complications including constipation, intestinal obstruction, perforation, and peritonitis. Timely diagnosis and management are crucial to improve patient outcomes. We present a case of a 19-year-old male who ingested Orbeez beads and presented with nausea, vomiting, and abdominal pain. A non-contrast CT scan of the abdomen confirmed the foreign bodies. Fifty to seventy beads were successfully removed via esophagogastroduodenoscopy (EGD) without any complications, and the patient is currently doing well.

A Gastric Magnetic Foreign Body Incidentally Detected Several Years after Ingestion

Foreign body ingestion is commonly seen in children. However, occasionally it may also be seen among adults and is often associated with intellectual disability, psychiatric disorders, and alcoholism. Ingestion of a magnetic foreign body may cause complications such as gastrointestinal tract perforation, wherein emergency endoscopic removal of the foreign body is generally required. Here, we report a rare case of a 59-year-old male with an intellectual disability and psychiatric disorder in whom metallic objects in the stomach cavity were accidentally discovered during abdominal CT. Esophagogastroduodenoscopy revealed several metallic objects attached to two magnets, which had been ingested several years before and had remained in the stomach cavity. The magnets and metallic objects were safely removed endoscopically using rat-tooth forceps without complications.

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.

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.

Extraction of large foreign bodies from the airway by gastrointestinal endoscopy

Foreign body aspiration is a worldwide health problem that often results in life-threatening complications. Although flexible bronchoscopy is a safe procedure for removal of foreign bodies, it is usually unsuccessful in removing large foreign bodies from the airway. Gastrointestinal (GI) endoscopy, which is frequently used to remove foreign bodies from the gastrointestinal tract, has not been reported for retrieval of airway foreign bodies. In this report, we described three successful cases of removal of large airway foreign bodies by GI endoscopy. To avoid rigid bronchoscopy, GI endoscopy can be considered if flexible bronchoscopy has failed to remove a large or heavy airway foreign body in adult patients.

Imaging spectrum of non-neoplastic and neoplastic conditions of the duodenum: a pictorial review

Given its crucial location at the crossroads of the gastrointestinal tract, the hepatobiliary system and the splanchnic vessels, the duodenum can be affected by a wide spectrum of abnormalities. Computed tomography and magnetic resonance imaging, in conjunction with endoscopy, are often performed to evaluate these conditions, and several duodenal pathologies can be identified on fluoroscopic studies. Since many conditions affecting this organ are asymptomatic, the role of imaging cannot be overemphasized. In this article we will review the imaging features of many conditions affecting the duodenum, focusing on cross-sectional imaging studies, including congenital malformations, such as annular pancreas and intestinal malrotation; vascular pathologies, such as superior mesenteric artery syndrome; inflammatory and infectious conditions; trauma; neoplasms and iatrogenic complications. Because of the complexity of the duodenum, familiarity with the duodenal anatomy and physiology as well as the imaging features of the plethora of conditions affecting this organ is crucial to differentiate those conditions that could be managed medically from the ones that require intervention.

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.

Management Challenges of Recurrent Foreign Body Ingestions in a Psychiatric Patient: A Case Report

Intentional foreign body ingestions (FBIs) are commonly seen in adult patients with intellectual disabilities, substance use, severe psychiatric conditions, or external motivations, but these cases are rarely reported in the psychiatric literature. We present the case of a patient with an extensive history of FBIs and suicide attempts and a multitude of psychiatric diagnoses including borderline personality disorder, major depressive disorder, posttraumatic stress disorder from significant abuse in foster care, obsessive-compulsive disorder, and pica. During the single hospitalization described in this report, she had multiple incidents of self-harm, aggression, and 9 FBIs. A multidisciplinary team involving psychiatry, emergency medicine, gastroenterology, surgery, internal medicine, nursing, social work, behavioral health technicians, case management, chaplain, the legal department, police officers, and hospital maintenance was necessary for care coordination. Interventions included 8 endoscopies and an abdominal surgery to retrieve swallowed foreign bodies, pain management, psychopharmacological and psychotherapeutic interventions for agitation, and environmental precautions to minimize the risk of ingestion. Ultimately, to prevent further trauma and limit additional opportunities for FBI, a collaborative decision was made with the patient to discharge her to her home with outpatient psychologist and psychiatrist support. This case describes the complexities of hospital management of a patient with intentional recurrent FBI, highlighting the importance of a critical assessment of risk versus benefit for prolonging hospitalization. Development of practical management protocols and risk assessments for continued hospitalization is necessary for patients with recurrent intentional FBIs.

Esophageal emergencies

The esophagus is a deeply located organ which traverses the neck, the thorax, and the abdomen and is surrounded at each level by vital organs. Because of its positioning injuries to the esophagus are rare. Their common denominator is the risk of the organ perforation leading to spillage of digestive contents in surrounding spaces, severe sepsis and eventually death. Most frequent esophageal emergencies are related to the ingestion of foreign bodies or caustic agents, to iatrogenic or spontaneous esophageal perforation and external esophageal trauma. Early diagnosis and appropriate management are the keys of successful outcomes.

Clinical Experiences and Selection of Accessory Devices for Pediatric Endoscopic Foreign Body Removal: A Retrospective Multicenter Study in Korea

BACKGROUND

Swallowing of foreign bodies (FBs) is the most common indication of therapeutic endoscopy in children. Endoscopic removal may be necessary depending on the type of FB, age of the child, and location of the FB. We attempted to analyze the characteristics of each device used for the endoscopic removal of FBs in children.

METHODS

Medical records of the patient's age, sex, weight, type, location, size, shape, type of device used for endoscopic removal, and endoscopic time were retrospectively collected.

RESULTS

A total of 424 FB removal procedures were analyzed. The average age of the patients at the time of FB removal was 4.1 ± 3.7 years. Coins were the most common FBs (192, 45.3%). The most common locations of the FBs were the esophagus (45.7%) and the stomach (48.3%), respectively. For a total of 371 cases, forceps were used in 96 cases (25.9%) for esophageal FBs and in 25 cases for gastric FBs (6.7%), while nets were used in 250 cases (67.4%) for gastric FBs retrieval; the average durations of the procedures were 7.2 ± 7.4 minutes, 8.5 ± 7.2 minutes, and 5.7 ± 7.3 minutes, respectively (P = 0.003). The procedure time was significantly shorter, in the group of patients with low body weights, when nets were used than when forceps were used to remove gastric FBs (P = 0.001).

CONCLUSION

The endoscopic procedure duration, in low-weight children, was shorter when retrieval nets were used than that with forceps.

Feasibility and safety of a self-developed sleeve for the endoscopic removal of refractory foreign body incarceration

Objective

This study aimed to assess the feasibility and safety of a novel self-designed sleeve for the endoscopic removal of a refractory incarcerated foreign body in the upper gastrointestinal tract (UGIT).

Methods

An interventional study was conducted between June and December 2022. A total of 60 patients who underwent an endoscopic removal of a refractory incarcerated foreign body from the UGIT were randomly allocated to the self-developed sleeve and the conventional transparent cap. The study evaluated and compared the operation time, successful removal rate, new injury length at the entrance of the esophagus, new injury length at the impaction site, visual field clarity, and postoperative complications between the two groups.

Results

The success rates of the two cohorts in the foreign body removal display no significant discrepancy (100% vs. 93%, P = 0.529). Nevertheless, the methodology of the novel overtube-assisted endoscopic foreign body removal has culminated in a significant reduction in the removal duration [40 (10, 50) min vs. 80 (10, 90) min, P = 0.01], reduction in esophageal entrance traumas [0 (0, 0) mm vs. 4.0 (0, 6) mm, P < 0.001], mitigation of injuries at the location of the foreign body incarceration [0 (0, 2) mm vs. 6.0 (3, 8) mm, P < 0.001], an enhanced visual field (P < 0.001), and a decrement in postoperative mucosal bleeding (23% vs. 67%, P < 0.001). The self-developed sleeve effectively negated the advantages of incarceration exclusion during removal.

Conclusion

The study findings support the feasibility and safety of the self-developed sleeve for the endoscopic removal of a refractory incarcerated foreign body in the UGIT, with advantages over the conventional transparent cap.

Perforation of ileum by unnoticed toothpick ingestion presenting as acute appendicitis: A case report

INTRODUCTION

Many distinct pathologic disorders can cause acute abdomen, and it can be challenging for doctors to distinguish between them. Appendicitis and small bowel perforation are two examples. This case is being reported to highlight a rare instance in which acute appendicitis can be mistaken for ileal perforation by sharp solid objects.

CASE PRESENTATION

We discuss the case of a 9-year-old boy who arrived at our hospital complaining of right iliac fossa abdominal pain that started two days earlier with no other associated symptoms. Physical examination revealed right iliac fossa tenderness and rebound tenderness. The results of the imaging and laboratory tests were inconclusive; therefore, the patient was admitted for observation and further assessment. Re-evaluation 4 h after admission found no clinical improvement, and abdominal examination revealed guarding and rebound tenderness, prompting the surgical team to opt for an appendectomy. During surgery, an elliptical incision was made to remove a sharp foreign body penetrating the ileum.

DISCUSSION

Even during surgery, diagnosing acute appendicitis is difficult. Some cases of small bowel perforation caused by foreign body ingestion have been linked to a clinical picture similar to acute appendicitis, while others present with acute peritoneal signs. This report describes a sealed ileal perforation by a sharp solid object, manifested as acute appendicitis.

CONCLUSION

Perforation of the small bowel by sharp solid objects may easily be missed on imaging, probably related to their ability to seal off the resulting perforation. A sharp solid object's perforation seems to cause localized tenderness mimicking appendicitis.

Effect and Safety of Painless and Conventional Endoscopic Management of Denture Impaction in the Esophagus

Objective

To improve the level of clinical diagnosis and treatment, reduce the incidence of complications, and provide the basis for clinicians to choose an appropriate treatment, this research explores the removal methods of the impacted denture in the esophagus by endoscopy.

Methods

Based on the clinical information, treatment methods and complications of 72 patients with denture impaction in the esophagus admitted to our hospital from January 2016 to March 2021, which were divided into the group treated with painless endoscopy and the group treated with conventional endoscopy, retrospective analysis of the therapeutic effect and complications was conducted.

Results

There was no statistically significant difference between the two groups in terms of denture removal rate (P > 0.05). There were statistically significant differences between the two groups in terms of operating time and incidence rates of complications during and after the procedure. The operating time of the group treated with painless endoscopy was significantly shorter than the group treated with conventional endoscopy (P < 0.05). The incidence rates of complications during and after the procedure of the group treated with painless endoscopy were significantly lower than the group treated with conventional endoscopy (P < 0.05).

Conclusions

Compared with the conventional endoscopy, painless endoscopic management of denture impaction in the esophagus under general anesthesia with tracheal intubation improves the clinical efficacy and reduces the adverse reactions. Thus, it is worthy of clinical popularization and application.

Fish Hook as Foreign Body: Not All Foreign Bodies Can Be Fished Out of the Esophagus With Endoscopy Alone

A 75-year-old male presented to the hospital with acute onset of neck pain. Although the patient did not report known ingestion of a foreign body, there was evidence of a fish hook in the cervical esophagus on plain neck radiography. Due to the location at the upper esophageal sphincter in the hypopharynx, the foreign body was not retrievable by endoscopy alone and required better visualization and airway protection with direct laryngoscopy and rigid esophagoscopy. A fish hook was promptly retrieved within 24 hours of the patient's presentation and his symptoms resolved without complications. We report this unusual case to emphasize the importance of proper food preparation, thoroughly chewing food before swallowing, and prompt management of foreign body ingestion in adults.

CT Evaluation of Swallowed Foreign Bodies Located in the Gastrointestinal System

Background and objective

CT imaging is important in detecting the location and the structure of swallowed foreign bodies and assessing their complications, due to its features such as the ability to show the detailed anatomical structure and enable multiplanar examination. In this study, we aimed to analyze the CT findings of swallowed foreign bodies located in the gastrointestinal tract and compare them with the data in the existing literature.

Materials and methods

We conducted a retrospective archive study to achieve our goals. Patients who presented to our radiology department with the preliminary diagnosis of foreign body ingestion, abdominal pain, or acute abdomen and were found to have a foreign body in the gastrointestinal tract on CT between April 2018 and April 2021, especially those in whom the presence of a foreign body was confirmed by endoscopy or surgery, were included in our study. The patients were evaluated in terms of age, gender, foreign body type, foreign body localization, and complications.

Results

A total of 31 patients (15 males and 16 females) were included in the study. The patients’ age ranged from 1 to 67 years, and the mean age was 28.5 ±5.4 years. The most common foreign bodies found were metallic toy parts (n=11, 35%), and most of the foreign bodies were located in the ileum (n=9, 29%) of the patients. Complications were observed in nine patients (29%). In patients with complications, the most common finding was perforation (n=3, 38%).

Conclusion

When a CT exam is performed on patients with abdominal pain, the gastrointestinal tract should be carefully evaluated to determine if a foreign body is involved and to analyze the complications caused by the foreign body.

A Prolonged History of Denture Impaction for 12 Weeks In Situ

Foreign body ingestion has serious consequences if left untreated. Impacted dentures for a prolonged period can lead to life-threatening complications. Therefore, prompt diagnosis and immediate intervention are lifesaving. Our patient presented to his local accident and emergency department after having swallowed his dentures during a meal. Initial investigations and workup detected no abnormalities and he was discharged back to the community. Twelve weeks following ingestion, he had developed dysphagia and weight loss which prompted an urgent referral for oesophago-gastro-duodenoscopy (OGD). This identified the dentures impacted within the upper oesophagus and initial attempts at removal were unsuccessful, therefore he required hospital admission for alternative feeding in the interim. A joint procedure with the Ear, Nose and Throat and upper gastrointestinal surgeons was carried out to successfully remove the dentures endoscopically. The patient made an immediate recovery, resuming his normal oral diet with appropriate follow up after discharge. It is suspected our patient had an impacted denture for a period of 12 weeks without sustaining any life-threatening complications, which makes this case rather unique. This case highlights the importance of thorough and careful clinical history taking and examination. 

Successful removal of an accidentally swallowed press‐through package sheet using a detachable snare: A case report

Accidental swallowing of press‐through package (PTP) sheets that could cause esophageal perforation is commonly encountered in emergency departments requiring early detection and removal. We report a case in which an accidentally swallowed PTP sheet was removed from the esophagus using a detachable snare after usual endoscopic methods proved ineffective. A Japanese woman in her 60s visited the emergency department with a persistent sore throat. Cervicothoracic computed tomography revealed presence of a PTP sheet in the cervical esophagus, and emergency endoscopy was performed. Pre‐endoscopy simulations using a sheet identical to the one swallowed by the patient indicated that the sheet would not have been retrievable using an overtube (its inner diameter was smaller than the sheet's diameter) and grasping forceps (they slipped off the sheet). It was successfully removed using a detachable snare, a device normally employed in colorectal polypectomy, allowing us to ligate the end of the sheet and pull it into the overtube. To the best of our knowledge, this is the first report of endoscopic removal of a PTP sheet from the esophagus using a detachable snare. We suggest that this novel method would facilitate removal of esophageal PTP sheets.

Rigid versus flexible endoscopy for managing ingested foreign bodies-can we improve pathways?

PURPOSE

This study aims to evaluate management pathways, outcomes and safety of rigid endoscopy (RE) and flexible endoscopy (FE) for the treatment of impacted foreign bodies of the upper gastrointestinal tract (UGIT) in adults.

METHODS

Retrospective study, included all patients undergoing RE or FE for impacted UGIT foreign body over an 11-year-period.

RESULTS

A total of 144 patients were included (95 FE and 49 RE). FE were performed under local anaesthetic or sedation, and RE under GA. Success rate of FE and RE were 95.8% and 95.9% respectively. During FE an intra-procedural biopsy was performed in 45/95 (47.3%); with 26/95(27.4%) identifying mucosal pathology. Complications was significantly higher in patients having RE (40.8% versus 6.3%, p = .001).

CONCLUSION

FE and RE are effective for the therapeutic management of impacted UGIT foreign bodies. However, FE can be performed under LA and was associated with fewer complications, favouring FE where possible as a first line option.

Perforation of the cecum from ingested foreign body in a 14 year old adolescent with autism spectrum disorder and epilepsy: A case report

INTRODUCTION AND IMPORTANCE

Although foreign body ingestion is a common medical issue, intestinal perforations following foreign body ingestion are rare. Diagnosing foreign body ingestion is challenging especially in children with neurodevelopmental disorders such as Autism Spectrum Disorder (ASD). It is believed that approximately 80-90% of ingested foreign bodies pass through the gastrointestinal tract without causing any luminal damage, and only approximately 1% of foreign bodies are known to remain lodged within the bowel and cause luminal erosion and perforation.

CASE PRESENTATION

A 14-year-old boy, diagnosed to have Autism Spectrum Disorder was brought in by his parents to our hospital with right lower quadrant (RLQ) abdominal pain and fever. On examination, he was tachycardic and there was direct tenderness over the RLQ of the abdomen. Acute appendicitis was entertained and the patient was examined with ultrasound. The ultrasound reported, "The tip of the appendix was dilated (0.62cm) and there is minimal RLQ intra-peritoneal fluid collection". With the impression of acute appendicitis, the patient was explored and he was found to have a cecum perforation due to an ingested foreign body (twig). Initially we did tube cecostomy but later we did right hemicolectomy because the cecostomy tube had leaked.

CONCLUSION

Foreign body ingestion should be taken into account during the evaluation of children and adolescents with neurodevelopmental disorders who presented with acute abdominal pain. Since diagnosis is difficult clinicians who are involved in acute care medicine should take a thorough history with a high index of suspicion for foreign body ingestion.

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.

Esophageal Foreign Body Removal: A Novel Approach

Upper esophageal foreign body impaction is a common clinical presentation and often requires medical attention. The most common foreign bodies encountered in the adult population are food-related, e.g., steak pieces and meat bones. Endoscopic interventions are indicated when the foreign objects fail to pass spontaneously. The standard methods to remove these foreign bodies include push technique and retrieval methods using various endoscopic instruments. However, we report a unique method that was used to remove a large upper esophageal impacted foreign body refractory to removal by standard procedures.

Novel Approach to Endoscopic Foreign Body Retrieval From the Gastric Body

Foreign body (FB) ingestion is a common occurrence in the United States with a reported incidence of 120 per 1 million people, accounting for up to 1500 fatalities annually. The majority of FB ingestions will pass through the gastrointestinal tract spontaneously, while in 10% to 20% of patients, intervention will be necessary. A variety of endoscopic devices can be utilized to facilitate FB removal from the gastrointestinal tract, including snares, retrieval nets, and grasping forceps. We report the case of a 58-year-old female who required utilization of endoscopic scissors for FB removal in the setting of multiple failed attempts with traditional methods. This case highlights a novel approach to gastric FB removal utilizing endoscopic scissor forceps, which should be considered in select cases to further improve the efficacy of endoscopic FB removal and reduce the need for surgical intervention.

Abdominal CT manifestations in fish bone foreign body injuries: What the radiologist needs to know

Fish bone is one of the most common foreign body ingestions encountered in the emergency department. Fish bone perforations occur most commonly in segments with acute angulation like the ileocecal region and rectosigmoid junction and can present acutely with obstruction and free air or with chronic complications like abscess and sepsis. Radiologists should be familiar with the high-risk clinical scenarios, the CT appearance of radiopaque fishbones, and the spectrum of imaging findings related to gastrointestinal (GI) tract so as to direct management and timely referral to GI endoscopists and surgeons.