Dr. Ümit AkyüzDr. Ümit AkyüzYeditepe University Yeditepe University

Department of GastroenterologyDepartment of Gastroenterology

Foreign Bodies and the Foreign Bodies and the Gastrointestinal TractGastrointestinal Tract

Populations at riskPopulations at risk

ChildrenChildren

Psychiatric patientsPsychiatric patients

AlcoholicsAlcoholics

Elderly with dementiaElderly with dementia

SmugglersSmugglers

Commonly ingested materialsCommonly ingested materials

CoinsCoins

BatteriesBatteries

Sex stimulant devicesSex stimulant devices

Some important remarksSome important remarks

80-90% of foreign bodies pass the GI tract 80-90% of foreign bodies pass the GI tract without causing further problems.without causing further problems.Lodged button batteries in the esophagus Lodged button batteries in the esophagus may cause liquefaction necrosis due to may cause liquefaction necrosis due to their alkaline effects… their alkaline effects… Prompt removal is Prompt removal is needed…needed…Sharp subjects longer than 6 cm become Sharp subjects longer than 6 cm become lodged in the duodenum, lodged in the duodenum, they should be they should be removed promptly.removed promptly.

What is your management ?What is your management ?

a. Observea. Observe

b. Endoscopeb. Endoscope

Initial investigationsInitial investigations

PEPE

CBC, CRPCBC, CRP

Plain radiographsPlain radiographs

Foreign Body Ingestion in Foreign Body Ingestion in ChildrenChildren

- Peak incidence in children aged 6 mo.– 3 - Peak incidence in children aged 6 mo.– 3 yr.yr.

- Serious morbidity <1% of all patients- Serious morbidity <1% of all patients

- Management based on:- Management based on:

1. type of foreign object1. type of foreign object

2. location in GI tr.2. location in GI tr.

3. asymptomatic/symptomatic3. asymptomatic/symptomatic

Common areas of luminal narrowing and Common areas of luminal narrowing and angulation in GI tract.angulation in GI tract.

Clinical FeaturesClinical Features

- 50% Asymptomatic- 50% Asymptomatic

- Objects that passed esophagus, do not- Objects that passed esophagus, do not

cause symptoms unless complicationscause symptoms unless complications

(bowel perforation, obstruction)(bowel perforation, obstruction)

- Majority of FB less than 2 cm. in diameter- Majority of FB less than 2 cm. in diameter

can pass esophagus spontaneouslycan pass esophagus spontaneously

Symptoms of Esophageal Foreign Symptoms of Esophageal Foreign BodiesBodies

Blood in saliva IrritabilityBlood in saliva IrritabilityCoughing * Coughing * Pain in neck, throat, or chestPain in neck, throat, or chestDrooling* Drooling* Recurrent aspiration pneumoniaRecurrent aspiration pneumoniaDysphagia/odynophagia* Dysphagia/odynophagia* Respiratory distress*Respiratory distress*Failure to thrive Failure to thrive StridorStridorFever Tachypnea or dyspneaFever Tachypnea or dyspneaFood refusal Food refusal Vomiting*Vomiting*Foreign body sensation in throat Foreign body sensation in throat WheezingWheezingGaggingGagging

Attention!!Attention!!

Swelling, erythema, tenderness, or Swelling, erythema, tenderness, or crepitus in neck region means……crepitus in neck region means……

Oropharyngeal or proximal esophageal Oropharyngeal or proximal esophageal perforationperforation

Identification of Ingested Foreign BodiesIdentification of Ingested Foreign Bodies

- - Plain radiographsPlain radiographs are initial investigation of are initial investigation of patients suspected FB ingestionpatients suspected FB ingestion

(neck,chest,abdomen PA and lat.)(neck,chest,abdomen PA and lat.)

- 64% of ingested objects were radiopaque.- 64% of ingested objects were radiopaque.

- Wooden, plastic,glass objects, fish and chicken - Wooden, plastic,glass objects, fish and chicken bones may not seen on radiographs.bones may not seen on radiographs.

- Barium esophagography ± (risk of aspiration,- Barium esophagography ± (risk of aspiration,

compromise subsequent endoscopy)compromise subsequent endoscopy)

Specific Types of Foreign BodiesSpecific Types of Foreign BodiesCoinsCoins

- most frequently swallowed FB, majority of- most frequently swallowed FB, majority of esophageal FB in children.esophageal FB in children.- esophagus : - esophagus : -symptomatic pt. : endoscope-symptomatic pt. : endoscope - FB usually passes into stomach within 24 hrs.- FB usually passes into stomach within 24 hrs. - > 24 hr. risk for complications (esophageal- > 24 hr. risk for complications (esophageal perforation, TE fistula, esophagoaortic fistula)perforation, TE fistula, esophagoaortic fistula) - Endoscopic removal- Endoscopic removal

Specific Types of Foreign BodiesSpecific Types of Foreign BodiesCoinsCoins

stomach : stomach :

- - coins 20 mm. or less expected to pass coins 20 mm. or less expected to pass spontaneously through GI tr.spontaneously through GI tr.

- Abdominal film every 7-10 d. to monitor - Abdominal film every 7-10 d. to monitor passage of coin.passage of coin.

- If after 4 wk. coin remains in stomach, it - If after 4 wk. coin remains in stomach, it should be removed endoscopically.should be removed endoscopically.

Disk (Button) BatteriesDisk (Button) Batteries

- > 90% pass through GI tr. within 72 hrs.- > 90% pass through GI tr. within 72 hrs.- Mercuric oxide, Silver oxide, Manganese oxide,- Mercuric oxide, Silver oxide, Manganese oxide, lithium + potassium/sodium hydroxide.lithium + potassium/sodium hydroxide. - Severity of injury- Severity of injury 1.battery size (>15 mm. in diameter more likely1.battery size (>15 mm. in diameter more likely lodge in esophagus)lodge in esophagus) 2.duration of contact with mucosa.2.duration of contact with mucosa. 3.type of heavy metal (mercury is potentially most 3.type of heavy metal (mercury is potentially most

toxic)toxic)

Disk (Button) BatteriesDisk (Button) Batteries

- Mucosal injury from 3 effects- Mucosal injury from 3 effects

1. 1. liquefaction necrosisliquefaction necrosis from alkali from alkali

2. 2. direct pressuredirect pressure necrosis from FB necrosis from FB

3. local pH changes due to electrical current 3. local pH changes due to electrical current dischargedischarge

- Most serious morbidities from lodged in - Most serious morbidities from lodged in esophagusesophagus

(burn within 4 hrs!!!, perforation within 6 hrs.!!!)(burn within 4 hrs!!!, perforation within 6 hrs.!!!)

Sharp or Elongated Foreign BodiesSharp or Elongated Foreign Bodies

- 15-35% of perforations from FB ingestion caused by sharp objects.- 15-35% of perforations from FB ingestion caused by sharp objects.

- Perforaions likely occur in C loop of duodenum, ligament of Trietz,- Perforaions likely occur in C loop of duodenum, ligament of Trietz,terminal ileum, IC region and sigmoid colon.terminal ileum, IC region and sigmoid colon.

- Object longer than 5 cm. , wider than 2 cm. ,not likely to pass.- Object longer than 5 cm. , wider than 2 cm. ,not likely to pass.

- High - risk objects and exceeding these dimension require urgent- High - risk objects and exceeding these dimension require urgentendoscopic removal from stomach or proximal duodenum.endoscopic removal from stomach or proximal duodenum.

- Serial Abd.films, if pin or sharp object stays in place or pt. develop- Serial Abd.films, if pin or sharp object stays in place or pt. developabdominal symptoms, surgical intervention is necessary.abdominal symptoms, surgical intervention is necessary.

Proposed algorithmProposed algorithm

Plain film:Plain film: - Free air: Surgery- Free air: Surgery - Asymptomatic: No Tx - Asymptomatic: No Tx ( Remember that lodged button batteries in ( Remember that lodged button batteries in

the esophagus and sharp objects wider the esophagus and sharp objects wider than 2 cm. and longer than 6 cm. should be than 2 cm. and longer than 6 cm. should be removed as sson as possible even if they removed as sson as possible even if they have caused no trouble on admission)have caused no trouble on admission)

- Symptomatic: Urgent endoscopy- Symptomatic: Urgent endoscopy