FORIEGN BODY UPPER GI

TRACTDr.G.Sathish kumar M.B.,B.S., D N B ., FMIBS.,

Consultant general &laparoscopic surgeon.

Sri vijaya hitech hospital and sudha institute of

medical seinces , erode , tamilnadu, india.

INTRODUCTION

The majority of foreign body ingestions occur in children between the ages of six months and three years .

Fortunately, most foreign bodies that reach the gastrointestinal tract pass spontaneously.

Only 10 to 20 percent will require endoscopic removal, and less than 1 percent require surgical intervention .

Although mortality from foreign body ingestion is extremely low, deaths have been reported .

Classification of foreign bodies

● Size

Length greater/smaller than 6 cm

● Surface consistency

– Sharp/pointed versus blunt

– Rounded versus sharp edges

●Material/contents, for example

– Food

– Drugs

– Battery

– Magnet

● Characteristics

– Radio-dense+/-

– Metallic+/-

– Chemically inert +/-

Food (typically meat) bolus impaction above a pre-existing esophageal stricture or ring is by far the most common cause of esophageal body obstruction in adults

Bones (chicken/fish), dentures, medication packaging, batteries and coins are uncommon in adults

Coins are the most common foreign body in children (76 % in one large series).

diagnosis

Detailed History and examination

Biplane radiographs identify most true foreign objects, steak bones, and free mediastinal or peritoneal air.

A contrast examination generally should not be performed because of aspiration risk, and contrast coating of the foreign body and esophageal mucosa can compromise subsequent endoscopy.

CT scanning may be useful, although it may not detect radiolucent objects. The sensitivity of CT may be improved with 3-dimensional reconstruction.

Management

Type of object

Location of the object

Clinical status

Expectant management is appropriate for the

majority of patients since most objects will

pass uneventfully

Specific approach varies with the type of

ingestion and the clinical setting

Always practice with equipment prior to

procedure

timing

Emergent endoscopy

Patients with esophageal obstruction (ie, unable to

manage secretions)

Disk batteries in the esophagus

Sharp-pointed objects in the esophagus

Urgent endoscopy

Esophageal foreign objects that are not sharp-pointed

Esophageal food impaction in patients without complete obstruction

Sharp-pointed objects in the stomach or duodenum

Objects 6 cm in length at or above the proximal duodenum

Magnets within endoscopic reach

Non-urgent endoscopy

Coins in the esophagus may be observed for 12 to 24 hours in asymptomatic patients

Blunt objects in the stomach that are >2.5 cm in diameter

Disk batteries and cylindrical batteries that are in the stomach in patients without signs of GI injury may be observed for up to 48 hours (however, disk batteries that are larger than 20 mm are unlikely to pass and should be removed)

Blunt objects that fail to pass the stomach in three to four weeks

Blunt objects distal to the duodenum that remain in the same location for more than a week (deep small bowel enteroscopyor surgery may be required depending on the location of the object)

Airway management

Airway protection is important for all patients

undergoing endoscopic foreign body removal

Oropharyngeal suction is required

Impactions in the esophagus require intubation

to protect the airway

Overtubes may be used to prevent an object

from accidentally being dropped into the patient's

airway

Equipment

Endoscopes

Most ingested foreign bodies are best treated with flexible endoscopes

However, rigid esophagoscopy may be helpful for proximal foreign bodies impacted at the level of the upper esophageal sphincter.

Video endoscopes.

Retrieval devices

rat-tooth and alligator forceps, polypectomy

snares, polyp graspers, Dormier baskets, Roth net, magnetic probes, and banding caps.

Before endoscopy, practicing grasping a similar object to the ingested foreign body may help determine the most appropriate available retrieval device and in what fashion to grasp the object.

Food bolus impaction

most common esophageal foreign body in adults.

Extraction may involve en bloc removal by using various grasping devices (polypectomysnare, retrieval net or banding cap) or removal by a piecemeal approach.

high incidence of esophageal pathology(stricture /eosinophilic esophagitis) is associated with food impaction.

it is safe to perform dilation after food bolus extraction when an esophageal stricture is present.

Short-blunt objects.

Object may be advanced into the stomach where it is easier to grasp

Endoscopy done using appropriate equipment Basket/Net for most objects

Long overtube to protect GEJ

If no long overtube not avalable give 1 mg of glucagon to relax GEJ prior to FB removal

If object has passed into stomach may observe for 4 w weeks unless > 2.5 cm

Management of long objects

Objects greater than 6 cm should be removed as they will not pass duodenal C sweep i.e. –toothbrush/spoon/chopstick

Grab with snare and remove via an overtube If overtube not available use 1mg of glucagon

Coins

Coins are by far the most common foreign body ingested by children

esophageal coin should be removed promptly if the patient is symptomatic or if the time of ingestion is not known.

If the child is asymptomatic and the coin does not pass spontaneously by 24 hours after ingestion, it should be removed. coins that reach the stomach can be managed expectantly.

If the coin has not passed beyond the stomach by four weeks, endoscopic removal is

Sharp-pointed objects

Chicken and fish bones, straightened paperclips, toothpicks, needles,pins, bread bag clips, and dental bridgework.

must be evaluated to define the location of the object.

Sharp-pointed objects lodged in the esophagus are a medical emergency.

Direct laryngoscopy is an option to remove objects lodged at or above the cricopharyngeus.

Sharp objects in the stomach often pass

- 35% complication rate, therefore all objects should be removed

Equipment for removal

Endoscope

Forceps, Snare or Roth net

Hood

Overtube

•Technique

Orientation of the sharp end to be trailing reduces mucosal injury

mucosal injury during retrieval can be minimized by orienting the object with its point trailing during extraction, by using an overtube, or by fitting the endoscope with a protector hood.

protector hood

Management of batteries

Button battery (hearing aids, watches, games,

toys, and calculators) are the most common

battery ingested

•Liquefaction necrosis/perforation can occur

rapidly

•Batteries lodged in the esophagus should be

emergently removed

•Overtube or endotracheal tube is essential to

Batteries generally removed with roth net/basket

Alternately push battery into the stomach and retrieve

If a battery has passed beyond the stomach no need to remove unless intestinal injury

Batteries >20 mm should be removed

No role for acid suppressive medications

Once past the duodenum, 85% pass out of the body within 72 hours.

A radiograph every 3 to 4 days is adequate to assess the progress through the GI tract.

Management of magnets

Magnets are rarely ingested

Dangerous as they can cause severe injury

Magnet can trap mucosa and cause necrosis

and fistula formation

All magnets need to be removed Can be

removed with a net or snare

Body Packing

Internal concealment of illegal drugs wrapped in plastic or contained in balloons or latex condoms is seen in regions of high drug trafficking

Diagnosis is made by plain X-rays or CT scan

Endoscopic drainage is contraindicated as leakage can be fatal

Surgical removal only suspected leakage or bowel obstruction

Take Home

Emergent removal of esophageal food bolus impactions and foreign bodies in patients with evidence of complete esophageal obstruction

Remove all objects with a diameter larger than 2.5 cm from the stomach

Remove sharp-pointed objects or objects longer 6 cm in the proximal duodenum or above

Emergent removal disk batteries in the esophagus

Urgent removal of all magnets within endoscopic reach

Coins within the esophagus may be observed in asymptomatic patients but should be removed within 24 hours of ingestion if spontaneous passage does not occur

Always practice with equipment prior to procedure

Thank you