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Foreign Bodies in the GI Tract

by Michael C. DiMarino, MD

A variety of foreign bodies may enter the GI tract. Many pass spontaneously, but some become impacted, causing symptoms of obstruction. Perforation may occur. The esophagus is the most common (75%) site of impaction. Nearly all impacted objects can be removed endoscopically, but surgery is occasionally necessary.

Undigestible objects may be intentionally swallowed by children and demented adults. Denture wearers, the elderly, and inebriated people are prone to accidentally swallowing inadequately masticated food (particularly meat), which may become impacted in the esophagus. Smugglers who swallow drug-filled balloons, vials, or packages to escape detection (body packers or body stuffers) may develop intestinal obstruction. The packaging may rupture, leading to drug overdose.

Esophageal foreign bodies

Foreign bodies usually lodge in an area of esophageal narrowing such as at the cricopharyngeus or aortic arch or just above the gastroesophageal junction. If obstruction is complete, patients retch or vomit. Some patients drool because they are unable to swallow secretions.

Immediate endoscopic removal is required for sharp objects, coins in the proximal esophagus, and any obstruction causing significant symptoms. Also, button batteries lodged in the esophagus may cause direct corrosive damage, low-voltage burns, and pressure necrosis and thus require prompt removal.

Other esophageal foreign bodies may be observed for a maximum of 12 to 24 h. Glucagon 1 mg IV and lorazepam 1 mg IV (may repeat 1 mg after 15 min if the initial dose is unsuccessful) sometimes relax the esophagus enough to allow spontaneous passage. Other methods, such as use of effervescent agents, meat tenderizer, and bougienage, are not recommended. Endoscopic removal is the treatment of choice. Removal is best achieved using a forceps, basket, or snare with an overtube placed in the esophagus to prevent aspiration.

Sometimes, foreign bodies scratch the esophagus but do not become lodged. In such cases, patients may report a foreign body sensation even though no foreign body is present.

Gastric and intestinal foreign bodies

Foreign bodies that pass through the esophagus are asymptomatic unless obstruction or perforation occurs. Of the foreign bodies that reach the stomach, 80 to 90% pass spontaneously, 10 to 20% require nonoperative intervention, and 1% require surgery. Thus, most intragastric foreign bodies can be ignored. However, objects larger than 5 x 2 cm rarely pass the stomach. Sharp objects should be retrieved from the stomach because 15 to 35% will cause intestinal perforation, but small round objects (eg, coins and button batteries) can simply be observed. The patient’s stools should be searched, and if the object does not appear, x-rays are taken at 48-h intervals. A coin that remains in the stomach for > 4 wk or a battery showing signs of corrosion on x-ray that remains in the stomach for > 48 h should be removed. A hand-held metal detector can localize metallic foreign bodies and provide information comparable to that yielded by plain x-rays.

Patients with symptoms of obstruction or perforation require laparotomy. Ingested drug packages are of great concern because of the risk of leakage and consequent drug overdose. Patients with symptoms of drug toxicity should have immediate laparotomy with interim medical management of symptoms (eg, benzodiazepines for cocaine toxicity). Asymptomatic patients should be admitted to the hospital. Some clinicians advocate oral polyethylene glycol solution as a cathartic to enhance passage of the material; others suggest surgical removal. The best practice is unclear.

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, as is present in Crohn’s disease. Sometimes objects such as toothpicks remain within the GI tract for many years, only to turn up in a granuloma or abscess.

Rectal foreign bodies

Gallstones, fecaliths, and swallowed foreign bodies (including toothpicks and chicken and fish bones) may lodge at the anorectal junction. Urinary calculi, vaginal pessaries, or surgical sponges or instruments may erode into the rectum. Foreign bodies, sometimes bizarre and/or related to sexual play, may be introduced intentionally but become lodged unintentionally. Some objects are caught in the rectal wall, and others are trapped just above the anal sphincter.

Sudden, excruciating pain during defecation should arouse suspicion of a penetrating foreign body, usually lodged at or just above the anorectal junction. Other manifestations depend on the size and shape of the foreign body, its duration in situ, and the presence of infection or perforation.

Foreign bodies usually become lodged in the mid rectum, where they cannot negotiate the anterior angulation of the rectum. They can be felt on digital examination. Abdominal examination and chest x-rays may be necessary to exclude possible intraperitoneal rectal perforation.

If the object can be palpated, a local anesthetic is given by sc and submucosal injections of 0.5% lidocaine or bupivacaine. The anus is dilated with a rectal retractor, and the foreign body is grasped and removed. If the object cannot be palpated, the patient should be hospitalized. Peristalsis usually moves the foreign body down to the mid rectum, and the above routine can be followed. Removal via a sigmoidoscope or proctoscope is rarely successful, and sigmoidoscopy usually forces the foreign body proximally, delaying its extraction. Regional or general anesthesia is infrequently necessary, and laparotomy with milking of the foreign body toward the anus or colotomy with extraction of the foreign body is rarely necessary. After extraction, sigmoidoscopy should be done to rule out significant rectal trauma or perforation. Removal of a rectal foreign body may be of high risk and should be done by a surgeon or gastroenterologist skilled in foreign body removal.

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