clinical guidelines for imaging and reporting inge

AJR:203, July 2014 37

Clinical Guidelines for Imaging and Reporting Ingested Foreign Bodies

Mark Guelfguat1Vladimir Kaplinskiy2Srinivas H. Reddy3Jason DiPoce4,5

Guelfguat M, Kaplinskiy V, Reddy SH, DiPoce CJ

1Department of Radiology, Jacobi Medical Center, 1400 S Pelham Pkwy, Bronx, NY 10461. Address correspondence to M. Guelfguat ([email protected]).

2Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA.

3Department of Surgery, Jacobi Medical Center, Bronx, NY.

4Radiology Department, Columbia University Medical Center, New York, NY.

5Present address: Department of Radiology, Hadassah Medical Center, Jerusalem, Israel.

Gastrointest ina l Imaging Review

This article is available for credit.

AJR 2014; 203:3753

0361803X/14/203137

American Roentgen Ray Society

Keywords: foreign bodies, gastrointestinal tract, ingestion

DOI:10.2214/AJR.13.12185

Received October 30, 2013; accepted after revision February 8, 2014.

Presented at the 2013 annual meeting of the ARRS, Washington, DC (Education Exhibit E183).

FOCU

S O

N:

Although the guidelines are set primarily for clinicians to determine the next step in clinical management, the guidelines require knowl-edge of the foreign bodys characteristics, such as its position and composition. Radio-logic examination can frequently provide this information. Therefore, radiologists should be familiar with these guidelines (Table 1).

Imaging ModalitiesRadiographs

Indications for radiography can be sub-divided according to the purposes of initial diagnosis or elimination follow-up. For the purpose of initial diagnosis, radiographs can confirm the location, size, shape, and num-ber of ingested foreign bodies and can help to exclude aspirated objects [5]. Radiographs identify most foreign bodies, especially if the object is likely to be radiopaque [13]. Nev-ertheless, nonradiopaque foreign bodies are common, which limits the reliability of ra-diographs for initial evaluation [14]. Fish and chicken bones, wood, plastic, and thin metal objects are some of the most common radio-lucent objects [5, 15, 16]. Thin fragments of aluminum, such as pull-tabs or pop-tabs of beverages, are not radiopaque [15]. Once a radiographically identified object is deemed likely to pass without intervention, serial im-aging is conducted to ensure prompt progres-sion and elimination [5].

On the basis of the location of a foreign object in the body determined by a preced-ing clinical evaluation, frontal and lateral

Foreign body ingestion is a com-mon problem that often requires little intervention. For example, 8090% of ingested foreign bod-

ies are able to pass without intervention, 1020% must be removed endoscopically, and only approximately 1% require surgery [1]. However, intentional ingestion results in in-tervention rates as high as 76% [2], and sur-gical intervention is performed in as many as 28% of patients [3]. Foreign body ingestion results in the death of approximately 1500 people annually in the United States [4]. As noted by Palta et al. [2], immediate clinical manifestations of foreign body ingestion range from epigastric pain (55%), vomiting (16%), dysphagia (7%), pharyngeal discom-fort (4%), and chest pain (3%) to the absence of symptoms (30%). Pediatric and mentally handicapped patients may present immedi-ate symptoms of foreign body ingestion, commonly including choking, refusal to eat, hypersalivation, wheezing, and respiratory distress [5]. Some patients may remain asymp-to matic for many years [6]. Without treat-ment, complications may include perforation [7], obstruction [8], esophageal-aortic fistula [9] or tracheoesophageal fistula formation [10], and sepsis [11].

Guidelines outlined by the American So-ciety of Gastrointestinal Endoscopy estab-lish multiple parameters for the clinical man-agement of foreign body ingestion based on knowledge of the chemical properties, size, sharpness, and location of the object [5, 12].

OBJECTIVE. The purpose of this article is to familiarize radiologists with the specif-ic characteristics of foreign bodies, obtained from image interpretation, to guide further management. Details of object morphologic characteristics and location in the body gained through imaging form the backbone of the classification used in the treatment of ingested for-eign bodies.

CONCLUSION. The characteristics of foreign bodies and predisposing bowel abnor-malities affect the decision to follow ingested objects radiographically, perform additional imaging, or proceed with endoscopic or surgical removal.

Guelfguat et al.Imaging of Ingested Foreign Bodies

Gastrointestinal ImagingReview

Dow

nloa

ded

from

ww

w.a

jronli

ne.or

g by 1

12.21

5.66.7

0 on 0

8/18/1

4 from

IP ad

dress

112.2

15.66

.70. C

opyri

ght A

RRS.

For p

erson

al use

only;

all ri

ghts

reserv

ed

38 AJR:203, July 2014

Guelfguat et al.

radiographs of the neck, chest, or abdomen can be obtained. Additional views, such as an oblique projection or a supplementary ex-piratory view of the thorax in the setting of a suspected endobronchial foreign body, can be used to confirm the diagnosis [5, 17, 18].

The visibility of low-opacity foreign bod-ies on head and neck radiographs can be im-proved by using a low-peak-kilovoltage tech-nique, at settings such as 6570 kVp [19, 20]. This low-kilovoltage technique would in-crease the contrast between tissues and ra-diopaque objects. At that level, image char-acteristics rely mostly on the photoelectric effect and depend on atomic number dif-ferences. Thus, the higher atomic numbers of iron, silicon, and calcium in the foreign bodies will be in greater contrast with low-er atomic numbers of hydrogen, oxygen, and carbon in the soft tissues. A suggested radio-graphic protocol for monitoring progress of foreign body passage through the gastroin-testinal tract is summarized in Table 2.

CTCT is considered to be a sensitive tool for

foreign body detection [21, 22]. However, inconsistencies in detecting radiolucent for-eign bodies have been reported [5].

The sensitivity of radiographs relative to CT in foreign body detection has been exten-sively studied in the orofacial region [19, 20]. Naturally, the ease of detection is directly re-lated to the opacity of an object. In addition, visualization also depends on the densities of the surrounding tissues. Proximity to osse-ous structures and intramuscular location di-minishes the visualization of faintly opaque objects on both radiographs and CT. The higher sensitivity of CT in foreign body de-tection relative to radiographs is even more apparent with faintly opaque objects, partic-ularly when surrounded by air. Some authors have found that the sensitivity of CT can be improved with use of 3D reformations [23] by enhancing the visualization of the foreign body, reassessing the extent of intestinal in-jury, and directing preprocedural planning.

The use of IV contrast agent in the detec-tion of foreign bodies is not clearly defined in the literature. However, the use of IV contrast agent has been long established for the diag-nosis of intraabdominal inflammatory proc-esses, such as diverticulitis [24]. Therefore, if foreign bodyrelated complications, such as an abscess, peritonitis, or fistula formation, are suspected, IV contrast agent would enhance the diagnostic quality of the examination.

TABLE 1: Indications for Foreign Body Removal by Endoscopy or Surgery, According to Our Institutional Experience and Literature Review

Object Type Endoscopic Removal Surgery

Long and short blunt objects If longer than 6 cm and proximal to the first portion of the duodenum [5]; if wider than 2.5 cm [5]

Surgical removal should be considered if objects remain in the same location distal to the duodenum for more than 1 week [30]

Coins If they remain longer than 1224 hours in the esophagus and 34 weeks in the stomach in an asymptomatic patient [1, 5]

Sharp and sharp-pointed objects

In the esophagus, they constitute a medical emergency and endoscopic removal should be attempted; in the stomach or duodenum, they require urgent endoscopic removal [5]; endoscopy should still follow a radiologic examination with negative findings because many sharp-pointed objects are not radiographically visible [5]

If the sharp foreign body beyond the duodenum fails to progress radiographically for 3 consecutive days, surgical intervention should be considered [1, 5]

Magnets Magnets within endoscopic reach are a reason for urgent endoscopy [5]

Failure of a magnet to move through the lumen on sequential radio-graphs, and location beyond endoscopic reach, should prompt surgical evaluation [29]; radio-graphic findings suggesting bowel entrapment, obstruction, or perforation should prompt emergent surgical evaluation [29]

Disk batteries Emergent endoscopic removal is indicated for a suspected disk battery discovered in the esophagus [5]

Formal laparotomy with removal should be considered if it appears that the passage of the battery in the bowel has been arrested [68]

Endoscopic capsule Effective removal can be achieved by endoscopic or surgical intervention [84]

Effective removal can be achieved by endoscopic or surgical intervention [84]

Narcotic packets Endoscopic removal should not be attempted if concerned for rupture and leakage of the contents [1, 5]

Surgical intervention is indicated when drug packets fail to progress or if there is intestinal obstruction [1, 5]

Bezoars In the acute clinical setting, endoscopic disruption and removal of the mass can be performed [89]

Many bezoars require surgical removal [89]

TABLE 2: Suggested Radiographic Protocol for Monitoring Progress of Foreign Body Passage Through the Gastrointestinal Tract, According to Our Institutional Experience and Literature Review

Object Type Radiographic Follow-Up

Long and short blunt objects Weekly radiographs to follow the progression in the absence of symptoms [5]

Coins Radiographic follow-up once a week is sufficient, unless symptom-atic [1]

Sharp and sharp-pointed objects If past the duodenum, should be followed radiographically daily to document passage [5]

Magnets Serial radiographs are advised if the object continues to show mobility and the patient remains asymptomatic [29]

Disk batteries If in the stomach and beyond, radiographic follow-up every 34 days should be obtained to monitor passage [5]; batteries remaining within the stomach longer than 48 hours should be retrieved endoscopically [5]

Dow

nloa

ded

from

ww

w.a

jronli

ne.or

g by 1

12.21

5.66.7

0 on 0

8/18/1

4 from

IP ad

dress

112.2

15.66

.70. C

opyri

ght A

RRS.

For p

erson

al use

only;

all ri

ghts

reserv

ed

AJR:203, July 2014 39

Imaging of Ingested Foreign Bodies

The ability of low-dose CT to diagnose acute appendicitis [25] and nephrolithiasis [26] has been shown to be comparable with that of conventional CT. There are studies showing the reliability of low-dose CT in the detection of intrabronchial foreign bodies [27] and ingested drug packets [28]. Thus, al-though we are not aware of a trial evaluating the use of low-dose CT for detecting ingested foreign bodies across the board, it would be reasonable to consider this option, especially in pregnant and pediatric patients. Low-dose CT already has been suggested for identifi-cation of magnet ingestion in children [29].

Oral contrast agent administration for foreign body diagnosis is controversial. Op-ponents of oral contrast agent use, influ-enced by endoscopists and surgeons, advise against oral contrast material administra-tion because of a potential aspiration risk. Contrast material coating the foreign body and esophageal mucosa can compromise a subsequent endoscopy [5]. Moreover, an un-suspected foreign body may be obscured by intraluminal contrast media [30] (Fig. 1). Review of the scout images and the use of bone windows help to accentuate a radi-opaque subject in a less dense pool of oral contrast material.

Recommendations for oral contrast agent use are based on its ability to outline the esophageal foreign body on fluoroscopy and to aid in the identification of esophageal and bowel perforation [31, 32] (Fig. 2). Water-soluble media should be used if perforation is suspected [31].

With the exception of American College of Radiology guidelines listing a suspect-ed thoracic foreign body in children as an indication for CT of the chest [33], we are not aware of other definitive guidelines de-termining general indications for CT in the evaluation of suspected ingestion of foreign bodies. If the location of the object in the body is indeterminate according to radio-graphs, CT has been used to provide more precise information. It can also unmask complications suggested by or even occult on radiographic evaluation. Indications per-taining to the specific type of ingested mate-rial are provided in the following individual sections of this article.

General Foreign Body Evaluation and Removal GuidelinesPharyngeal or Proximal Esophageal Considerations

Because pharyngeal and esophageal per-forations are the most ominous complica-

tions of foreign body ingestion to be recog-nized by imaging, this section will serve as an opening topic for this article. Esophageal perforation is a potentially life-threatening condition with high morbidity and mortality (> 20% of cases) [34], and foreign body in-gestion is a common cause of perforation (335% of cases) [35, 36]. The pyriform sinuses and cervical esophagus are common sites of foreign body impaction and perforation, es-pecially with sharp objects [31]. The extent of inflammation, the perforation site, and the relationship of the extraluminal object to the vital organs are the crucial pieces of imaging information to be reported to the clinicians.

If perforation occurs in the cervical re-gion, prevertebral soft-tissue emphysema can be seen on lateral cervical radiographs. Per-foration of the thoracic esophagus presents as hydrothorax, pneumothorax, or hydro pneumo-thorax on chest radiographs. The radiographic appearance of pneumomediastinum and sub-cutaneous emphysema may lag for at least 1 hour subsequent to injury [36, 37].

Currently, the diagnosis of esophageal for-eign bodies heavily relies on CT use [38, 39]. The sensitivity (97%) and accuracy (98%) of CT are higher when compared with radiog-raphy (47% and 52%, respectively) [39]. To our knowledge, no clear guidelines regard-ing the use of fluoroscopic contrast esoph-agram versus CT with oral contrast agent versus CT without oral contrast agent exist. Anecdotal cases illustrate that fluoroscopic contrast esophagram can be beneficial for lo-calization of radiolucent foreign bodies [40].

Wall thickening, surrounding soft-tissue stranding, extraluminal air, and esophageal wall laceration have been described with vis-ceral perforation by foreign bodies on CT. More-specific signs include the presence of a radiopaque object in an abscess or inflamma-tory mass [38, 39, 41] (Figs. 35).

The presence of extraluminal orally ad-ministered contrast agent is a known CT sign of esophageal perforation [41, 42] and has been found to be highly sensitive and specif-ic [43]. Unfortunately, no data regarding the negative predictive value of this finding are currently available, to our knowledge. The absence of extraluminal oral contrast agent does not exclude esophageal perforation, and in a setting of other findings suggestive of esophageal perforation, surgical consulta-tion is warranted.

To achieve a good outcome, early clini-cal suspicion and imaging are important fea-tures in case management [34]. With sus-

pected foreign body ingestion, persistent esophageal symptoms should be evaluated by endoscopy, even in the setting of a nega-tive radiographic evaluation [5]. Esophageal foreign objects and food impactions should be removed within 24 hours. Further delay increases the likelihood of perforation and fistula formation [5, 30]. Sharp-pointed ob-jects in the esophagus require emergent en-doscopic removal [5]. Most foreign bodies, including sharp objects, pass uneventfully once through the esophagus [5].

Size of Foreign BodyUncomplicated passage of foreign bodies

through the gastrointestinal tract largely de-pends on their shape and size [29]. Urgent endoscopy is recommended for objects lon-ger than 6 cm and proximal to the first por-tion of the duodenum [5]. Long objects are likely to be arrested in the duodenum be-cause of their length relative to the duodenal curvature. They may perforate viscera any-where but are most likely to penetrate the du-odenum at the level of the ligament of Treitz [31]. Nonurgent endoscopic removal of ob-jects wider than 2.5 cm is also recommended because they are less likely to pass the py-lorus [5]. The ileocecal valve may also im-pede passage of large foreign bodies. Thus, the dimensions of an ingested foreign body in multiple planes should be measured and reported to the clinician (Fig. 6). Because the passage of small blunt objects may take up to 4 weeks, weekly radiographs are suffi-cient to follow the progression in the absence of symptoms [5]. Surgical removal should be considered if objects remain in the same lo-cation distal to the duodenum for more than 1 week [30].

Ingestion of coins occurs most commonly in young children [5]. The most likely posi-tions of the coins irrespective of their sizes are the postcricoid area (upper esophagus) and the stomach [44]. Larger coins (such as quarters, measuring 23 mm) have a higher propensity to lodge at the level of the cricopharyngeus mus-cle or just distal to it, compared with a dime or a penny (measuring 17 and 18 mm, respective-ly) [45]. On a lateral radiograph of the neck, a coin in the esophagus will be projected on end (in profile) and positioned posterior to the tra-cheal air column (Fig. 7). However, a coin in the trachea will project en face on a lateral ra-diograph [1].

Coins may be observed for 1224 hours in the esophagus and for 34 weeks in the stom-ach before nonurgent endoscopic removal in

Dow

nloa

ded

from

ww

w.a

jronli

ne.or

g by 1

12.21

5.66.7

0 on 0

8/18/1

4 from

IP ad

dress

112.2

15.66

.70. C

opyri

ght A

RRS.

For p

erson

al use

only;

all ri

ghts

reserv

ed

40 AJR:203, July 2014

Guelfguat et al.

an asymptomatic patient, because they com-monly pass spontaneously. Most coins will eventually leave the stomach and pass through the gastrointestinal tract without obstruction [1, 5]. A radiographic follow-up once a week is sufficient, unless the patient is symptomatic [1]. Patients with marked symptoms, includ-ing drooling, chest pain, and stridor, should have emergent intervention to remove the coin [5]. Metal detector use has been advocated for the localization of most swallowed metal ob-jects, including coins, especially in pediatric patients [1, 5, 46].

Shape of Foreign BodyPatients suspected of swallowing sharp-

pointed objects must be evaluated to define the location of the object and the directions of its sharp ends [5]. The risk of perforation with sharp objects is higher than that with blunt objects. In the esophagus and hypo-pharynx, complications of perforation range from more common retropharyngeal abscess and mediastinitis to less frequent fistula for-mations. Foreign body migration into the surrounding tissues, including airway and blood vessels, also has been described [47].

The sensitivity of neck radiographs for for-eign body detection has been reported in the range of 80% [48]. When viewing the radio-graphs, particular attention should be paid to the assessment of the soft tissues at the lev-el of the lower cervical spine, because sharp objects are more likely to impact at the re-gion of the cricopharyngeus muscle. Besides direct visualization of a foreign body, addi-tional signs include retropharyngeal soft-tis-sue thickening and straightening of the cer-vical lordosis [47, 48].

Superior sensitivity and specificity of CT (100% and 93.7%, respectively) relative to ra-diographs in detection of sharp foreign bodies has been found in cases of bones lodging in the upper alimentary tract [21]. Sharp foreign body complications of perforation, fistula, and abscess can be also detected with CT [47].

Sharp-pointed objects detected in the stomach or duodenum require urgent endo-scopic removal [5]. If sharp-pointed objects pass the duodenum, then they should be fol-lowed radiographically daily to document passage. Such cases should be managed cau-tiously, because 1535% of sharp objects that pass the stomach cause intestinal per-foration, usually in the area of the ileocecal valve [1]. If the sharp foreign body fails to progress radiographically for 3 consecutive days, surgical intervention should be consid-

ered [1, 5]. Many sharp-pointed objects are not radiographically visible, and therefore endoscopy should still follow a radiologic examination with negative findings [5]. In a setting of negative or inconclusive radio-graphs for the presence of sharp objects, CT can be considered for planning before endos-copy, because it has been found to be an ef-fective tool used in the diagnosis of trauma-related complications [49].

Sharp elongated objects are the most like-ly to penetrate or perforate the bowel. Perfo-rations may produce chronic inflammation, being discovered months or years later [16]. Complications include mucosal ulceration, perforation, obstruction, intussusception, fis-tula formation, or abdominal abscess [11, 50].

Toothpicks and bones are the most com-mon foreign bodies requiring surgery in the United States [1]. If a razor blade passes the stomach and duodenum, then it usually pass-es through the lower gastrointestinal tract without difficulty [51] (Fig. 8).

Glass can either escape detection or be readily identifiable on radiographs [16, 44, 52], depending on the fragment size, compo-sition, and surrounding material [31, 53]. CT, however, is consistently accurate in the de-tection of glass fragments (Fig. 9).

Fish bones are the most commonly seen objects leading to bowel perforation in southeast Asia and Korea [54, 55]. Radiog-raphy poorly visualizes fish bones in soft tis-sues, with visibility varying by fish species and the location and orientation of the bone. Clinical presentation and radiography are unreliable in the preoperative diagnosis of fish bone perforation of the gastrointestinal tract [38]. CT is the test of choice to radio-graphically diagnose fish bone impactions [56] and is consistently accurate in revealing the offending fish bone [38, 5761] (Fig. 10).

Unique Foreign Body Physical PropertiesMagnets

Small magnets are widely available and com-monly used in toy manufacturing. Because even small ingested magnets possess high potency and are associated high morbidity, a high in-dex of suspicion is required [29]. Testing with a compass has been advocated to determine whether swallowed objects are magnetic [62].

The bowel can become trapped between attracted magnets or other ingested ferro-magnetic objects. Magnets attached to each other across the bowel wall are unlikely to disengage spontaneously. Ensuing pressure

necrosis develops within several hours [62, 63]. This can lead to fistula formation, bowel perforation, obstruction, volvulus, peritoni-tis, or sepsis [62].

Even though most magnets are radiopaque, radiographic diagnosis of magnet ingestion can be confounded by stacked magnets, which can simulate a single object [29]. Magnifying an ingested object on a radiograph helps to better appreciate notches between the individual at-tached pieces, improving the detection of mul-tiple magnets [64]. Fluoroscopy and low-dose limited-field CT are potential adjunct modali-ties useful for problem solving [29] (Fig. 11).

Detection of a gap between magnets on an imaging study raises the possibility of en-trapment and ischemic damage to the inter-posed bowel wall and should trigger emer-gent surgical evaluation [29, 62] (Figs. 12 and 13). Failure of a magnet to move through the lumen on sequential radiographs should also prompt surgical or endoscopic evalua-tion [29]. Magnets within endoscopic reach are a reason for urgent endoscopy [5].

Disk and Cylindric BatteriesA rising incidence of disk battery inges-

tion has been attributed to the increased use of this type of power supply in portable elec-tronic devices [65]. Most cases of battery in-gestion have a relatively benign course, and most patients have no clinical manifestations after ingestion [1, 66, 67].

The smaller size disk batteries are in-gested most frequently, with the majority of batteries less than 15 mm in diameter [66]. The outcome is related to battery size. But-ton cells with diameter greater than 15 mm were linked to a greater proportion of minor and moderate complications. In patients with major complications, larger-diameter batter-ies were ingested (20 and 23 mm) [66].

Relative to low-voltage burns and pressure necrosis, the direct corrosive action of a leak-ing alkaline solution is the major mechanism of injury produced by a disk battery [1]. The alkaline base in these batteries is capable of causing rapid liquefaction necrosis, leading to esophageal mucosal damage as early as 1 hour. Perforation can result as soon as 6 hours after ingestion, almost always in the esopha-gus [1, 66, 68]. In addition to perforation, ma-jor complications include tracheoesophageal or esophageal-aortic fistula and esophageal scarring [66].

Because the corrosive activity of a leak-ing disk battery is extremely damaging, im-aging diagnosis of a disk battery lodged in

Dow

nloa

ded

from

ww

w.a

jronli

ne.or

g by 1

12.21

5.66.7

0 on 0

8/18/1

4 from

IP ad

dress

112.2

15.66

.70. C

opyri

ght A

RRS.

For p

erson

al use

only;

all ri

ghts

reserv

ed

AJR:203, July 2014 41


the esophagus requires immediate commu-nication to the treating physician. If a foreign body suspected to be a disk battery is noted in the esophagus, emergent endoscopic re-moval is indicated [5, 68].

Once in the stomach, most disk batteries pass without complications. The local effects of the battery on the small-bowel mucosa can be assumed to be similar to those on the esophageal mucosa. Therefore, formal lapa-rotomy with removal should be considered if it appears that the passage of the battery has been arrested [68].

A radiograph every 34 days is adequate to assess the progress through the gastroin-testinal tract [5, 66]. With a history of bat-tery ingestion, radiographic confirmation of the presence of a foreign body with postero-anterior and lateral radiographs from the na-sopharynx to the anus should be performed. Both views are necessary because the bat-tery may be easily confused with a coin [68]. Distinguishing between the radiographic ap-pearances of a coin and a button battery is ex-tremely important, because management of these entities is very different (Fig. 14).

Mercury toxicity after disk battery inges-tion is infrequent [66]. Some 15.6-mm diam-eter batteries may contain mercuric oxide. These devices have a greater likelihood than others to split in the gastrointestinal tract and release inorganic mercury. Subsequent ab-sorption has been shown to lead to elevated serum and urine mercury levels, although no clinical manifestations of mercury poisoning have been reported [66, 68, 69]. On radio-graphs, free mercuric oxide appears as radi-opaque foci in the bowel [66].

Cylindric battery ingestions generally do not result in major life-threatening symptoms, and minor or moderate symptoms are infre-quent [5]. Disk batteries and cylindric batter-ies located in the stomach of a patient without signs of gastrointestinal injury may be ob-served for as long as 48 hours. Batteries re-maining within the stomach longer than 48 hours should be retrieved endoscopically [5]. A battery beyond the stomach can be man-aged expectantly by checking the stool for the passage of the battery with a follow-up radio-graph in 1014 days [66]. Emetics should not be used because they have been reported to cause retrograde migration of batteries [70].

Foreign Bodies With Various Chemical Compositions

Ingested coins are typically chemically in-ert, although the rare occurrence of zinc tox-

icity has been reported after the ingestion of large quantities of pennies produced af-ter 1981 [71]. Abdominal radiographs help to determine the gastrointestinal burden of zinc and guide the decision whether to continue decontamination [72, 73].

Ingested lead-containing paint chips are seen as flecks of radiopacities in the bowel. These are classically sought in cases of pediatric lead poisoning [74]. More recently, the practice of alternative medicine has been linked to lead poisoning. In patients with a history of alter-native medicine use and abdominal pain, ra-diopaque spots identified on abdominal radio-graphs may correspond to a lead-containing folk remedy, such as Deshi Dewa [75].

Chemical PrecipitationChemical precipitation in the gastrointesti-

nal tract can form masses and lead to obstruc-tion. For example, small-bowel bacterial over-growth can cause the decomposition of bile salts, allowing precipitation and enterolith for-mation [76]. The interaction of antacids and tube-feeding solution can create a thick sub-stance completely occluding the esophagus and necessitating endoscopic removal [77]. Orally ingested calcium supplement can orga-nize in a fecalith and adhere to the large bow-el wall [78], or to sediment in the esophagus, leading to obstruction (Fig. 15).

Plastic SubstancesThe damage produced by plastic foreign bod-

ies depends on their size, shape, and location in the gastrointestinal tract. For example, small plastic items like ballpoint pen caps and bottle tops are completely harmless when encountered below the diaphragm [14, 31, 79]. An ingested plastic clip used for fastening plastic packets can obstruct the lumen by attaching the claws to the wall. The degree of damage depends on the thickness of the pinched area, ranging from mucosal ulceration to perforation and stricture formation [50]. Plastic foreign bodies are radio-lucent on routine radiographs [1, 15].

Endoscopic CapsulesCapsule endoscopy has become a method

of choice for diagnosing a variety of small-bowel diseases [80]. Capsule retention is a major complication with an overall incidence of 12% [8183]. The most common causes of retention include small-bowel tumors, strictures, or stenoses [81]. Abdominal radio-graphs should be obtained if the colon is not entered during the allotted acquisition time, if there are symptoms of obstruction, if the

patient needs to undergo MRI, or if the pa-tient desires reassurance that the capsule has passed [84]. If capsule retention is diagnosed, effective removal can be achieved by endo-scopic or surgical intervention [84] (Fig. 16).

Narcotic PacketsIngestion of narcotics wrapped in plastic

or packed in latex condoms for purposes of illegal drug trafficking can be fatal, because rupture of even one of the packages can re-lease a lethal dose [1, 5]. The uniform shape of multiple oblong intraluminal objects, fre-quently outlined by bowel gas, and a thin layer of air between the container wall and its contents are radiographic features help-ful in identifying the drug packets [74]. The variable success of radiographs in the detec-tion of intraabdominal containers is related to the radiologic attenuation and quantity of the containers [28]. Isoattenuation of ingest-ed drug packets used by drug smugglers is one of the causes for the high false-negative results (23%) of radiography [28].

On the other hand, the accuracy of CT in detecting the packets is well established [85] (Fig. 17). Even though false-negative CT scan results have been reported [86], CT is superior to radiography for packet detection [28, 87]. The high specificity of low-dose CT has been outlined in a recent study [28].

The presence of broken containers, packets susceptible to breaking, or gastrointestinal ob-struction places the patient at an increased risk of toxicity [1]. Surgical intervention is indicat-ed when drug packets fail to progress or if there is intestinal obstruction. Because rupture and leakage of the contents can be fatal, endoscopic removal should not be attempted [1, 5].

BezoarsBezoars are a conglomeration of mate-

rial in the gastrointestinal tract, commonly within the stomach, that is not readily digest-ed [88]. Bezoars can fill the entire stomach, conforming to the gastric wall [88]. Psycho-logically or metabolically unbalanced chil-dren may intentionally ingest various foreign materials. Ingested hair aggregating into an intraluminal mass, termed a trichobezoar [31], can cause significant gastric distention and outlet obstruction [89].

An intraluminal mass constituting a be-zoar can be detected on abdominal radiog-raphy if it is outlined by gas [88]. On fluo-roscopic studies, the majority of bezoars are mobile and associated with gastric dilatation. They are visualized as either inhomogeneous

Dow

nloa

ded

from

ww

w.a

jronli

ne.or

g by 1

12.21

5.66.7

0 on 0

8/18/1

4 from

IP ad

dress

112.2

15.66

.70. C

opyri

ght A

RRS.

For p

erson

al use

only;

all ri

ghts

reserv

ed

42 AJR:203, July 2014

Guelfguat et al.

or homogeneous filling defects surrounded by contrast agent [90]. CT shows inhomoge-neous, round, or ovoid masses containing ar-eas of soft-tissue density intermixed with gas and oral contrast material [90].

Poor mechanical breakdown of ingested material leads to conglomerate mass forma-tion. Accordingly, most gastric bezoars result from gastroparesis, surgical resection, or by-pass of the gastric antrum and body. For ex-ample, in a series of 19 patients with gastric bezoars, 11 (58%) had risk for gastroparesis and six (32%) had undergone previous gastric surgery [90]. Radiologists should be aware of these associations and seek evidence of be-zoars in this population (Fig. 18).

Obstruction in a patient with a history of bariatric surgery does not necessarily imply an anastomotic stricture, adhesion, or hernia. Bezoars should also be a consideration, and the classic signs of a bezoar, such as intralu-minal masses that have air or contrast agent trapped in interstices, should be sought. Be-zoars can form in a gastric remnant, either proximal or distal to the jejunojejunal anasto-mosis [9096] (Fig. 19).

Some bezoars resolve rapidly and sponta-neously or with conservative medical treat-ment [90, 97]. In the acute clinical setting, endoscopic disruption and removal of the mass can be performed, but many patients require surgical removal [89].

Other Management ConsiderationsOverview of Intrinsic Gastrointestinal Causes Impeding Passage of a Foreign Body

Preexisting narrowing of the gastrointesti-nal tract lumen would predispose to lodging of an ingested object within the affected seg-ment. Causes of the underlying conditions in the esophagus are vast, ranging from extrinsic compressions (dilated aortic arch or left atri-um, or vascular ring), postprocedural (atresia repair and radiation therapy), postinflamma-tory strictures (caustic burns and reflux esoph-agitis), to intrinsic and extrinsic tumors. In the stomach and small-bowel adhesion, postoper-ative causes (altered anatomy from surgical bypass and resection), strictures (ischemic and inflammatory enteritis), and neoplasms should be considered. Please refer to the dia-gram illustrating the most common points of impedance to passage of foreign bodies in the gastrointestinal tract (Fig. 20).

Repeated and Multiple Item IngestionIngestion of multiple foreign objects and re-

peated episodes of ingestion are common [5].

For example, as many as 2533 foreign bodies have been recorded in the stomach of a single patient [14]. The possibility of a second for-eign body should be considered when one is known to have been ingested. Prisoners, psy-chiatric patients, and patients with peptic stric-tures have a tendency for recurrent episodes of foreign body ingestion [1] (Fig. 21).

Radiologists should be wary of search sat-isfaction when a foreign body is discovered and seek second and third foreign bodies [15]. Thus, especially in pediatric patients, radiographs from the base of the skull to the anus should be made to determine whether more than one foreign body is present [1, 31].

ConclusionDespite the common occurrence of foreign

body ingestion, the majority of foreign objects pass without intervention. Uneventful passage depends on the favorable size, shape, and com-position of the object, as well as an absence of underlying structural bowel abnormality. En-doscopic removal and, less frequently, surgery are reserved for some magnets; long, sharp, or pointed objects; and toxic materials. Diag-nostic imaging can frequently directly visual-ize the swallowed objects and describe their dimensions, structure, and location in the pa-tient. Knowledge of these parameters is crucial in the management of ingested foreign bodies. Timely implementation of appropriate treat-ment strategies depends on the radiologists fa-miliarity with and communication of the sa-lient radiographic and cross-sectional imaging features of ingested foreign objects.

AcknowledgmentsWe thank Greg Chulsky and Noah Weg

for help with manuscript preparation and William Robeson and Steven H. King for as-sistance with physics-related topics.

References 1. Webb WA. Management of foreign bodies of the

upper gastrointestinal tract: update. Gastrointest Endosc 1995; 41:3951

2. Palta R, Sahota A, Bemarki A, Salama P, Simpson N, Laine L. Foreign-body ingestion: characteris-tics and outcomes in a lower socioeconomic popu-lation with predominantly intentional ingestion. Gastrointest Endosc 2009; 69:426433

3. Weiland ST, Schurr MJ. Conservative manage-ment of ingested foreign bodies. J Gastrointest Surg 2002; 6:496500

4. Schwartz GF, Polsky HS. Ingested foreign bodies of the gastrointestinal tract. Am Surg 1976; 42:236238

5. Ikenberry SO, Jue TL, Anderson MA, et al. Man-agement of ingested foreign bodies and food im-pactions. Gastrointest Endosc 2011; 73:10851091

6. Yamamoto M, Mizuno H, Sugawara Y. A chop-stick is removed after 60 years in the duodenum. Gastrointest Endosc 1985; 31:51

7. Ragazzi M, Delco F, Rodoni-Cassis P, Brenna M, Lavanchy L, Bianchetti MG. Toothpick ingestion causing duodenal perforation. Pediatr Emerg Care 2010; 26:506507

8. Tai AW, Sodickson A. Foreign body ingestion of blister pill pack causing small bowel obstruction. Emerg Radiol 2007; 14:105108

9. Wu MH, Lai WW. Aortoesophageal fistula in-duced by foreign bodies. Ann Thorac Surg 1992; 54:155156

10. Slamon NB, Hertzog JH, Penfil SH, Raphaely RC, Pizarro C, Derby CD. An unusual case of button battery-induced traumatic tracheoesophageal fis-tula. Pediatr Emerg Care 2008; 24:313316

11. Schwartz JT, Graham DY. Toothpick perforation of the intestines. Ann Surg 1977; 185:6466

12. Eisen GM, Baron TH, Dominitz JA, et al. Guide-line for the management of ingested foreign bod-ies. Gastrointest Endosc 2002; 55:802806

13. Hodge D 3rd, Tecklenburg F, Fleisher G. Coin in-gestion: does every child need a radiograph? Ann Emerg Med 1985; 14:443446

14. Pellerin D, Fortier-Beaulieu M, Gueguen J. The fate of swallowed foreign bodies: experience of 1250 instances of sub-diaphragmatic foreign bod-ies in children. Progr Pediatr Radiol 1969; 2:286302

15. Hunter TB. Foreign bodies. In: Hunter TB, ed. Radiologic guide to medical devices and foreign bodies. St Louis, MO: MosbyYear Book, 1994:64107

16. Hunter TB, Taljanovic MS. Foreign bodies. Ra-dioGraphics 2003; 23:731757

17. American College of Radiology. ACR-SPR prac-tice guideline for the performance of abdominal radiography. American College of Radiology website. www.acr.org/~/media/79a594819bbd4631a7e31404daa66ef6.pdf. Published 2001. Revised 2011. Accessed January 29, 2014

18. American College of Radiology. ACR-SPR prac-tice guideline for the performance of chest radiog-raphy. American College of Radiology website. w w w.a c r.o rg / ~ / me d ia / B4 030 2E E286D -4120AAEDE44B409DD45E.pdf. Published 1993. Revised 2011. Accessed January 29, 2014

19. Aras MH, Miloglu O, Barutcugil C, Kantarci M, Ozcan E, Harorli A. Comparison of the sensitivity for detecting foreign bodies among conventional plain radiography, computed tomography and ul-trasonography. Dentomaxillofac Radiol 2010; 39:7278

20. Oikarinen KS, Nieminen TM, Makarainen H,

Dow

nloa

ded

from

ww

w.a

jronli

ne.or

g by 1

12.21

5.66.7

0 on 0

8/18/1

4 from

IP ad

dress

112.2

15.66

.70. C

opyri

ght A

RRS.

For p

erson

al use

only;

all ri

ghts

reserv

ed

AJR:203, July 2014 43


Pyhtinen J. Visibility of foreign bodies in soft tis-sue in plain radiographs, computed tomography, magnetic resonance imaging, and ultrasound: an in vitro study. Int J Oral Maxillofac Surg 1993; 22:119124

21. Eliashar R, Dano I, Dangoor E, Braverman I, Si-chel JY. Computed tomography diagnosis of esophageal bone impaction: a prospective study. Ann Otol Rhinol Laryngol 1999; 108:708710

22. Marco De Lucas E, Sadaba P, Lastra Garcia-Bar-on P, et al. Value of helical computed tomography in the management of upper esophageal foreign bodies. Acta Radiol 2004; 45:369374

23. Takada M, Kashiwagi R, Sakane M, Tabata F, Ku-roda Y. 3D-CT diagnosis for ingested foreign bodies. Am J Emerg Med 2000; 18:192193

24. Hulnick DH, Megibow AJ, Balthazar EJ, Naidich DP, Bosniak MA. Computed tomography in the evaluation of diverticulitis. Radiology 1984; 152:491495

25. Kim K, Kim YH, Kim SY, et al. Low-dose ab-dominal CT for evaluating suspected appendici-tis. N Engl J Med 2012; 366:15961605

26. Mulkens TH, Daineffe S, De Wijngaert R, et al. Urinary stone disease: comparison of standard-dose and low-dose with 4D MDCT tube current modulation. AJR 2007; 188:553562

27. Koucu P, Ahmetolu A, Koramaz I, et al. Low-dose MDCT and virtual bronchoscopy in pediat-ric patients with foreign body aspiration. AJR 2004; 183:17711777

28. Poletti PA, Canel L, Becker CD, et al. Screening of illegal intracorporeal containers (body pack-ing): is abdominal radiography sufficiently ac-curate? A comparative study with low-dose CT. Radiology 2012; 265:772779

29. Otjen JP, Rohrmann CA Jr, Iyer RS. Imaging pe-diatric magnet ingestion with surgical-pathologi-cal correlation. Pediatr Radiol 2013; 43:851858

30. Ng KC, Mansour E, Eguare E. Retention of an in-gested small blunt foreign body. JBR-BTR 2011; 94:339342

31. Alexander WJ, Kadish JA, Dunbar JS. Ingested foreign bodies in children. Progr Pediatr Radiol 1969; 2:256285

32. Hanks PW, Brody JM. Blunt injury to mesentery and small bowel: CT evaluation. Radiol Clin North Am 2003; 41:11711182

33. American College of Radiology. ACR-SPR prac-tice guideline for the performance of pediatric computed tomography (CT). American College of Radiology website. www.acr.org/~/media/ACR/Documents/PGTS/guidelines/CT_Pediat-ric.pdf. Published 2008. Revised 2009. Accessed January 29, 2014

34. Sreide JA, Viste A. Esophageal perforation: di-agnostic work-up and clinical decision-making in the first 24 hours. Scand J Trauma Resusc Emerg

Med 2011; 19:66 35. Vidarsdottir H, Blondal S, Alfredsson H, Geirs-

son A, Gudbjartsson T. Oesophageal perforations in Iceland: a whole population study on incidence, aetiology and surgical outcome. Thorac Cardio-vasc Surg 2010; 58:476480

36. Chirica M, Champault A, Dray X, et al. Esopha-geal perforations. J Visc Surg 2010; 147:e117e128

37. Han SY, McElvein RB, Aldrete JS, Tishler JM. Perforation of the esophagus: correlation of site and cause with plain film findings. AJR 1985; 145:537540

38. Goh BK, Tan YM, Lin SE, et al. CT in the preop-erative diagnosis of fish bone perforation of the gastrointestinal tract. AJR 2006; 187:710714

39. Ma J, Kang DK, Bae JI, Park KJ, Sun JS. Value of MDCT in diagnosis and management of esophageal sharp or pointed foreign bodies according to level of esophagus. AJR 2013; 201:[web]W707W711

40. Bloom J, Rapoport Y, Zikk D. Dairy products containers as a source of unusual esophageal for-eign bodies. J Otolaryngol 1988; 17:404408

41. De Lutio di Castelguidone E, Pinto A, Merola S, Stavolo C, Romano L. Role of spiral and mul-tislice computed tomography in the evaluation of traumatic and spontaneous oesophageal perfora-tion: our experience. Radiol Med (Torino) 2005; 109:252259

42. de Lutio di Castelguidone E, Merola S, Pinto A, Raissaki M, Gagliardi N, Romano L. Esophageal injuries: spectrum of multidetector row CT find-ings. Eur J Radiol 2006; 59:344348

43. Hermansson M, Johansson J, Gudbjartsson T, et al. Esophageal perforation in South of Sweden: results of surgical treatment in 125 consecutive patients. BMC Surg 2010; 10:31

44. Cheng W, Tam PK. Foreign-body ingestion in children: experience with 1,265 cases. J Pediatr Surg 1999; 34:14721476

45. Webb WA, McDaniel L, Jones L. Foreign bodies of the upper gastrointestinal tract: current man-agement. South Med J 1984; 77:10831086

46. Maurice S, Mackway-Jones K. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmaryingested coins and metal detection. J Accid Emerg Med 2000; 17:282283

47. Pinto A, Muzj C, Gagliardi N, et al. Role of imag-ing in the assessment of impacted foreign bodies in the hypopharynx and cervical esophagus. Se-min Ultrasound CT MR 2012; 33:463470

48. Haglund S, Haverling M, Kuylenstierna R, Lind MG. Radiographic diagnosis of foreign bodies in the oesophagus. J Laryngol Otol 1978; 92:11171125

49. American College of Radiology. ACR-SPR prac-tice guideline for the performance of computed tomography (CT) of the abdomen and computed

tomography (CT) of the pelvis. American College of Radiology website. www.acr.org/~/media/ACR/Documents/PGTS/guidelines/CT_Abdo-men_Pelvis.pdf. Published 1995. Revised 2011. Accessed January 29, 2014

50. Guindi MM, Troster MM, Walley VM. Three cases of an unusual foreign body in small bowel. Gastrointest Radiol 1987; 12:240242

51. Johnson WE. On ingestion of razor blades. JAMA 1969; 208:2163

52. Allotey J, Duncan H, Williams H. Mediastinitis and retropharyngeal abscess following delayed diagnosis of glass ingestion. Emerg Med J 2006; 23:e12

53. Felman AH, Fisher MS. The radiographic detec-tion of glass in soft tissue. Radiology 1969; 92:15291531

54. Chen C-K, Su Y-J, Lai Y-C, Cheng HK-H, Chang W-H. Fish bone-related intra-abdominal abscess in an elderly patient. Int J Infect Dis 2010; 14:e171e172

55. Chung SM, Kim HS, Park EH. Migrating pharyn-geal foreign bodies: a series of four cases of saw-toothed fish bones. Eur Arch Otorhinolaryngol 2008; 265:11251129

56. Lue AJ, Fang WD, Manolidis S. Use of plain radi-ography and computed tomography to identify fish bone foreign bodies. Otolaryngol Head Neck Surg 2000; 123:435438

57. Abid M, Derbel R, Annabi S, et al. Intestinal per-foration in a Tunisian woman: peritonitis due to a fishbone (in French). Med Trop (Mars) 2010; 70:7779

58. Al-Abduwani JA, Bhargava D, Sawhney S, Al-Abri R. Bimanual, intra-operative, fluoroscopy-guided removal of nasopharyngeal migratory fish bone from carotid space. J Laryngol Otol 2010; 124:786789

59. Guilln-Paredes MP, Lirn-Ruiz R, Torralba-Martnez JA, Martn-Lorenzo JG, Aguayo-Albas-ini JL. Intestinal perforation caused by incidental ingestion of a fish bone: value of CT in the diagno-sis. Rev Esp Enferm Dig 2010; 102:573574

60. Hirasaki S, Inoue A, Kubo M, Oshiro H. Esopha-geal large fish bone (sea bream jawbone) impac-tion successfully managed with endoscopy and safely excreted through the intestinal tract. Intern Med 2010; 49:995999

61. Hsu C-L, Chen C-W. A prolonged buried fish bone mimicking Ludwig angina. Am J Otolaryn-gol 2011; 32:7576

62. Centers for Disease Control and Prevention. Gas-trointestinal injuries from magnet ingestion in children: United States, 2003-2006. MMWR Morb Mortal Wkly Rep 2006; 55:12961300

63. McCormick S, Brennan P, Yassa J, Shawis R. Children and mini-magnets: an almost fatal at-traction. Emerg Med J 2002; 19:7173

Dow

nloa

ded

from

ww

w.a

jronli

ne.or

g by 1

12.21

5.66.7

0 on 0

8/18/1

4 from

IP ad

dress

112.2

15.66

.70. C

opyri

ght A

RRS.

For p

erson

al use

only;

all ri

ghts

reserv

ed

44 AJR:203, July 2014

Guelfguat et al.

64. Oestreich AE. Worldwide survey of damage from swallowing multiple magnets. Pediatr Radiol 2009; 39:142147

65. McLarty JD, Krishnan M, Rowe MR. Disk bat-tery aspiration in a young child: a scarcely report-ed phenomenon. Arch Otolaryngol Head Neck Surg 2012; 138:680682

66. Litovitz T, Schmitz BF. Ingestion of cylindrical and button batteries: an analysis of 2382 cases. Pediatrics 1992; 89:747757

67. Bronstein AC, Spyker DA, Cantilena LR Jr, et al. 2007 Annual Report of the American Association of Poison Control Centers National Poison Data System (NPDS): 25th Annual Report. Clin Toxi-col (Phila) 2008; 46:9271057

68. Maves MD, Lloyd TV, Carithers JS. Radiographic identification of ingested disc batteries. Pediatr Radiol 1986; 16:154156

69. Sue Y-J. Mercury. In: Nelson LS, Lewin NA, Howland MA, Hoffman RS, Goldfrank LR, Flo-menbaum NE, eds. Goldfranks toxicologic emer-gencies, 9th ed. Beijing, China: McGraw-Hill, 2011:12991307

70. Church RG, Babu KM. Gastrointestinal principles. In: Nelson LS, Lewin NA, Howland MA, Hoffman RS, Goldfrank LR, Flomenbaum NE, eds. Goldfranks toxicologic emergencies, 9th ed. Beijing, China: McGraw-Hill, 2011:359366

71. Pawa S, Khalifa AJ, Ehrinpreis MN, Schiffer CA, Siddiqui FA. Zinc toxicity from massive and pro-longed coin ingestion in an adult. Am J Med Sci 2008; 336:430433

72. Dhawan SS, Ryder KM, Pritchard E. Massive penny ingestion: the loot with local and systemic effects. J Emerg Med 2008; 35:3337

73. Majlesi N. Zinc. In: Nelson LS, Lewin NA, How-land MA, Hoffman RS, Goldfrank LR, Flomen-baum NE, eds. Goldfranks toxicologic emergen-cies, 9th ed. Beijing, China: McGraw-Hill, 2011:13391344

74. Schwartz D. Diagnostic imaging. In: Nelson LS, Lewin NA, Howland MA, Hoffman RS, Gold-frank LR, Flomenbaum NE, eds. Goldfranks toxicologic emergencies, 9th ed. Beijing, China: McGraw-Hill, 2011:4569

75. Kulshrestha MK. Lead poisoning diagnosed by abdominal X-rays. J Toxicol Clin Toxicol 1996; 34:107108

76. Beal SL, Walton CB, Bodai BI. Enterolith ileus resulting from small bowel diverticulosis. Am J Gastroenterol 1987; 82:162164

77. Schulthess HK, Valli C, Escher F, Asper R, Hacki WH. Esophageal obstruction in tube feeding: a result of protein precipitation caused by antacids? Schweiz Med Wochenschr 1986; 116:960962

78. Ginaldi S, Reisman T. Calcified rims: uncommon radiologic finding and potential pitfall due to or-ganization of deposits of oyster shell tablets. Dis Colon Rectum 1986; 29:471473

79. Payne SD, Henry M. Radiolucent dentures im-pacted in the oesophagus. Br J Surg 1984; 71:318

80. Boivin ML, Lochs H, Voderholzer WA. Does pas-sage of a patency capsule indicate small-bowel patency? A prospective clinical trial. Endoscopy 2005; 37:808815

81. Karagiannis S, Faiss S, Mavrogiannis C. Capsule retention: a feared complication of wireless cap-sule endoscopy. Scand J Gastroenterol 2009; 44:11581165

82. Purdy M, Heikkinen M, Juvonen P, Voutilainen M, Eskelinen M. Characteristics of patients with a retained wireless capsule endoscope (WCE) ne-cessitating laparotomy for removal of the capsule. In Vivo 2011; 25:707710

83. Van Weyenberg SJB, Van Turenhout ST, Bouma G, et al. Double-balloon endoscopy as the prima-ry method for small-bowel video capsule endo-scope retrieval. Gastrointest Endosc 2010; 71:535541

84. Cave D, Legnani P, de Franchis R, Lewis BS. ICCE consensus for capsule retention. Endoscopy 2005; 37:10651067

85. Schmidt S, Hugli O, Rizzo E, et al. Detection of ingested cocaine-filled packets: diagnostic value of unenhanced CT. Eur J Radiol 2008; 67:133138

86. Eng JG, Aks SE, Waldron R, Marcus C, Issleib S. False-negative abdominal CT scan in a cocaine body stuffer. Am J Emerg Med 1999; 17:702704

87. Hergan K, Kofler K, Oser W. Drug smuggling by body packing: what radiologists should know about it. Eur Radiol 2004; 14:736742

88. Otjen JP, Iyer RS, Phillips GS, Parisi MT. Usual and unusual causes of pediatric gastric outlet ob-struction. Pediatr Radiol 2012; 42:728737

89. Gorter RR, Kneepkens CMF, Mattens ECJL, Ar-onson DC, Heij HA. Management of trichobe-zoar: case report and literature review. Pediatr Surg Int 2010; 26:457463

90. Hewitt AN, Levine MS, Rubesin SE, Laufer I. Gastric bezoars: reassessment of clinical and ra-diographic findings in 19 patients. Br J Radiol 2009; 82:901907

91. Zapata R, Castillo F, Cordova A. Gastric food be-zoar as a complication of bariatric surgery: case report and review of the literature. Gastroenterol Hepatol 2006; 29:7780

92. Parameswaran R, Ferrando J, Sigurdsson A. Gas-tric bezoar complicating laparoscopic adjustable gastric banding with band slippage. Obes Surg 2006; 16:16831684

93. Patel C, Van Dam J, Curet M, Morton JM, Baner-jee S. Use of flexible endoscopic scissors to cut obstructing suture material in gastric bypass pa-tients. Obes Surg 2008; 18:336339

94. Sammut SJ, Majid S, Shoab S. Phytobezoar: a rare cause of late upper gastrointestinal perforation following gastric bypass surgery. Ann R Coll Surg Engl 2012; 94:e85e87

95. Sarhan M, Shyamali B, Fakulujo A, Ahmed L. Jejunal bezoar causing obstruction after laparo-scopic Roux-en-Y gastric bypass. JSLS 2010; 14:592595

96. Ripolls T, Garca-Aguayo J, Martnez MJ, Gil P. Gastrointestinal bezoars: sonographic and CT characteristics. AJR 2001; 177:6569

97. Martnez de Juan F, Martnez-Lapiedra C, Picazo V. Phytobezoar dissolution with Coca-Cola (in Spanish). Gastroenterol Hepatol 2006; 29:291293

98. Pfau PR, Gregory G. Foreign bodies and bezoars. In: Feldman M, Friedman LS, Sleisenger MH, eds. Sleisinger and Fordtrans gastrointestinal and liver disease, 7th ed. Philadelphia, PA: Saun-ders, 2002:386398

99. Hung C-W, Hung S-C, Lee CJ, Lee W-H, Wu KH. Risk factors for complications after a foreign body is retained in the esophagus. J Emerg Med 2012; 43:423427

(Figures start on next page)

Dow

nloa

ded

from

ww

w.a

jronli

ne.or

g by 1

12.21

5.66.7

0 on 0

8/18/1

4 from

IP ad

dress

112.2

15.66

.70. C

opyri

ght A

RRS.

For p

erson

al use

only;

all ri

ghts

reserv

ed

AJR:203, July 2014 45


Fig. 214-year-old boy who experienced dysphagia while eating chicken. Sagittal CT multiplanar recon-struction shows intraluminal mass (arrow) isodense to muscle in upper thoracic esophagus. Oral contrast agent helps to outline foreign body on CT.

A

C

Fig. 1Female patient with foreign body obscured by oral contrast agent on CT.A, CT image with bone windows shows ingested piece of glass (arrow) as linear density.B, CT image with soft-tissue windows shows oral contrast agent (arrow) obscur-ing foreign body.C, Scout radiograph readily identifies piece of glass (arrow) in pelvis. Object is obscured by oral contrast agent when viewed in soft-tissue windows.

B

A B

Fig. 333-year-old man from long-term psychiatric facility who ingested multiple foreign bodies. Ballpoint pen perforated esophageal wall and lodged in paraesophageal soft tissues.A, Lateral neck soft-tissue radiograph shows outline of mostly radiolucent body of plastic pen (arrows). Prever-tebral soft tissues are thickened.B, Cropped frontal chest radiograph shows radiopaque ballpoint tip (black straight arrow). Note right pneumo-mediastinum in abscess (curved white arrow), bulging right mediastinal contours (black arrowheads), and mild tracheal deviation to left.

(Fig. 3 continues on next page)

Dow

nloa

ded

from

ww

w.a

jronli

ne.or

g by 1

12.21

5.66.7

0 on 0

8/18/1

4 from

IP ad

dress

112.2

15.66

.70. C

opyri

ght A

RRS.

For p

erson

al use

only;

all ri

ghts

reserv

ed

46 AJR:203, July 2014

Guelfguat et al.

C D

Fig. 3 (continued)33-year-old man from long-term psychiatric facility who ingested multiple foreign bodies. Ballpoint pen perforated esophageal wall and lodged in paraesophageal soft tissues.C, Axial CT shows paraesophageal abscess (curved arrow) formed around ballpoint pen (straight arrow).D, Angled multiplanar reconstruction helps to better visualize relationship of radiolucent body of pen (straight arrows) relative to abscess (curved arrow) and air-filled esophagus (arrowhead).

A B

Fig. 477-year-old man who swallowed sharp rib during meal. A and B, Consecutive coronal CT multiplanar reconstruction images show bone fragment (arrows) obliquely lodged in cervical esophagus. Endoscopy revealed portion of rib with attached meat, which was dislodged, moved to stomach, broken in two pieces, and removed.

Fig. 5Patient who swallowed chicken bone 1 year before presentation. Bone (black arrow) is lodged within bowel wall. Surgical removal revealed perfora-tion at antimesenteric border. Pericolonic soft-tissue stranding (white arrow) and short segmental wall thickening (black arrowheads) are evident on CT. (Courtesy of Alterman D, Albert Einstein College of Medicine, Bronx, NY)D

ownl

oade

d fro

m w

ww

.ajro

nline

.org b

y 112

.215.6

6.70 o

n 08/1

8/14 f

rom IP

addre

ss 11

2.215

.66.70

. Cop

yrigh

t ARR

S. Fo

r pers

onal

use on

ly; al

l righ

ts res

erved

AJR:203, July 2014 47


Fig. 632-year-old man with history of schizophrenia and repeated toothbrush ingestions. Thick coronal maximum-intensity-projection CT image shows 17-cm-long hypodense plastic toothbrush (arrows) lodged in gastric body. Because pa-tient refused endoscopy, surgical removal was performed.

A B

Fig. 72-year-old boy who swallowed quarter, which lodged at upper esophagus.A, On frontal radiograph, coin (arrow) is projected en face.B, On lateral radiograph, coin (arrow) is projected in profile, posterior to tracheal air column.

Dow

nloa

ded

from

ww

w.a

jronli

ne.or

g by 1

12.21

5.66.7

0 on 0

8/18/1

4 from

IP ad

dress

112.2

15.66

.70. C

opyri

ght A

RRS.

For p

erson

al use

only;

all ri

ghts

reserv

ed

48 AJR:203, July 2014

Guelfguat et al.

A B

Fig. 842-year-old man who swallowed razor blades.A, A few opacities (arrows) are noted in stomach on abdominal radiograph.B, Thick coronal maximum-intensity-projection (MIP) CT image better characterizes one foreign body (arrow) lodged in stomach. Note central apertures characteristic of razor blade. Thick MIP helps to accentuate small dense object.

A B

C

Fig. 947-year-old woman with history of drug abuse who swallowed crack cocaine glass pipe in two pieces to avoid police arrest.A and B, Scout (A) and axial CT (B) images show two glass tubular fragments (arrows) in stomach.C, Only one piece of glass (arrows) was retrieved from gastric body during endoscopy. Other piece was fol-lowed with radiographs until elimination.

Dow

nloa

ded

from

ww

w.a

jronli

ne.or

g by 1

12.21

5.66.7

0 on 0

8/18/1

4 from

IP ad

dress

112.2

15.66

.70. C

opyri

ght A

RRS.

For p

erson

al use

only;

all ri

ghts

reserv

ed

AJR:203, July 2014 49


A B C

Fig. 1039-year-old man who developed throat pain after eating fish.A, Sagittal CT multiplanar reconstruction shows opacity (arrow) in prevertebral soft tissues.B, Lateral neck radiograph reveals no abnormality in corresponding region (arrow).C, Photograph shows fish bone that was removed endoscopically. Dime is provided for scale purposes. Removal was difficult because of 3-pronged shape of bone.

A B

Fig. 119-year-old boy who admitted to swallowing magnets after ferromagnetic material was noted in abdomen by metal detector in MRI suite. Serial radio-graphic follow-up shows chain of metallic objects (ar-row) that maintain spatial relationship to each other in space and time for more than 4 days, remaining in left hemiabdomen. Beads were removed surgically. Enteroenteric fistula discovered intraoperatively was likely due to pressure necrosis.

Fig. 122.5-year-old boy with history of battery ingestion who was brought to hospital with signs of complete small-bowel obstruction. (Courtesy of Blumfield E, Albert Einstein College of Medicine, Bronx, NY)A, Frontal abdominal radiograph reveals dilated small bowel loops consistent with obstruction. One of three foreign bodies (curved arrow) is homogeneously dense. Other two objects have lucent rim, consistent with disk batteries.B, Lateral abdominal radiograph shows two disk batteries, identified by beveled edges (straight black and white arrows) connected by another metallic object (curved white arrow). During surgery, lithium CR927 battery at-tached to magnet was recovered from distal ileum, and second disk battery was identified in other small-bowel loop. Necrosis and perforation were evident in both bowel segments. Note that one disk battery (straight black arrow) is projecting on opposite side of bowel wall relative to magnet (curved white arrow), illustrating attach-ment to magnet across bowel wall.

Dow

nloa

ded

from

ww

w.a

jronli

ne.or

g by 1

12.21

5.66.7

0 on 0

8/18/1

4 from

IP ad

dress

112.2

15.66

.70. C

opyri

ght A

RRS.

For p

erson

al use

only;

all ri

ghts

reserv

ed

50 AJR:203, July 2014

Guelfguat et al.

Fig. 137-year-old boy who had two groups of magnets surgically removed from small bowel. Radio-graph reveals central gap between two magnet con-glomerates, suggesting entrapment of bowel wall.With kind permission from Springer Science+Business Media: Pediatric Radiology, Imaging pediatric magnet ingestion with surgical-pathological correlation, volume 43, 2012, 851858, Otjen JP, Rohrmann CA Jr, Iyer RS [29].

A B

C D

Fig. 14Cropped radiographs of four different patients highlight distinguishing features of disk battery from coin.A, En face view of battery shows double-density shadow, or halo (arrow), due to bilaminar structure of battery.B, Coin (arrow) does not have double density on en face projection.C, End on view shows step-off (arrow) at junction of cathode and anode.D, Coin (arrow) does not have step-off in this projection.

Dow

nloa

ded

from

ww

w.a

jronli

ne.or

g by 1

12.21

5.66.7

0 on 0

8/18/1

4 from

IP ad

dress

112.2

15.66

.70. C

opyri

ght A

RRS.

For p

erson

al use

only;

all ri

ghts

reserv

ed

AJR:203, July 2014 51


A B

Fig. 1555-year-old woman with end-stage renal disease receiving hemodialysis who had been using oral calcium acetate. She presented with symptoms of esoph-ageal obstruction pre-ceded by 2-day history of worsening dysphagia.A, Sagittal maximum-intensity-projection CT, bone windows, shows obstructing calcific mass (white arrow) and food stasis (black arrow) above level of obstruction.B, Bolus of crystallized calcium obstructing lower cervical esopha-gus corresponding to CT finding was found and removed on endoscopy.

Fig. 1669-year-old man who developed small-bowel obstruction 1 year after examination with endoscopic capsule. Examination was negative, but no obvious excretion of capsule was noted at that time. Intraluminal location of foreign body (black ar-row) representing capsule (Pillcam SB2, Given Imag-ing) was confirmed intraoperatively with fluoroscopy by placement of metallic probe (white arrow) next to palpable intraluminal mass.

A B

C

Fig. 1727-year-old man from Central American country with vomiting. More than 40 drug containers were surgically removed. (Courtesy of Obedian M, Strong Memorial Hospital, Rochester, NY)AC, Multiple drug-containing radiopaque pack-ets (white straight arrows, AC) are visualized on abdominal radiograph (A), coronal CT multiplanar reconstruction (B), and 3D volume-rendered image (C). Note small-bowel distention (black arrow, A) due to obstruction. Lucent line of trapped air between container wall and content (white curved arrows, A and B) is radiographic feature helpful in identification of drug packets.

Dow

nloa

ded

from

ww

w.a

jronli

ne.or

g by 1

12.21

5.66.7

0 on 0

8/18/1

4 from

IP ad

dress

112.2

15.66

.70. C

opyri

ght A

RRS.

For p

erson

al use

only;

all ri

ghts

reserv

ed

52 AJR:203, July 2014

Guelfguat et al.

A B

Fig. 1869-year-old woman with distant history of pyloroplasty who presented with 2 months of worsening abdominal pain.A, Abdominal radiograph reveals mottled left abdominal mass (arrows).B, Coronal CT multiplanar reconstruction shows partially obstructive phytobezoar (arrows) markedly distend-ing stomach. Diagnosis was confirmed endoscopically.

A B

Fig. 1953-year-old woman who presented with nausea, vomiting, and abdominal pain 3.5 months after Roux-en-Y gastric bypass surgery.A, CT scan, soft-tissue windows, revealed small-bowel obstruction (curved arrow) with dilated small-bowel loops. Transition point (straight arrow) was localized to distal small bowel.B, Same slice in lung windows showed substance that did not look like feces and was therefore suggestive of bezoar (arrow). Gross examination of substance revealed minimally chewed piece of pineapple.

Dow

nloa

ded

from

ww

w.a

jronli

ne.or

g by 1

12.21

5.66.7

0 on 0

8/18/1

4 from

IP ad

dress

112.2

15.66

.70. C

opyri

ght A

RRS.

For p

erson

al use

only;

all ri

ghts

reserv

ed

AJR:203, July 2014 53


Fig. 20Diagram of most common points of impedance to passage of foreign bodies in gastrointestinal tract, as described elsewhere [98, 99]. Each site of impedance (curved white arrows) is marked on corresponding CT image. (Drawing by Guelfguat M)

A BFig. 2133-year-old man from long-term psychiatric facility who ingested multiple foreign bodies.A, Postoperative removal photograph revealed diverse collection ranging from plastic ballpoint pen (black arrow) to USB cable (white arrow).B, Preoperative coronal CT multiplanar reconstruction identified numerous gastric foreign bodies. Note that plastic ballpoint pen (black arrow) is radiolucent, whereas USB cable is radiopaque (white arrow). Multiple disposable plastic spoons (arranged to right of ballpoint pen in A) are radiolucent and not visualized on CT.

F O R Y O U R I N F O R M A T I O N

This article is available for CME and Self-Assessment (SA-CME) credit that satisfies Part II requirements for maintenance of certification (MOC). To access the examination for this article, follow the prompts associated with the online version of the article.

Dow

nloa

ded

from

ww

w.a

jronli

ne.or

g by 1

12.21

5.66.7

0 on 0

8/18/1

4 from

IP ad

dress

112.2

15.66

.70. C

opyri

ght A

RRS.

For p

erson

al use

only;

all ri

ghts

reserv

ed