Removal of a Foreign Body from the Upper Gastrointestinal Tract with a Flexible Endoscope: a Prospective Study

• Introduction
• Patients and Methods
• Results
• Discussion
• References

Background and Study Aims: There have so far been no prospective studies on the value of flexible endoscopy for removing foreign bodies in the upper gastrointestinal tract. This study presents a clinical analysis of accidents with foreign bodies and prospectively evaluates the effectiveness of flexible endoscopy for removing them.
Patients and Methods: A total of 105 cases of foreign-body ingestion in the upper gastrointestinal tract were evaluated, 29 (27.6 %) in children and 76 (72.4 %) in adults. Thirty patients (28.5 %) had esophageal strictures.
Results: Thirty-nine of the foreign bodies (37.1 %) consisted of food and 66 (62.9 %) were not food-related. The success rate of foreign-body extraction using only a conventional flexible endoscope and accessories for treatment was 98.0 %, and with only a polypectomy snare and rat-toothed forceps it was 91.2 %. Complications at the moment of foreign-body removal occurred in nine patients (8.6 %); there was only one (1 %) esophageal perforation. The incidence of complications related to the duration of foreign-body impaction was six (10.5 %) with foreign bodies impacted for up to 24 h, 13 (52.0 %) for those impacted for 24 - 48 h, and three (60.0 %) for those impacted for 48 - 72 h (P < 0.05).
Conclusions: The flexible endoscope is an effective and safe device for removing foreign bodies from the upper gastrointestinal tract, with a high success rate using only the polypectomy snare and the rat-toothed forceps as accessories. If foreign-body impaction lasts for more than 24 h, there is a significant increase in the incidence of complications.

Introduction

Since the first report in 1972 on the removal of foreign bodies with a flexible endoscope [1], there has been increasing use of the method, due to advantages such as avoiding the need for general anesthesia in the majority of adults, reducing the costs of the procedure; technical facility; excellent visualization; the ability to remove foreign bodies even from the duodenum; incidental diagnosis of other diseases; and a low rate of morbidity. There have been no controlled prospective studies comparing flexible and rigid endoscopes for the treatment of foreign bodies in the upper gastrointestinal tract, owing to the wide variety of factors involved, such as varying locations; the different sizes and shapes of the foreign bodies found; different periods of foreign-body impaction; concomitant presence of esophageal diseases; and varying levels of expertise among endoscopists.

Some 10 - 20 % of ingested foreign bodies require treatment. They are generally managed by endoscopy, and surgical treatment is needed in less than 1 % of cases [2] [3]. There are now many options available for removing foreign bodies from the upper gastrointestinal tract, but further research is still needed to confirm the effectiveness of flexible endoscopy in cases of this type. The aim of the present study was to carry out a prospective clinical analysis of patients with foreign bodies in the upper gastrointestinal tract, and to evaluate the effectiveness of flexible endoscopy for removing foreign bodies.

Patients and Methods

A total of 105 cases of foreign bodies in the upper gastrointestinal tract, in 103 patients treated at the Emergency Division of the Gastrointestinal and Bronchoesophagoscopy Center at the University of São Paulo Medical School Hospital, were included in this prospective study during a 2-year period. One patient ingested foreign bodies on three different occasions. The total corresponded to 75 % of all cases of foreign-body impaction treated in the emergency unit. The study included patients with foreign bodies lodged in the upper gastrointestinal tract, ranging from the cervical esophagus to the second part of the duodenum.

All of the patients were treated by the same endoscopist and were studied prospectively. Before the foreign-body extraction procedure, plain chest radiography and cervical radiography were carried out, or abdominal radiography if there was a suspicion of a gastric or duodenal foreign body. Upper gastrointestinal endoscopy examinations were carried out in all patients with symptoms suggestive of foreign-body impaction, independent of the radiography findings.

Conventional Olympus and Pentax video endoscopes were used to remove the foreign bodies. The following accessories were available for removing the foreign bodies: polypectomy snare, rat-toothed forceps, Dormia basket, and a transparent acrylic cap adapted to the tip of the endoscope for extraction by suction (an endoscopic mucosal resection cap). A latex protector hood or an overtube was also available to protect the esophagus during removal. Extraction of the foreign bodies was started either with snare or rat-toothed forceps, depending on the shape of the object; the other devices were only used if these two failed. The choice of forceps was made on a case-to-case basis, depending on the type and shape of the foreign body. If foreign-body extraction with the conventional endoscope was unsuccessful, an Olympus therapeutic double-channel endoscope was used. If this was still unsuccessful, a rigid esophagoscope was used as a last option.

Any children and adults with psychiatric disturbance underwent general anesthesia; the remainder of the patients received sedation with a combination of diazepam and pethidine (meperidine). None of the patients had previously undergone foreign-body removal, except for one who had a cartilaginous bone impacted in the upper esophagus, in whom two previous attempts by other physicians to remove the object with rigid esophagoscopy had failed. After removal of the foreign body, patients with complications remained in hospital until they had completely recovered, and if necessary they were followed up as outpatients for a further 30 days.

The foreign bodies were classified as food-related or as true foreign bodies (the latter not consisting of food). Depending on shape, they were classified as sharp, pointed, or blunt, and the widest diameter was recorded in all cases.

Seventy-six of the cases (72.4 %) were in adults and 29 in children (27.6 %). The age of the adult patients ranged from 20 to 98 (mean 46.8 years), and in children the range was from 9 months to 11 years (mean 4.3 years).

Results

Of the 105 foreign bodies, 94 (89.5 %) were located in the esophagus, 10 (9.5 %) in the stomach, and one (0.9 %) in the duodenum. In the esophagus, 52 (49.5 %) were located in the cervical part, 31 (29.5 %) in the thoracic part, and 11 (10.5 %) in the abdominal part.

The symptoms and clinical signs presented by patients attending the emergency service were: dysphagia in 82 patients (78.1 %); sialorrhea in 54 (51.4 %); odynophagia in 29 (27.6 %); local discomfort in 19 (18.1 %); and vomiting in seven (6.7 %). Fever occurred in three patients (2.9 %) with esophageal perforation, and in a further three (2.9 %) with deep esophageal ulceration. Thoracic pain in the back was reported by three patients (2.9 %) with perforation of the esophagus and pneumothorax. Hoarseness was observed in only one (0.9 %) patient, who had had a metal pendant lodged in the cervical esophagus for 10 days, causing deep local ulceration. Eight patients were asymptomatic, seven of whom presented with foreign bodies in the stomach or duodenum, without complications, and a 1-year-old child, apparently asymptomatic, with a coin in the cervical esophagus. Epigastric pain was described by two patients, one of whom had a gastric perforation 12 h after voluntary ingestion of eight sewing needles. The other had a gastric ulceration 16 h after voluntary ingestion of two batteries.

Forty-one of the adults treated (53.9 %) had dental prostheses, and three (3.9 %) were edentulous. Thirty patients (28.6 %) had a prior esophageal stricture; 28 (93.3 %) of these were adults and two (6.7 %) were children. Among the 30 esophageal strictures, four (13.3 %) were in the cervical segment, 21 (70.0 %) in the thoracic segment, and five (16.7 %) in the abdominal segment.

Plain radiographs were made in 104 cases, providing confirmation of the presence of a foreign body in 56 (53.8 %), raising a suspicion in three cases (2.9 %), or showing indirect signs (two with straightness in the cervical spine and one with a prevertebral enlargement), with an overall sensitivity of 56.7 %. Excluding food-related foreign bodies, none of which was visible on radiography, the sensitivity was 90.8 %.

No attempt at endoscopic removal was made with two of the 105 foreign bodies, as the objects had perforated the esophagus and were outside of the lumen - one sewing needle removed by thoracoscopy (Figure [1]) and a small fishbone in a cervical location, for which conservative treatment was given.

Foreign-body removal was successful in 102 of the remaining 103 cases (99.0 %). In one case, it was necessary to use a double-channel endoscope to remove the foreign body. In the other 101 cases (98.0 %), the foreign bodies were removed with only a conventional endoscope and various accessories. It was possible to remove 94 of the foreign bodies (91.2 %) using a conventional endoscope with a polypectomy snare and rat-toothed forceps as accessories.

All types of food-related foreign body were removed successfully (32 meat boluses, two food residues, one boiled potato, one piece of lard, one piece of orange skin, one pea, one bean grain). The snare was used to remove 35 foreign bodies of this type (89.7 %), the cap twice (5.1 %), the rat-toothed forceps once (2.6 %), and the Dormia basket once (2.6 %).

With the true foreign bodies (13 coins in the esophagus, six coins in the stomach, 12 metal foreign bodies, 13 pieces of chicken or animal bone, three pieces of cartilage, five fishbones, five dental prostheses, four plastic foreign bodies, one orange seed, one battery, and one cigarette lighter), removal was not possible in only one case. The polypectomy snare was used 21 times (32.8 %) to grasp the true foreign bodies, and the rat-toothed forceps 42 times (65.6 %). The only unsuccessful case was a large cartilaginous foreign body in the cervical esophagus, close to the cricopharyngeal muscle. It was not possible to remove this with a polypectomy snare, as the edges were in tight contact with the local structures; nor was removal with a rat-toothed forceps possible, as it would have torn the cartilage or slid over its surface. It was removed with a rigid esophagoscope and Jackson alligator grasping forceps.

The most frequently used accessory was the polypectomy snare, which was employed in a total of 56 cases (54.3 %), including 31 meat boluses, for which it was extremely effective, with a 100 % success rate (Figure [2]). A rat-toothed forceps was used as the first choice in only one case, to remove a small meat bolus in the esophageal lumen. Coins lodged in the stomach were also removed without problems by adjusting the snare to their diameter. A rat-toothed forceps was the second most frequently used accessory with conventional endoscopy, employed in 43 cases (41.7 %). It had limited efficacy for removing foreign bodies with a soft consistency, smooth surface, or thick edges, as these did not have any parts that were suitable for grasping. The endoscopic mucosal resection cap adapted to the tip of the endoscope was used to removed two food-related foreign bodies by suction, as it was not possible to capture them with the polypectomy snare or rat-toothed forceps, due to their soft consistency. In another two patients, the cap provided better visualization of true foreign bodies lodged in the cricopharyngeal constriction, facilitating their removal. An overtube introduced into the gastric lumen allowed safe removal of a razor blade, protecting the cardia and esophagus from any injury. The latex hood was very useful for removing a large dental prosthesis, with pointed metal hooks, that was moved into the stomach after the esophagus had been perforated during attempted removal. Removal of the prosthesis was only possible after it had been protected with the latex hood (Figure [3]). The Dormia basket was used to remove a loose pea in the esophagus, after unsuccessful attempts with a polypectomy snare and rat-toothed forceps.

The size of the foreign bodies, measured by their maximum diameters, ranged from 0.5 cm to 10.0 cm; 59 (56.1 %) measured 2.1 - 4.0 cm; 20 (19.1 %) were larger than 4.0 cm, and 26 (24.8 %) were smaller than 2.0 cm.

Of a total of 40 (38.0 %) complications related to the foreign bodies, only nine (8.6 %) occurred during the removal procedure, all in the esophagus: laceration in seven patients (6.7 %), perforation in one patient (0.1 %), and a small hematoma in another (0.1 %). Twenty-nine complications (27.6 %) resulted from direct injury to the esophagus by the foreign body before removal, and two (1.9 %) involved injury to the stomach. In the esophagus, 15 patients (14.3 %) had erosions, six (5.7 %) had ulcers, seven (6.%) had perforations, and one (0.95 %) had piriform sinus edema.

Esophageal ulcers occurred in six patients (5.7 %), all of them in the cervical esophagus when the foreign body had been impacted for more than 2 days. Four patients had fever, three of whom presented with deep ulcers (Figure [4]). They were treated with an enteral or nasogastric tube for feeding during the first 48 - 72 h, and triple antibiotic therapy (penicillin, amikacin, and metronidazole) was administered for 7 days. The only case of gastric ulcer occurred in a patient 16 h after voluntary ingestion of two batteries; she was treated with omeprazole 20 mg/day.

One gastric perforation occurred in a patient with a psychiatric disorder who ingested eight sewing needles. Twelve hours after ingestion, two of the needles had perforated the stomach, and all were successfully removed. All of the foreign bodies that caused perforations were sharp or pointed. The types of foreign body that most frequently resulted in esophageal perforation were fishbones (Figure [5]), chicken bones, and animal bones (four patients). The perforation that occurred during foreign-body removal was caused by a dental prosthesis with pointed metal hooks. Conservative treatment (nasogastric tube and antibiotic therapy) was started in all of the patients at the moment a perforation was diagnosed, and all had a good subsequent course.

No relationship was observed between the size and shape of the foreign bodies and the complication rate. Impaction of a true foreign body for more than 24 h resulted in a higher complication rate (P < 0.001). When the period was 24 h or less, there were six complications (10.5 %); at 24 - 48 hours, there were 13 complications (52.0 %); and when it was 48 - 72 h, there were three complications (60.0 %).

Discussion

There have been few studies, even retrospective ones, comparing rigid and flexible endoscopes for foreign-body removal. Berggreen et al. [4] reported a success rate of 96.2 % and a complication rate of 5.1 % with fiber endoscopy, and a success rate of 100 % and a complication rate of 10.0 % with rigid endoscopy. There were no statistically significant differences, but these data suggest that rigid endoscopy should be the second-best option for removing foreign bodies from the upper gastrointestinal tract.

In this study, two previous attempts by other endoscopists with rigid esophagoscopes had failed to remove a round cartilaginous foreign body completely occluding the cervical esophageal lumen just below the cricopharyngeal constriction. It was successfully removed using a double-channel flexible endoscope, by double grasping with a polypectomy snare at the moment of retrieval.

Some reports have described the use of special accessories to remove foreign bodies in the upper gastrointestinal tract, including a Roth net [5], overtube [6], rubber bands and cap [7] [8], latex hood [9] [10] and needle-knife [11]. There can be no standard practices for removing foreign bodies, as each case is different and success depends on a variety of factors. During the procedure, the endoscopist needs to choose the best option depending on the type, size, shape, and location of the foreign body.

Success rates of 83 - 98 % for removing foreign bodies with flexible endoscopes have been reported in various studies, with the incidence of esophageal perforation during foreign-body removal ranging from 0 to 1 % [2] [12] [13].

If the double-channel endoscope, overtube, Dormia basket, cap, and latex hood had not been available, the success rate in the present series would have been 91.2 % instead of 99.0 %. This clearly reflects the value of the accessories and the importance of a skilled endoscopist acquainted with all the available methods.

The incidence of preexisting diseases may reflect the frequency with which each segment of the esophagus is affected by foreign bodies [14]. In this study, caustic strictures were the most common condition affecting patients with foreign bodies in the thoracic esophagus - 21 of 31 (67.7 %), and were the main factor involved in the high incidence of foreign bodies in the thoracic segment of the esophagus.

In a substantial percentage of patients with a clinical history of foreign-body ingestion, nothing is identified on either radiography or endoscopy. Radiography is used by most physicians as the initial procedure in patients suspected of having a foreign-body impaction. However, if the findings are normal and the patient is symptomatic, an upper gastrointestinal endoscopy examination is needed. It is sometimes necessary to compare radiographic images before and after the endoscopic procedure in order to confirm any complications that may occur during the procedure.

The diagnostic sensitivity of plain radiography for diagnosing foreign bodies ranges from 44.0 % to 77.0 % [15] [16] [17]. In the present study, the sensitivity for all types of foreign body was 56.7 %, and that for true foreign bodies was 90.8 %.

Meat boluses are the commonest type of food-related foreign body. They are more frequent in adults with stenotic conditions and those who are edentulous. In this study, 28 of 38 patients (73.5 %) with food-related foreign bodies in the esophagus had some degree of stricture in the organ.

Since 80 - 90 % of ingested foreign bodies do not need treatment, as they pass through the gastrointestinal tract spontaneously [1] [18] [19], it is necessary to establish when there is an indication for removal. The decision is based on the type of foreign body and its location. According to some studies [1] [20], all foreign bodies in the esophagus should be removed, preferably within 24 h, since any extended period of contact under pressure may lead to local necrosis, increasing the risk of complications. When a foreign body is associated with respiratory symptoms, treatment must be urgent. If the location is in the proximal esophagus, where it is frequently associated with sialorrhea, it must be removed as soon as possible to avoid a higher risk of pulmonary aspiration. In the case of small and blunt foreign bodies in the distal esophagus, there is a strong possibility of spontaneous migration into the stomach, and observation for up to 12 h after ingestion is therefore permissible unless the object is causing considerable discomfort and sialorrhea.

When a foreign body in the stomach is considered to be toxic, sharp, or pointed, and is longer than 6 cm in children or 10 cm in adults, removal immediately after diagnosis is indicated. The risk of gastrointestinal perforation is high for all types of pointed and sharp foreign bodies, reaching 35 % in some studies [12]. In particular, long and thin foreign bodies, such as hairpins, nails, and toothbrushes, may become trapped at points of angulation in the gastrointestinal tract and lead to perforation. Toothpicks, which are long and pointed at both ends, are associated with a high risk of gastrointestinal perforation.

Round foreign bodies in the stomach with a diameter of less than 2.5 cm can be treated conservatively, as most of them tend to progress to the pylorus. An observation period of up to 2 weeks is appropriate for this type of foreign body [18], with a radiographic check-up after 1 week in case the object is not eliminated. The average time for a foreign body to pass through the whole gastrointestinal tract is approximately 1 week. Observation should be stopped at about the sixth day if the object remains in the duodenum, or on the tenth day if it is in the intestines or if there are any complications.

With batteries, the concern is the possibility of necrosis of the gastrointestinal wall if the contents leak. There are three mechanisms for battery injury - corrosive action, low-voltage burning, and pressure necrosis due to compression - but the most important of these is the corrosive action of alkaline chemicals [2]. In the esophagus, batteries must be urgently removed due to the high incidence of stenosis and even perforation resulting from leakage. However, if a battery passes the esophagus, it is usually spontaneously eliminated without complications and does not need removal. Once it has passed the duodenum, elimination follows within about 72 h in more than 85 % of cases. When batteries are located in the stomach, removal is indicated to avoid symptomatic gastric lesions if the diameter is larger than 2.5 cm or if the battery does not pass the pylorus within 48 h [2] [21] [22]. A radiographic check-up therefore has to be carried out 48 - 120 h after ingestion. In the present study, a patient who presented with two batteries that had been in the stomach for 16 h already had ulceration.

Pointed or sharp foreign bodies are often associated with complications; the objects most frequently involved are fishbones and chicken bones. The prevailing mechanism of injury is direct penetration into the wall of the organ. Blunt foreign bodies cause lesions due to prolonged compression or chronic injury; the most common of these are coins [23].

No relationship was observed between the incidence of complications and the size or shape of the foreign bodies in this study. However, the incidence of complications was higher the longer the foreign bodies had been impacted. In this study, complications were observed in 60 % of foreign bodies that had been impacted for 48 - 72 h and in 10.5 % of those impacted for up to 24 h.

The total incidence of complications caused by foreign bodies in the upper gastrointestinal tract is 15 - 42 % [12] [13] [15] [24]. These are usually limited complications such as erosions, superficial lacerations, edema, hematoma, and mild respiratory complications. The incidence of severe complications ranges from 0.5 % to 7.5 %, and the reported mortality rate is 0 - 3.5 %. Among the major complications, esophageal perforation is the most frequent, and hemorrhage resulting from injury to large vessels is the most fatal [25] [26] [27].

The high incidence of complications in the present study, relative to the findings in the majority of published reports, is explained by the fact that our hospital is a referral center receiving many complicated cases. Another reason is that the study was a prospective one with flexible endoscopy, with even small lesions in the mucosa being diagnosed and reported. In retrospective studies, minor lesions of this type are probably often disregarded in records or are not diagnosed with rigid esophagoscopes, due to the limitations of the method.

In conclusion, this study shows that the flexible endoscope is a safe and effective tool for removing foreign bodies from the upper gastrointestinal tract, even with only a polypectomy snare and rat-toothed forceps as accessories. An important observation is that the incidence of complications increases significantly in proportion to the length of time an object is impacted.

References

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D. M. Chaves, M. D.

Rua Montezuma 183 - Jd. das Bandeiras · São Paulo 05436-080 · Brazil ·

Fax: +55-11-30697579

Email: dalton.chaves@fleury.com.br

References

• 1 Brady P G. Management of esophageal and gastric foreign body. In: Dimarino AJ, Benjamin SB (eds.) Gastrointestinal disease: an endoscopic approach. London; Blackwell Science 1997: 407-417
  Search in Google Scholar
• 2 Webb W A. Management of foreign bodies of the upper gastrointestinal tract.  Gastroenterology. 1988;  94 204-216
  PubMedSearch in Google Scholar
• 3 Schwartz G F, Polsky H S. Ingested foreign bodies of the gastrointestinal tract.  Am Surg. 1976;  42 236-238
  PubMedSearch in Google Scholar
• 4 Berggreen P J, Harrison E, Sanowski R A. et al . Techniques and complications of esophageal foreign body extraction in children and adults.  Gastrointest Endosc. 1993;  39 626-630
  Search in Google Scholar
• 5 Neustater B, Barkin M S. Extraction of an esophageal food impaction with a Roth retrieval net.  Gastrointest Endosc. 1996;  43 66-67
  PubMedSearch in Google Scholar
• 6 Werth R W, Edwards C, Jennings W C. A safe and quick method for endoscopic retrieval of multiple gastric foreign bodies using a protective sheath.  Surg Gynecol Obstet. 1990;  171 419-420
  PubMedSearch in Google Scholar
• 7 Saeed Z A, Michaletz P A, Feiner S D. et al . A new endoscopic method for managing food impaction in the esophagus.  Endoscopy. 1990;  22 226-229
  PubMedSearch in Google Scholar
• 8 Pezzi J S, Shiau Y F. A method for removing meat impactions from the esophagus.  Gastrointest Endosc. 1994;  40 634-636
  PubMedSearch in Google Scholar
• 9 Bertoni G, Sassatelli R, Conigliano R. A simple latex protector hood for safe endoscopic removal of sharp-pointed gastroesophageal foreign bodies.  Gastrointest Endosc. 1996;  44 458-461
  CrossrefPubMedSearch in Google Scholar
• 10 Kao L S, Nguyen T, Dominitz J. et al . Modification of a latex glove for the safe endoscopic removal of a sharp gastric foreign body.  Gastrointest Endosc. 2000;  52 127-129
  CrossrefPubMedSearch in Google Scholar
• 11 Nijhawan S, Shimpi L, Jain N K, Rai R R. Impacted foreign body at the pharyngoesophageal junction: an innovative management.  Endoscopy. 2002;  34 353
  Thieme ConnectPubMedSearch in Google Scholar
• 12 Vizcarrondo F J, Brady P G, Nord H J. Foreign bodies of the upper gastrointestinal tract.  Gastrointest Endosc. 1983;  29 208-210
  PubMedSearch in Google Scholar
• 13 Moral L Y, Morante A JL, Lorente J LM. et al . Terapeutica fibroendoscopica de los cuerpos extraños intraesofagicos.  Rev Esp Enferm Dig. 1992;  81 95-98
  PubMedSearch in Google Scholar
• 14 Blair S R, Graeber G M, Cruzzavala J L. et al . Current management of esophageal impactions.  Chest. 1993;  104 1205-1208
  PubMedSearch in Google Scholar
• 15 Roura J, Morello A, Comas J. et al . Esophageal foreign bodies in adults.  J Otorhinolaryngol. 1990;  52 51-56
  PubMedSearch in Google Scholar
• 16 Watanabe K, Kikuchi T, Katori Y. et al . The usefulness of computed tomography in the diagnosis of impacted fish bones in the oesophagus.  J Laryngol Otol. 1998;  112 360-364
  PubMedSearch in Google Scholar
• 17 Gonzales J H, Vidal J M, Sarandeses A G. et al . Esophageal foreign bodies in adults.  Otolaryngol Head Neck Surg. 1991;  105 649-654
  PubMedSearch in Google Scholar
• 18 Bendig D W, Mackie G G. Management of smooth-blunt gastric foreign bodies in asymptomatic patients.  Clin Pediatr. 1990;  29 642-645
  PubMedSearch in Google Scholar
• 19 Selivanov V, Sheldon G F, Cello J P, Crass R A. Management of foreign body ingestion.  Ann Surg. 1984;  199 187-191
  PubMedSearch in Google Scholar
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D. M. Chaves, M. D.

Rua Montezuma 183 - Jd. das Bandeiras · São Paulo 05436-080 · Brazil ·

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Email: dalton.chaves@fleury.com.br