Gastric and Intestinal Foreign Bodies
(See also Overview of Foreign Bodies in the GI Tract.)
A variety of swallowed objects can become lodged in the stomach or intestines. Some foreign bodies cause obstruction or perforation. Diagnosis is by x-ray. Some foreign bodies can be removed endoscopically.
Of the foreign bodies that reach the stomach, 80 to 90% pass spontaneously through the GI tract, 10 to 20% require nonoperative intervention, and ≤ 1% require surgery. Thus, conservative management is appropriate for most blunt objects in asymptomatic patients. However, objects > 6 cm in length or objects > 2.5 cm in diameter rarely pass through the stomach (1).
Ingested drug packages (see Body Packing and Body Stuffing) are of great concern because of the risk of leakage and consequent drug overdose. Packages can also cause mechanical obstruction.
1. ASGE Standards of Practice Committee, Ikenberry SO, Jue TL, Anderson MA, et al: Management of ingested foreign bodies and food impactions. Gastrointest Endosc 73:1085–1091, 2011. doi: 10.1016/j.gie.2010.11.010.
Foreign bodies that pass through the esophagus are asymptomatic unless perforation or obstruction occurs. Perforation of the stomach or intestines manifests with symptoms and signs of peritonitis such as abdominal pain, guarding, and rebound tenderness. Obstruction of the intestines causes abdominal pain and distention and vomiting.
Abdominal x-rays may be done to identify the foreign object and are useful for following the progression of the object through the GI tract. Abdominal x-rays with chest x-rays are also important for identifying signs of perforation (eg, free air that is subdiaphragmatic, mediastinal, or subcutaneous). A hand-held metal detector can localize metallic foreign bodies and provide information comparable to that yielded by plain x-rays. If plain x-rays are negative, a CT scan may helpful.
Suspected body packers and stuffers are usually brought to medical attention by law enforcement officials. Plain x-rays can often confirm the presence of packets in the GI tract. If these x-rays are negative, a CT scan may be helpful.
Management depends on several factors:
Sharp objects should be retrieved from the stomach because 15 to 35% will cause intestinal perforation. Small round objects (eg, coins) can simply be observed for a period of time that varies depending on the nature of the object. The patient’s stools should be searched, and if the object does not appear, x-rays are taken at 48-h intervals and then at weekly intervals. The following objects should be removed endoscopically:
Batteries that cause symptoms or signs of GI tract injury
Cylindrical batteries and disk batteries that remain in the stomach for > 48 h without causing signs of GI injury
Sharp-pointed objects in the stomach
Objects > 2.5 cm diameter in the stomach
Small, round objects (eg, coins) that remain in the stomach after 3 to 4 wk
Any magnets within endoscopic reach
Most foreign objects that have passed into the small intestine usually traverse the GI tract without problem, even if they take weeks or months to do so. They tend to be held up just before the ileocecal valve or at any site of narrowing. Sometimes objects such as toothpicks remain within the GI tract for many years, only to turn up in a granuloma or abscess.
Single-balloon and double-balloon enteroscopy can be used to access the small bowel and may have a role in the treatment of small-bowel foreign body ingestions in some patients.
Surgical removal should be considered for short, blunt objects that are located in the small bowel, distal to the duodenum, but have not changed location for more than 1 wk and cannot be managed endoscopically.
Patients who have ingested drug packages and who present with symptoms and signs of drug toxicity should receive medical treatment immediately. Prompt surgical evaluation should be obtained when sympathomimetic toxicity, bowel obstruction, perforation, or drug leakage is suspected. Asymptomatic patients should be admitted to the hospital and closely monitored in an intensive care setting.
Endoscopic removal is not recommended for ingested drug packages because of the high risk of package perforation. Some clinicians advocate whole-body irrigation using oral polyethylene glycol solution as a cathartic to enhance passage of the material; others suggest surgical removal. The best practice is unclear.
Foreign bodies that pass through the esophagus are asymptomatic unless perforation or obstruction occurs.
Abdominal x-rays may identify the foreign object and are useful for following the progression through the GI tract.
Management depends on the nature of the object, but sharp objects should be retrieved from the stomach.
Impacted drug packages can cause serious or fatal toxicity; even asymptomatic patients require close monitoring.