Few pages test a GI fellow's triage instincts like the call for a swallowed object or a steak stuck since dinner. Foreign body ingestion (FBI) and esophageal food impaction (EFI) sit alongside GI bleeding among the most common nonbiliary GI emergencies, with EFI alone occurring at roughly 13 episodes per 100,000 person years.¹ Most ingested objects pass spontaneously, but the minority that do not can perforate, obstruct, or kill, and the difference between a routine case and a catastrophe often comes down to recognizing who needs a scope now. This article reviews the clinical presentation, initial medical management, and endoscopic management of FBI and EFI, with emphasis on timing, underlying pathology, and the tools every fellow should know how to reach for.
Clinical Presentation
Adults with FBI or EFI most often present with acute retrosternal pain, sudden dysphagia, odynophagia, globus sensation, or drooling.² Two findings should immediately raise the acuity in your mind: drooling or inability to handle secretions, which signals complete esophageal obstruction and mandates emergent endoscopy, and crepitus, neck swelling, or severe pain out of proportion, which suggests perforation. Remember that the patient's perceived level of discomfort is unreliable for localizing the obstruction, particularly below the cricopharyngeus.
History should establish what was ingested (and whether bones may be involved), when it happened, prior dysphagia or food impactions, prior esophageal or gastric surgery, and psychiatric history in cases of intentional ingestion. Examination begins with airway and hemodynamics; palpate the neck and chest for crepitus and the abdomen for peritoneal signs if the object may have passed distally.
Most adult EFI occurs above a point of underlying esophageal pathology, and this is where the fellow's job extends beyond disimpaction. Eosinophilic esophagitis (EoE) accounts for a third to half of adult food impactions, with Schatzki rings, peptic strictures, motility disorders, and, less commonly, malignancy making up much of the remainder.³ An impaction is frequently the presenting event of the underlying disease.
Initial Evaluation and Medical Management
Imaging. For suspected foreign bodies, biplanar radiographs of the neck, chest, and abdomen localize most radiopaque objects; plastic, wood, glass, and small bones are commonly radiolucent. CT is indicated when perforation is suspected or when sharp objects or bones must be localized, with sensitivity for perforation of 80% to 100%.² Two caveats matter at 2 AM: imaging should never delay endoscopy when complete obstruction is suspected, and uncomplicated food impactions without suspected bones generally do not require imaging at all before EGD.
Pharmacologic therapy. Glucagon (1 mg IV) remains widely used for EFI on the theory that it relaxes the lower esophageal sphincter, but meta-analysis data show no significant benefit over placebo, and it can provoke vomiting.⁴ It is reasonable as a bridge while mobilizing the endoscopy team but never as a substitute for it. Effervescent agents fall into the same category. For button battery ingestion, early administration of honey or sucralfate suspension (within 12 hours of ingestion, with honey avoided in infants under 1 year) can mitigate alkaline mucosal injury while awaiting emergent removal.² Emetics, cathartics, and acid suppression do not hasten battery passage. For caustic ingestions, keep the patient NPO, start a proton pump inhibitor, avoid neutralizing agents and blind nasogastric tube placement, and use endoscopic grading (Zargar classification) to direct management.
Endoscopic Management
Timing: The Triage Backbone
Guidance from ASGE and ESGE can be distilled into a practical hierarchy:⁵,⁶
- Emergent (within 2 to 6 hours): complete esophageal obstruction (inability to manage secretions), sharp objects in the esophagus, button or disk batteries in the esophagus, and evaluation of unstable patients after caustic ingestion. These cases proceed regardless of NPO status, with airway protection strongly considered.
- Urgent (within 24 hours): esophageal foreign bodies without complete obstruction; gastric sharp objects, magnets, batteries with concerning features, and objects longer than 5 to 6 cm or wider than 2.5 cm that are unlikely to clear the pylorus.
- Nonurgent (within 72 hours): medium sized blunt gastric objects. Blunt objects that fail to leave the stomach within 3 to 4 weeks warrant elective removal.
A few rules specific to certain objects deserve memorization. Sharp objects anywhere proximal to the ligament of Treitz should be retrieved given a perforation risk of roughly 4%. Multiple magnets (or a magnet with metal coingestion) risk transmural attraction, fistula, and necrosis and should be removed. Drug packets are the one absolute contraindication to endoscopic retrieval because rupture risks fatal overdose; these are managed with observation, serial imaging, and surgery if packets stall or toxicity develops.² Objects above the cricopharyngeus belong to our ENT colleagues via laryngoscopy.
The Fellow's Toolbox
Device selection follows the object.⁵,⁷ Rat tooth and alligator forceps grip irregular or sharp objects for controlled retrieval; retrieval (Roth) nets securely envelop coins, batteries, and flat or fragile objects; polypectomy snares handle food boluses, coins, and larger items and permit piecemeal extraction; and baskets excel with round objects. For food impactions, gentle piecemeal retrieval with a net, snare, or cap assisted suction is preferred. The classic push technique may be used cautiously once the scope can visualize beyond the bolus, recognizing that blind pushing against an unappreciated stricture risks perforation.
Two adjuncts elevate safety in higher risk retrievals. An overtube (esophageal length of at least 50 cm) protects the airway and esophageal mucosa during sharp object removal and allows repeated intubations for piecemeal work. A latex protector hood or cap serves a similar shielding function for pointed objects; orient the sharp end trailing on withdrawal. Fluoroscopy, balloon assisted enteroscopy for small bowel objects, and even EUS guided retrieval of embedded foreign bodies round out the modern armamentarium.⁷
Don't Scope and Run: The Underlying Pathology
The disimpaction is half the procedure. Given the strong association between EFI and EoE, obtain esophageal biopsies (proximal and distal, away from the impaction site) at the index endoscopy whenever feasible; roughly a third of adults with EFI will prove to have EoE.³,⁸ Document rings, furrows, strictures, and Schatzki rings. Dilation of a stricture at the index procedure is permitted by guidelines but discretionary based on mucosal trauma, and patients with suspected untreated EoE are generally better served by staged outpatient dilation after medical therapy.⁵,⁸
Follow Up
Recurrence after EFI is 10% to 20%, and a quarter of patients historically fail to receive appropriate follow up after emergency endoscopy, a gap fellows are well positioned to close before discharge.⁹ Arrange GI follow up for biopsy results, initiation of PPI or EoE therapy, and dilation planning; ensure surveillance after high grade caustic injury given the risks of stricture and eventual squamous cell carcinoma; and engage psychiatry early for intentional recurrent ingestion, where behavioral therapy and pragmatic inpatient prevention strategies outperform prolonged hospitalization.
Bottom Line for Fellows
Triage by secretions, object, and location; scope emergently for obstruction, sharps, and esophageal batteries; know your retrieval devices before the case, not during it; and treat every food impaction as a diagnostic opportunity. Biopsy, plan follow up and find the disease behind the bolus.
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References
- Longstreth GF, Longstreth KJ, Yao JF. Esophageal food impaction: epidemiology and therapy. A retrospective, observational study. Gastrointest Endosc. 2001;53(2):193-198.
- Kamalumpundi V, Saha B, Leggett C. Management of foreign body ingestions and food impactions: advice for general practitioners. Mayo Clin Proc. 2025;100(8):1411-1419.
- Lenz CJ, Leggett C, Katzka DA, et al. Food impaction: etiology over 35 years and association with eosinophilic esophagitis. Dis Esophagus. 2019;32(4):doy093.
- Peksa GD, DeMott JM, Slocum GW, Burkins J, Gottlieb M. Glucagon for relief of acute esophageal foreign bodies and food impactions: a systematic review and meta-analysis. Pharmacotherapy. 2019;39(4):463-472.
- Ikenberry SO, Jue TL, Anderson MA, et al; ASGE Standards of Practice Committee. Management of ingested foreign bodies and food impactions. Gastrointest Endosc. 2011;73(6):1085-1091.
- Birk M, Bauerfeind P, Deprez PH, et al. Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016;48(5):489-496.
- Shahid Y. Modern endoscopist's toolbox: innovations in foreign body removal. World J Gastrointest Endosc. 2025;17(6):106099.
- Aceves SS, Alexander JA, Baron TH, et al. Endoscopic approach to eosinophilic esophagitis: American Society for Gastrointestinal Endoscopy Consensus Conference. Gastrointest Endosc. 2022;96(4):576-592.e1.
- Guo H, Hamilton P, Enns E, et al. Postendoscopy care for patients presenting with esophageal food bolus impaction: a population-based multicenter cohort study. Am J Gastroenterol. 2023;118(10):1787-1796.
Author
Vibhu Chittajallu, MD, ABOM is an Assistant Professor of Medicine and Advanced Endoscopist in the Division of Gastroenterology at UT Southwestern Medical Center in Dallas, TX. His clinical and research interests include endoscopic management of obesity and interventional EUS, including EUS guided radiofrequency ablation.