GuidelineManagement of ingested foreign bodies and food impactions
Introduction
Foreign body ingestion and food bolus impaction occur commonly. The majority of ingested foreign bodies will pass spontaneously. Pre-endoscopic series have shown that 80% or more of foreign objects will likely pass without the need for intervention.2, 3 However, 2 recent studies have shown that in the setting of intentional ingestion, the rate of endoscopic intervention may be much higher (63%-76%) and the need for surgical intervention ranges from 12% to 16%.4, 5 Mortality rates have been extremely low; a compilation of multiple studies including 2 large series report no deaths in 852 adults and 1 death in 2206 children.6, 7, 8, 9, 10, 11, 12, 13, 14
The majority of foreign body ingestions occur in the pediatric population, with a peak incidence between the ages of 6 months and 6 years.8, 11, 13, 14 In adults, true foreign body ingestion (ie, nonfood objects) occurs more commonly in those with psychiatric disorders, developmental delay, alcohol intoxication, and in incarcerated individuals seeking secondary gain via release to a medical facility.4, 5, 8, 15, 16 Ingestion of multiple foreign objects and repeated episodes of ingestion are common. Edentulous adults are also at greater risk of ingesting foreign bodies, including an obstructing food bolus or their dental prosthesis.17 Patients presenting with food bolus impaction often have underlying esophageal pathology directly causing the impaction.8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18
Impaction, perforation, or obstruction often occurs at GI angulations or narrowing.19 Hence, patients with previous GI tract surgery or congenital gut malformations are at increased risk.20, 21 Once through the esophagus, most foreign bodies, including sharp objects, pass uneventfully.2, 3, 8 However, ingestion of sharp and pointed objects, animal or fish bones, bread bag clips, magnets, and medication blister packs increase the risk of perforation.2, 4, 5, 6, 18, 22, 23, 24, 25
Section snippets
Diagnosis
Older children and nonimpaired adults may identify the ingestion and localize discomfort. However, the area of discomfort often does not correlate with the site of impaction.26 Frequently, symptoms occur well after the patient ingests the foreign body.27, 28, 29, 30 Young children, mentally impaired adults, and those with psychiatric illness may thus present with choking, refusal to eat, vomiting, drooling, wheezing, blood-stained saliva, or respiratory distress.13, 16, 31 Oropharyngeal or
Airway
Initial management includes assessment of the patient's ventilatory status and an airway evaluation. Patients unable to manage their secretions are at high aspiration risk and require urgent management. In some cases of proximal esophageal foreign body ingestion, endotracheal intubation is appropriate for airway protection. Endotracheal intubation, typically performed with the patient under general anesthesia, may also be required for patients with objects that are difficult to remove, for
Recommendations
- 1
We suggest avoiding contrast radiographic examinations with before removal of foreign objects. ⊕○○○
- 2
We suggest an otorhinolaryngology consultation for foreign bodies at or above the level of the cricopharyngeus. ⊕○○○
- 3
We recommend emergent removal of esophageal food bolus impactions and foreign bodies in patients with evidence of complete esophageal obstruction. ⊕⊕○○
- 4
We suggest that acceptable methods for the management of esophageal food impactions include en bloc removal, piecemeal removal, and
Disclosure
The following authors disclosed financial relationships relevant to this publication: Dr. Ben-Menachem: consultant to Boston Scientific; Dr. Decker: consultant to Facet Biotech; Dr. Harrison: consultant to Fujinon. All other authors disclosed no financial relationships relevant to this publication.
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This document is a product of the Standards of Practice Committee. The document was reviewed and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy.