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Ingested foreign bodies in adults

Background: Foreign body ingestion is a common occurrence. Children between the ages of 6 months and 6 years are most frequently affected. In adults, the ingestion of a foreign body usually occurs when eating and is promoted by pathological changes in the gastrointestinal tract.

Method: A selective literature search was carried out in PubMed.

Results: Adults are most likely to ingest fish bones and chicken bones. The clinical procedure is influenced by the type of ingestion, the subjective complaints and the clinical findings. In about 80% of the cases, the ingestate can be passed without problems. Endoscopic intervention takes place in around 20% of the cases. Surgery is performed in less than 1% of the cases. An emergency esophagogastroduodenoscopy (EGD) is recommended for: complete occlusion of the esophagus because of the risk of aspiration and pressure necrosis, for a pointed / sharp ingestat because of the risk of perforation with mediastinitis / peritonitis and for ingestion of batteries because of the risk of necrosis and fistula formation . Urgent EGD within 12 to 24 hours is recommended for non-occluding esophageal foreign bodies and magnets.

Conclusions: Conservative observational therapy is justified in most cases. The indication for ÖGD is generous. Surgery is performed if there are complications.

The treatment of patients with swallowed foreign bodies (FK) occurs regularly in practice and clinic. A distinction is made between accidental foreign body ingestion and intentional FK ingestion with secondary gain in disease. In addition, a bolus can get stuck while eating and lead to the clinical picture of a foreign body impaction in the esophagus.

FK ingestions are most common in children between the ages of 6 months and 6 years (1, 2). In adults, foreign body impacts are usually seen in the context of a pre-existing pathology. A work by Sung et al. According to the following causes of the impaction (3):

  • Strictures (about 37%)
  • Malignancies (around 10%)
  • oesophageal rings (about 6%)
  • Achalasia (about 2% of cases).

Eosinophilic esophagitis, which plays a subordinate role in pure FK impaction, is described in up to 33% of cases with bolus impaction (4). Sometimes there is also a lack of pathological predisposition. In addition, there is an increasing number of reports of FK ingestion at an advanced age, with mental retardation, and with psychiatric illnesses (5). The physiological and anatomical constrictions of the gastrointestinal tract make passage through the ingestate difficult and serve as predilection points for a foreign body impaction (1, 5).

According to the data available, information on the frequency of swallowed foreign bodies varies greatly. Most commonly swallowed by adults (3, 6, 7):

  • Herringbone (9–45%)
  • Bone (8-40%)
  • Dentures (4–18%).

For the bolus impaction as a separate sub-entity, an annual prevalence of 13 in 100,000 is estimated by Longstreth et al. specified (8).

Unless there is an occlusion or other complication, the clinical signs need not be dramatic; they can also be absent. Most patients present with a feeling of foreign bodies, difficulty swallowing, chest and abdominal pain, or vomiting (6).

In about 80% of the cases, the FK is discontinued without further ado. Endoscopic intervention is indicated in around 20% of cases. Surgical intervention is indicated in less than 1% of cases (1, 3, 5–7, 9). Despite the predominantly benign natural course, foreign body ingestion is associated with increased morbidity. In the USA alone, around 1,500 deaths are reported annually (10).

The aim of this work is to present a diagnostic and therapeutic algorithm for the evaluation and treatment of FK ingestion in the gastrointestinal tract in adults. For information on dealing with ingested foreign bodies in the airways and in children, reference is made to the work from ENT and paediatrics (11, 12).

method

To create this overview, a selective literature search was carried out in the PubMed database (last accessed: September 22, 2012). The search term “foreign body ingestion AND adult NOT child NOT case report” generated a total of 135 hits for the period 1970–2012. Searching for publications in English reduced the hit result to 55 articles.

After excluding studies on intentional foreign body ingestion and studies with fewer than 10 patients, 24 publications remained. With the same setting in PubMed, using the search terms “ingested foreign bodies” and “food bolus impaction”, 15 and 18 further publications respectively could be selected. In the same way, 16 papers on the “body packing syndrome” could be filtered out.

Due to the lack of data from randomized studies, the underlying studies are exclusively retrospective publications, reviews and recommendations from specialist societies.

Classification of foreign bodies

A classification of the ingestate according to material, size, superficial nature and chemical composition appears to be sensible, because the urgency of an intervention is determined by the properties of the ingestate (1, 5, 13). The passage of the duodenum depends on both the diameter and length of the ingestate. A length> 6 cm and a diameter> 2.5 cm make duodenal passage more difficult (9, 14). According to the opinion of the author, a further classification of ingested FC according to radiopacity is also useful. In the box, the FKs were systematically classified in order to be able to develop a diagnostic and therapeutic algorithm based on this.

Diagnosis

As a rule, after FK ingestion, the patient visits the practice / clinic and provides information about the ingestion as part of the anamnesis. The patient can also point out a possible localization of the ingestate (15). According to a study by Connolly et al. does not always match the actual location of the foreign body (16). Thus, the physical examination should not be limited to the area of ​​complaints. In some cases, the diagnosis of FK ingestion is only made later, i.e. days or months after ingestion (e1).

The diagnosis of FK ingestion is mainly made on the basis of the patient's medical history. According to this, based on the information obtained about the ingestion, the subjective complaints and the clinical findings, a decision is made about the type of confirmation of the diagnosis and the extent and urgency of a possible intervention (1, 5, 6, 9, e2).

An X-ray examination of the affected body region, possibly in two planes, is recommended by many authors as an initial screening (e3, e4). The working group of Mosca et al. demonstrate a positive result in 144 of 414 patients with ingested FC on the basis of X-ray overview images (17). Such recordings make it possible not only to gain information about the location of the ingestate, but mostly also about the configuration, number and size of the FC, and may indicate complicated courses with perforation, for example through a pneumoperitoneum or pneumomediastinum (Figure 1).

The authors support this approach if a radiopaque LC is suspected. In the opinion of the author, imaging as part of the diagnostic work-up serves not only to confirm the diagnosis but also to document the findings.

For non-radiopaque and some radiopaque LC, the native X-ray examination is usually not sufficient to rule out LC ingestion. Ngan and colleagues were able to show a sensitivity of only 32% and a specificity of 91% for ingested fishbones in native X-rays from 354 patients (18). Although small FRs such as fish bones and chicken bones have enough density to be shown in the X-ray overview, they are masked by fluid and soft tissue mass (19, 20). Such FC can be - as in the work by Coulier et al. - excellent visualization using computed tomography (CT) (20). With a sensitivity of 100% and a specificity of 91%, CT plays an important role in the diagnosis of FK ingestion (21).

Some authors do not recommend the use of contrast media in the context of radiological diagnostics because of the risk of aspiration, the reduced ability to assess the mucosa and possibly the masking of the ingestate (1, 5, 9).

The use of ultrasound in LC diagnostics does not seem to be widespread. This is confirmed by the limited number of published case reports (22). The largest series in the adult cohort was published by Coulier with only 6 patients in 1997 (23). This also shows how seldom ultrasound is used to clarify an FK ingestion.

The use of metal detectors in the diagnosis of swallowed LC has also been described by some authors (24, 25). A work by Sacchetti et al. According to this, the metal detector has a sensitivity of 94% and a specificity of 100% for metallic FK (25). This method is inexpensive, can be repeated any number of times and is radiation-free. Although metal detectors are mainly used in children, Ryan and colleagues recommend generous use of this simple diagnostic tool in adults as well (24). In the opinion of the authors, this method does not provide any tangible information and is rarely used in everyday clinical practice in adults.

It is important that the diagnostic imaging is used as soon as possible before a planned intervention, since the position of the ingestion can change significantly afterwards.

therapy

The natural course after foreign body ingestion is asymptomatic in around 80% of cases with problem-free passage through the ingestion. Endoscopic intervention is indicated in around 20% of cases. Surgery is required in less than 1% of cases (1, 2, 5, 9, 13, 15, 17, 18, 26).

Conservative treatment

The majority of all ingested FCs pass through the gastrointestinal tract (GIT) without any problems. Thus, in most cases, conservative observational therapy can be justified. This is the therapy of choice for blunt, short (< 6 cm)="" und="" schmalen="">< 2,5 cm="" durchmesser)="" fk="" vor="" allem="" nach="" passage="" des="" pylorus="" (13–15).="" ein="" spontaner="" abgang="" ist="" meistens="" in="" 4–6="" tagen="" zu="" erwarten.="" seltener="" kann="" diese="" bis="" zu="" 4="" wochen="" dauern="" (1,="" 5,="" 9).="" bis="" zum="" sicheren="" abgang="" des="" fk="" sollte="" der="" stuhl="" ständig="" beobachtet="" werden.="" eine="" änderung="" des="" essverhaltens="" ist="" in="" dieser="" zeit="" nicht="" notwendig.="" bei="" fehlender="" passage="" wird="" bei="" asymptomatischen="" patienten="" wöchentlich="" eine="" ambulante="" röntgenkontrolle="" zur="" dokumentation="" der="" lokationsänderung="" des="" fk="" empfohlen="" (1,="" 5,="" 9,="" 13).="">

Drug treatment for oesophageal food bolus impaction has been described by some authors (27, 28). Because of its relaxing effect on smooth muscles, glucagon is used to treat food bolus impaction in the esophagus (27, 28). The extension of this glucagon effect to the treatment of swallowed LC in the upper GIT appears to be sensible, but the effectiveness has not yet been proven. It also remains questionable whether a similar effect can be achieved with Buscopan.

Endoscopic Intervention

Endoscopic intervention is necessary for almost every fifth ingested FK. In most cases, an ES in the upper digestive tract has to be removed by an esophagogastroduodenoscopy (EGD) (1, 2, 5–7, 9, 13–15, 17, 18). The procedure is very widespread and accessible almost everywhere.

Ginsberg and Ciriza et al. recommend laryngoscopy for acute dysphagia and a suitable medical history (5, 29). If the foreign body is in a location that can be reached by laryngoscopy, it can possibly be retrieved at the same time as the examination with relatively little complication. If the foreign body cannot be seen but there is acute dysphagia, impaction in the esophagus must be ruled out (5). A foreign body sensation with dysphagia can still be present several hours after an FC has passed and thus simulate an FC impaction. Since a differentiation is not clinically possible, EGD is indicated on an emergency basis. The ÖGD serves to confirm the diagnosis or to exclude an FK ingestion as well as the simultaneous therapy in the case of positive results.

According to the current data, the indication for ÖGD is very generous (2, 3, 14, 17, 18, 26). In a work by Zhang et al. the total collective of 561 patients who presented after FK ingestion was referred to the EGD (26). The urgency of the endoscopy depends on the risk of aspiration in the case of complete occlusion of the esophagus and the risk of perforation through the FC, as well as the risk of the FC getting stuck (table). Accordingly, emergency EGD is indicated in the case of complete occlusion of the esophagus with the formation of a lake of saliva (1, 8) (Figure 2a). This also applies to the ingestion of pointed objects, which can lead to complications (mediastinitis / peritonitis) through perforation of the GIT (5, 9, 13, 17) (Figure 2b). The authors of these studies (5, 9, 13, 17) also recommend emergency EGD when batteries are ingested, as these contain alkaline substances and toxic metals such as mercury. The pressure on the mucosa (pressure necrosis) and / or the release of alkaline substances can lead to necrosis (liquification necrosis), fistula formation and possibly mercury poisoning (30). These patients should be hospitalized.

Endoscopic and intraoperative confirmation of the diagnosis with simultaneous treatment after foreign body ingestion
Indication for esophagogastroduodenoscopy (ÖGD) and recommendation for immediate further treatment

If a foreign body does not necessarily have to be removed, such as a food bolus impaction in the esophagus, it can also be pushed into the stomach by applying mild pressure (31). In the case of impaction in the middle third of the esophagus, the risk of perforation is particularly high due to the relatively narrow cardia. A foreign body impaction in the esophagus over a period of 12–24 hours must be prevented in any case (9).

Urgent EGD is indicated for other oesophageal FCs and incompletely occluding food boluses. This also applies to long (> 6 cm) FK (15). (Figure 2c) When magnets are ingested, there is not only the risk of intestinal obstruction, but also the risk of perforation and fistula formation due to the attraction between the individual magnets (or between the magnet and swallowed metallic FK) (e5). In-patient observation is recommended in this case.

Rescue of an FK by colonoscopy does not seem to be very common based on currently available data. After overcoming the Bauhinschen flap, the FK is usually removed without complications. If the passage is difficult, a colonoscopic rescue attempt as described in the report by Chung et al. (32).

Surgical treatment

Surgical intervention is necessary in less than 1% of the cases. With the advancement of endoscopic techniques, surgical therapy is increasingly being pushed back. The absolute indication for surgery is given only in the case of the perforation. Relative indications for surgery for foreign body ingestion are given in the case of endoscopically uncontrollable complications or after unsuccessful endoscopic rescue attempts (33). A surgical consultation is recommended by many authors for more than a week if the FC localization in the distal duodenum has not changed (1, 5, 9, 13). In the era of minimally invasive surgery, laparoscopic surgery may be sought (Figure 2d) (e1).

Body packing

The term "body packing" describes the smuggling of drugs in the gastrointestinal tract. Several packets containing 5 to 10 g of the drug to be smuggled, preferably cocaine and heroin, are swallowed (34). The incidence of body packing varies greatly depending on the location. De Bakker's working group from Amsterdam, for example, reports 143 cases in 5 years, whereas 193 cases are documented within 7 months in New York alone (35, 36). Over 90% of body packers remain asymptomatic. In just under 10% of cases, an operation has to be performed (35).

The asymptomatic body packer is usually brought in by the police. After the appropriate medical history and physical examination, an X-ray overview of the abdomen is performed as a screening (37). In the work by Gsell et al. All body packers were admitted to the hospital and housed in a room specially made for the accommodation of body packers (37). In some cases, the diagnosis can only be made using computed tomography (37). The examination of the urine is generally not recommended because of the rather poor sensitivity of just under 35% (38).

Body packers should be treated conservatively. Endoscopic rescue should be avoided because of the risk of packet perforation with the following intoxication (1, 5, 9, 15, 34, 39). The administration of laxatives is recommended by the Swiss working group. This can accelerate the passage of drug packets (within 0–9 days) (37). Since not every hospital has a room specially designed for the accommodation of a body packer, the authors recommend the accommodation of a body packer in a monitoring room with a toilet chair.Thus, both the passage of the parcel and changes in the vital parameters as a sign of intoxication can be detected promptly. With a failure rate of only 2–5%, a conservative approach to asymptomatic body packers should always be sought (39).

Symptomatic body packers are identified either by signs of intoxication or intestinal obstruction (34, 35, 39). If there are signs of intoxication, a packet rupture must be assumed. The lethal dose for cocaine is given as 1–3 g (35). There is thus the indication for emergency laparotomy after circulatory stabilization. Mortality in this context has changed dramatically over the years. Wetli and Mittlemann reported an alarming mortality rate of over 50% in the 1980s (40) compared to the 2% mortality reported by de Bakker et al. was published in 2012 (35). This significant decrease in mortality can be explained, among other things, by an improvement in packaging.

Conflict of interest
The authors declare that they have no conflict of interest.

Manuscript dates
Taken in: May 6, 2012, revised version accepted on October 4, 2012

Address for the authors
Dr. med. Peter Ambe
Clinic for general, visceral and pediatric surgery
Heinrich Heine University Hospital Düsseldorf
Moorenstrasse 5, 40225 Düsseldorf
[email protected]

Citation style
Ambe P, Weber SA, Schauer M, Knoefel WT: Swallowed foreign bodies in adults. Dtsch Arztebl Int 2012; 109 (50): 869-75.
DOI: 10.3238 / arztebl.2012.0869

@ The German version of this article is available online:
www.aerzteblatt-international.de

Webb WA: Management of foreign bodies of the upper gastrointestinal tract: update. Gastrointest Endosc 1995; 41: 39-51. CrossRefMEDLINE
Cheng W, Tam PK: Foreign-body ingestion in children: experience with 1,265 cases. J Pediatr Surg 1999; 34: 1472-6. CrossRefMEDLINE
Sung SH, Jeon SW, Son HS, et al .: Factors predictive of risk for complications in patients with oesophageal foreign bodies. Dig Liver Dis 2011; 43: 632-5. CrossRefMEDLINE
Kerlin P, Jones D, Remedios M, Campbell C: Prevalence of eosinophilic esophagitis in adults with food bolus obstruction of the esophagus. J Clin Gastroenterol 2007; 41: 356-61. CrossRefMEDLINE
Ginsberg GG: Management of ingested foreign objects and food bolus impactions. Gastrointest Endosc 1995; 41: 33-8. CrossRefMEDLINE
Chiu YH, Hou SK, Chen SC, et al .: Diagnosis and endoscopic management of upper gastrointestinal foreign bodies. On J Med Sci 2012; 343: 192-5. CrossRefMEDLINE
Peng A, Li Y, Xiao Z, Wu W: Study of clinical treatment of esophageal foreign body-induced esophageal perforation with lethal complications. Eur Arch Otorhinolaryngol 2012; 269: 2027-36. CrossRefMEDLINE
Longstreth GF, Longstreth KJ, Yao JF: Esophageal food impaction: epidemiology and therapy. A retrospective, observational study. Gastrointest Endosc 2001; 53: 193-8. CrossRefMEDLINE
Ikenberry SO, Jue TL, Anderson MA, et al .: Management of ingested foreign bodies and food impactions. Gastrointest Endosc 2011; 73: 1085-91. CrossRefMEDLINE
Schwartz GF, Polsky HS: Ingested foreign bodies of the gastrointestinal tract. Am Surg 1976; 42: 236-8. MEDLINE
Tiago RS, Salgado DC, Correa JP, et al .: Foreign body in ear, nose and oropharynx: experience from a tertiary hospital. Braz J Otorhinolaryngol 2006; 72: 177-81. MEDLINE
Winkler U, Henker J, Rupprecht E: Foreign body ingestions in childhood. Dtsch Arztebl 2000; 97 (6): A 316-9. FULL TEXT
Smith MT, Wong RK: Foreign bodies. Gastrointest Endosc Clin N Am 2007; 17: 361-82. CrossRefMEDLINE
Palta R, Sahota A, Bemarki A, et al .: Foreign-body ingestion: characteristics and outcomes in a lower socioeconomic population with predominantly intentional ingestion. Gastrointest Endosc 2009; 69: 426-33. CrossRefMEDLINE
Eisen GM, Baron TH, Dominitz JA, et al .: Guideline for the management of ingested foreign bodies. Gastrointest Endosc 2002; 55: 802-6. CrossRefMEDLINE
Connolly AA, Birchall M, Walsh-Waring GP, Moore-Gillon V: Ingested foreign bodies: patient-guided localization is a useful clinical tool. Clin Otolaryngol Allied Sci 1992; 17: 520-4.