A 21-Year-Old Man With Epigastric Pain After a Wild Party

Abraham A. Ayantunde, MB BS, FRCS; George G. Araklitis, MB BS, BSc

Disclosures

February 25, 2019

The diagnosis of foreign body ingestion is usually made on the basis of the patient history and appropriate imaging; however, making the diagnosis can be difficult because most patients who ingest foreign objects are either children or those in whom a proper history-taking would prove challenging (such as psychiatric patients or intoxicated patients). These patients may only present after the onset of symptoms such as choking, pain, refusal to eat, vomiting, wheezing, or respiratory distress.[1] Examination may reveal swelling, erythema, tenderness, or crepitus in the neck; additionally, the abdomen may also show signs of obstruction or peritonitis secondary to perforation.[1]

A study from 2006 showed that a majority (39.5%) of patients presented with no clinical signs or symptoms, and only 10.5% presented with abdominal pain.[2] Radiologic investigations are used to localize the object. X-rays can identify most foreign objects and free air in the mediastinum or peritoneum. In the previously mentioned study, 87% of foreign objects were identified on plain x-ray.[2] A lateral x-ray may help identify multiple foreign bodies, such as coins, or it may help differentiate a coin from a disc battery.[1,3] Serial x-rays over a period of time may show the progress of the foreign body through the gastrointestinal tract if the object is small, has no sharp edges, and the patient is stable. Some objects, such as fish bone, plastic, or glass, are more difficult to see on x-rays.[1] A CT scan or contrast study may help locate more difficult objects.[1]

The risks of a foreign body in the alimentary canal include impaction, perforation, obstruction, erosion, and fistulation anywhere along the gastrointestinal tract. Rounded and/or smooth objects, such as coins, pass more easily than sharp objects.[3] Anatomically, the esophagus is one of the narrowest sections of the gastrointestinal tract,[3] which makes it a common site of foreign-object impaction. Other common sites include the pyloric channel and ileocecal valve. The esophagus is about 7.9-9.4 in (20-24 cm) long, starting 5.5-6.3 in (14-16 cm) distal to the incisor teeth[4] at the upper esophageal sphincter. This is the narrowest part of gastrointestinal tract. It is formed by the cricopharyngeal fibers of the constrictor muscles of the pharynx.[4] Distally, the esophagus also narrows at sites where it is indented by the aorta, the left main bronchus, and the heart[4]; these are also sites for potential foreign-body impaction. The most common site of foreign-body impaction is at the level of the thoracic inlet,[1] followed by the gastroesophageal junction.[3]

Once an object passes through the esophagus into the stomach, the risk of it lodging somewhere along the rest of the alimentary canal is relatively small, even for sharp objects.[1,3] Sharp objects that have passed into the stomach, however, still pose a 35% risk for complication, and most authorities recommend that removal be attempted.[7] A Chinese study showed that 84.5% of 439 patients with foreign-body ingestion had the object lodged in the esophagus, with the majority in the upper esophagus.[5]

Management of patients with ingested foreign bodies depends on the age and clinical condition of the patient as well as the size, shape, and nature of the object (eg, sharp, corrosive, or poisonous[1]) and the site at which the foreign body is lodged. Foreign objects should not remain in the esophagus for more than 24 hours from the time of presentation to the emergency department.[1] Endoscopy should usually be performed within that timeframe. Most foreign bodies pass through the gastrointestinal tract without requiring intervention, whereas 10%-20% of foreign bodies require nonoperative intervention and less than 1% require surgery (eg, laparotomy).[5] Upper gastrointestinal endoscopy can be used to remove the foreign body. Initial attempts to dislodge a food bolus are usually made with ingestion of a carbonated beverage or via intravenous glucagon; however, this is not done with foreign-body ingestions. Ingested foreign body is the second most common indication for emergency endoscopy (gastrointestinal bleeding is the first).[5]

During endoscopy, forceps are more successful in removing sharp objects, while the basket is more successful in removing blunt objects, such as coins or a food bolus.[5] An overtube or protector hood should be used to avoid puncture of the esophagus and/or aspiration upon withdrawal. Failure of endoscopic removal usually means that the foreign body in question is a bone, with 76.5% of cases being fish bone,[5] usually in the upper esophagus.[5] It is important to keep in mind the potential for luminal abnormalities that result in obstruction. An esophageal stricture, achalasia, esophageal diverticula, and eosinophilic esophagitis are common pathologies that are found at follow-up endoscopy.

An American study concluded that adopting a conservative approach in the asymptomatic patient allowed spontaneous passage of nearly all swallowed foreign objects.[6] This study did not include corrosive objects or those stuck in the esophagus. Narcotic packets concealed internally for drug trafficking should be allowed to progress through the gastrointestinal tract naturally.[1] If removal becomes a necessity because of obstruction or rupture of the packet contents, endoscopic removal should not be attempted because of the risk for iatrogenic rupture and leakage of the drug packets, leaving surgical intervention as the only choice.[1]

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