The flexible upper gastrointestinal endoscope should be inserted under direct visualization to avoid inadvertently striking an object and further impacting it or causing it to penetrate the esophageal wall. Blunt foreign bodies such as coins can be securely grasped with a forceps or a snare. A firm grasp on the foreign body is required before withdrawal is attempted. Otherwise, the foreign body may become dislodged as it is withdrawn through points of anatomic narrowing. This can result in aspiration of the foreign body. An overtube should be used if multiple insertions and withdrawals of the endoscope are needed. Pointed foreign bodies should be withdrawn with the point trailing to avoid perforating any structures. Objects with sharp edges, such as razor blades, should be extracted through an overtube to prevent secondary injury. Elongated foreign bodies such as wires or pens should be grasped with a snare close to the cephalad end of the object so it can align itself with the long axis of the esophagus during withdrawal. Foreign bodies that penetrate the mucosa can be safely extracted with the endoscope if frank perforation or vascular penetration has not occurred.
Food impactions are more likely to occur in the distal esophagus. If the patient is symptomatic, there is no need for barium studies because it will obscure visualization during endoscopy. Endoscopic intervention should be carried out immediately to prevent aspiration if the patient is salivating and unable to handle oral secretions. The impacted food bolus should not remain in the esophagus for more than 12 hours. Thereafter, the risk of complications increases significantly.
Underlying esophageal disease is found in 65% to 97% of adults presenting with an esophageal food impaction.8,15 Endoscopic removal is the procedure of choice if a meat bolus does not pass spontaneously or after an unsuccessful trial of gas-forming agents, glucagon, nifedipine, or nitroglycerine. The entire bolus could be removed slowly with a polypectomy snare or Dormia basket under direct visualization. When the endoscope is just below the cricopharyngeus muscle, snugly pull the snare with the food bolus against the tip of the endoscope. Extend the patient's head and quickly remove the endoscope.16
If the food bolus is soft, a piecemeal approach can be accomplished with several passages of the endoscope through an overtube.17 The overtube will facilitate reinsertion of the endoscope. Insert a Maloney rubber dilator (44 French) into the esophagus and proximal to the foreign body. Pass the overtube, lubricated internally and externally, over the Maloney dilator. Remove the Maloney dilator. Introduce the flexible endoscope through the overtube.
Another method, the push technique, has been useful in dealing with an impacted food bolus.9 A small-caliber flexible endoscope may be used to bypass the food bolus and evaluate the area distal to the obstruction. If the endoscope is able to pass into the stomach successfully, pull it back until it is just proximal to the food bolus. Use the endoscope to gently push the food bolus into the stomach. It is preferable to push from the right side of the food bolus rather than straight, especially in patients with a hiatal hernia, since the gastroesophageal junction usually takes a left turn as it enters the hernia. The presence of a bone spicule should always be considered, whether the meat bolus is being extracted or pushed into the stomach.
A newer technique is accomplished by attaching the Stiegmann-Goff friction-fit adaptor of the esophageal variceal rubber banding ligating kit to the tip of the endoscope.18 The tip of the endoscope is replaced with a screw-on drum from the variceal ligation kit. After placing an esophageal overtube proximal to the food bolus, the endoscope is passed through the overtube.19–22 To avoid the risk of dropping the food in the trachea, a Roth retrieval net may be passed through the endoscope to retrieve food from the esophagus.23,24
A last resort approach is the use of Nd:YAG laser to burn an opening in the center of an impacted meat bolus. This method is expensive and carries a high risk of complications.25 Finally, if a food impaction of the esophagus cannot successfully be removed using the flexible endoscope, rigid endoscopy under general anesthesia should be considered.26
Gas-forming agents can be used to relieve a distal esophageal food impaction. They are occasionally used in an attempt to relieve a food impaction in the proximal and middle thirds of the esophagus. These agents produce carbon dioxide gas that distends the esophagus, relaxes the lower esophageal sphincter, and “pushes” the food bolus through the gastroesophageal junction with the aid of esophageal peristalsis. Gas-forming agents may be used in conjunction with glucagon, nifedipine, or nitroglycerine to help relieve the impacted food bolus. Complications associated with gas-forming agents include aspiration, vomiting, forceful vomiting, and esophageal perforation due to distention and/or vomiting. Many physicians do not use these agents due to the risk of perforation.
Three classes of gas-forming agents have been used. Commonly used are commercially available agents that are used by Radiologists for upper gastrointestinal contrast studies. A mixture of tartaric acid (1.5 to 3.0 g in 15 mL H2O) immediately followed by sodium bicarbonate (1.5 to 3.0 g in 15 mL H2O) has been successfully used. A final agent is carbonated soda pop.
A trial of intravenous glucagon before endoscopic therapy is a reasonable approach. It may disimpact a food bolus in the distal esophagus and allow it to pass into the stomach. Glucagon relaxes the smooth muscle of the lower esophagus and decreases lower-esophageal sphincter tone. It relaxes the esophageal smooth muscle within 1 minute of intravenous injection, and its effects last approximately 20 to 25 minutes. Glucagon has no effect on the proximal third of the esophagus that is composed of skeletal muscle. It has a minimal effect on the middle third of the esophagus that is composed of both skeletal and smooth muscle. Glucagon has an overall success rate of ≤50%. Glucagon has been also combined with gas-forming agents to enhance esophageal clearance.
The dose of glucagon is 0.03 to 0.1 mg/kg intravenously with a maximum dose of 1 mg in children and 2 mg in adults. It should be administered over 1 to 2 minutes. It is recommended to give a test dose (1/10 of the full dose) and observe the patient for 5 minutes for signs of hypersensitivity or hypotension before giving the full dose. Have the patient take one to two sips of water after the administration of glucagon to stimulate lower esophageal peristalsis. Administer a second dose of glucagon if the food bolus impaction is not relieved within 10 to 20 minutes.
Glucagon is a relatively safe medication. It should not be administered to patients with known hypersensitivity to glucagon, esophageal fibrosis, esophageal rings, esophageal strictures, insulinomas, pheochromocytomas, sharp or irregular foreign bodies, or Zollinger–Ellison syndrome. Exogenous glucagon stimulates the release of catecholamines. It can stimulate a pheochromocytoma to release catecholamines resulting in marked hypertension and tachycardia. The hypertension can be controlled using 5 to 10 mg of intravenous phentolamine. Glucagon's hyperglycemic effect can cause an insulinoma to release insulin and cause subsequent hypoglycemia. Common complications associated with glucagon include nausea, vomiting, transient hyperglycemia, allergic reactions, tachycardia, and hypertension. Glucagon is a polypeptide hormone synthesized in nonpathogenic Escherichia coli that have been genetically altered. This is the basis of the allergic/hypersensitivity reactions. A transient rise in blood pressure and heart rate is often seen after administration of glucagon. Patients taking β-blockers may be more susceptible to transient hypertension and tachycardia. These side effects are short-lived as the half-life of glucagon is 8 to 18 minutes.
Nifedipine is a calcium channel blocker that decreases lower esophageal sphincter tone. It has been administered to allow an impacted food bolus to pass into the stomach. It should not be administered if the patient has an allergy to calcium channel blockers, has hypotension, or ingested a sharp or irregular shaped foreign body. With a single dose, nifedipine has few side effects. These are usually minimal (i.e., dizziness, flushing, headache, hypotension, lightheadedness, muscle cramps, nausea, nervousness, and palpitations) and do not preclude its use. The most significant effect of nifedipine is hypotension that may last 6 to 8 hours. Some patients will have a significant hypotensive response to nifedipine and there is no way to predict which patients will be affected. For these reasons, many physicians will not use nifedipine in the elderly or in patients with a history of cardiac disease, coronary artery disease, stroke, or who are concurrently taking antihypertensive medications. The typical dose is 10 mg of oral nifedipine. The medication may be chewed then held in the mouth and subsequently swallowed. Alternatively, open the capsule, place the medicine sublingually, and have the patient hold it in their mouth and then swallow the dissolved nifedipine. Attempt another technique if the food bolus does not pass with one dose of nifedipine.
Sublingual nitroglycerine (0.3, 0.4, or 0.5 mg) relaxes vascular smooth muscle and the smooth muscle contained within the middle and distal thirds of the esophagus. The use of sublingual nitroglycerine may allow the esophagus to dilate enough so that a food bolus can pass into the stomach. Nitroglycerine should not be administered if the patient is hypotensive or has ingested a sharp or irregular shaped foreign body. It should also not be administered if the patient is taking prescription medications for erectile dysfunction (e.g., Levitra, Cialis, and Viagra). The combination of these medications with nitroglycerine can result in life-threatening hypotension. The onset of action is within 1 to 3 minutes with a maximum effect by 4 to 5 minutes. The major side effect of nitroglycerine is hypotension, but that is short-lived. Administer one pill sublingually and allow 4 to 5 minutes for an effect. The dose may be repeated a second time. Attempt another technique if the food bolus does not pass after two doses of nitroglycerine.
Papain is a proteolytic enzyme that has been used to dissolve an impacted food bolus. It is available in markets as meat tenderizer and in health food stores as a digestive supplement. It will dissolve the esophageal mucosa and continue to work its way through the esophageal wall and into the mediastinum if it does not first dissolve the food bolus. The use of papain to dissolve an impacted food bolus may be associated with a fatal esophageal perforation and, if aspirated, hemorrhagic pulmonary edema. Papain should never be used to dissolve an impacted food bolus.
Sumatriptan is a 5-HT1 agonist that reduces fasting fundic tone, prolongs fundic relaxation, and delays gastric emptying.27 It also increases the number of esophageal motor waves. This may be useful in cases of distal esophageal food boluses and coins, although no formal studies have been conducted.
Sharp and Pointed Foreign Bodies
Removal of sharp and pointed objects requires extreme caution due to potential life-threatening complications, higher morbidity, and higher mortality. An experienced Endoscopist should manage these cases. It may be safer, in some cases, to consider surgical intervention. Toothpicks and bones are the most common foreign bodies requiring surgical removal.28–30 Nails, needles, razor blades, safety pins, and dental prostheses may be removed endoscopically.28–30 It is important to remember that “advancing points puncture while trailing points do not.”31 Objects longer than 5 cm and wider than 2 cm require removal as they will rarely pass through the pylorus.32 Intravenous glucagon (0.4 to 0.6 mg in adults) may be used to facilitate extraction from the stomach and duodenum.
An alligator forceps or snares are needed to grasp the object over the feeding tube. A plastic overtube should be considered for the removal of any sharp object.19,33 The overtube should be at least 60 cm long to remove a sharp object from the stomach. This will limit objects for endoscopic removal to those smaller than 11 to 15 mm in diameter that fit within the overtube.34 A soft latex protector hood may be used for the removal of large objects.
Razor blade ingestions may be managed with the flexible esophagoscope in adults. An alligator forceps, a snare, and an overtube will be needed. A razor blade that has passed the pylorus will often traverse through the intestinal tract without difficulty.
Safety pins and toothpicks pose additional risks due to their sharp ends that may perforate the esophagus. An open safety pin in the esophagus, with the open end proximal, should be pushed into the stomach with the flexible endoscope. Once in the stomach, the object is turned and the hinged end is grasped and pulled out first. A closed safety pin in the stomach will often pass without difficulty. Grasp a toothpick with an alligator forceps or snare very close to the tip so that the longitudinal axis of the toothpick is parallel to the scope as it is withdrawn into the overtube.16
Numerous other sharp objects are often encountered in the esophagus. Pens, pencils, thermometers, and wires are extracted in a fashion similar to a toothpick with a snare grasping the end of the object.15 Glass may be withdrawn similarly or by using an end-hood attachment.33,35
Attempts should be made to remove all sharp and pointed foreign bodies before they pass from the stomach. Approximately 15% to 35% of sharp or pointed foreign bodies will cause intestinal perforation, especially in the area of the ileocecal valve.36,37
Most button batteries ingested (96%) are small and 7.9 to 11.6 mm in diameter.39 Batteries less than 15 mm in diameter almost never lodge in the esophagus. Only 3% of button batteries are larger than 20 mm but are responsible for the severe esophageal injuries.39,50–53 Guidelines for the evaluation and treatment of button battery ingestions are available from the National Capital Poison Center.54
Button batteries cause injury by multiple methods. Their electrical discharge causes hydrolysis and the creation of hydroxide ions in tissue, which causes alkali burns. Leakage of the high pH contents can result in alkali burns. Their physical presence cause direct pressure necrosis. Some button batteries contain mercuric oxide. Mercury toxicity can result if the mercuric oxide leaks from the batteries.
The majority of these batteries contain manganese dioxide, silver oxide, mercuric oxide, zinc air, or lithium. Obtain anteroposterior and lateral abdominal and chest radiographs to distinguish between coins and button batteries. A double density shadow is suggestive of batteries. The coin has a much sharper edge.
A button battery lodged in the esophagus is a true emergency and immediate removal is indicated to avoid the rapid corrosive action of the alkaline substance on the mucosa and subsequent complications.38,40 Endotracheal intubation is usually necessary to protect the airway prior to endoscopic removal. The battery is removed from the esophagus under direct viewing using a through-the-scope balloon. A biopsy forceps may be needed to free the edge of the battery prior to removal. Alternatively, the battery may be pushed to the stomach and then removed using a polypectomy snare or a Dormia basket. Do not use a Foley catheter or a magnet to remove a button battery without the aid of endotracheal intubation and general anesthesia due to the possibility of the button battery falling into the airway. The patient should be admitted to the intensive care unit and monitored for signs of perforation and sepsis if they suffered severe esophageal injury when evaluated by endoscopy after removal of the button battery. If the injury is localized to the anterior wall of the esophagus, bronchoscopy may be performed to evaluate the extent of injury.
Generally, a button battery in the stomach need not be removed unless the patient is symptomatic with abdominal pain, tenderness, or gastrointestinal bleeding. Asymptomatic patients with button batteries less than 15 mm in diameter in their stomachs need follow-up abdominal radiographs every 24 hours to document forward progress until it is expelled. In a child less than 6 years old, the battery should be endoscopically removed if it is larger in size and has not passed within 48 hours.38,41 Patients may be placed on H2 blockers and/or proton pump inhibitors to decrease the acid in the stomach and therefore decrease the battery reaction. If mercury poisoning is expected, serum and urine mercury levels should be obtained and monitored.
Magnets are commonly found in homes and are easily accessible to children. They are contained in appliances, jewelry, and toys. The ingestion of a single magnet is usually not problematic. The ingestion of multiple magnets should be considered an emergency requiring removal. The magnets can move separately through the gastrointestinal tract. They then have the potential to attract each other and trap bowel between them. This can result in pressure necrosis, fistula formation, and perforation.
Perform plain radiographs to determine the number and the location of the magnets. A single magnet should be treated as any other small, nonsharp, foreign body ingestion. Multiple magnets require removal. Remove them endoscopically if they are located within the esophagus and/or stomach. If they have passed the pylorus, consult a Surgeon for urgent removal versus careful inpatient monitoring by the Surgeon and frequent radiographs to localize the magnets.
A Foley catheter has been successfully used to remove recently ingested, radiographically opaque, smooth and blunt foreign bodies from the esophagus. This technique is inexpensive, has a high success rate, does not require hospitalization, and avoids the complications associated with endotracheal intubation and general anesthesia. Coins are the foreign bodies primarily removed with a Foley catheter. The technique has also been used to remove button batteries, food boluses, and other smooth foreign bodies.
This technique cannot be used on all patients with an esophageal foreign body. This technique should not be attempted in patients who are confused or uncooperative. Patients with an altered mental status, airway compromise, or potential airway compromise should be endotracheally intubated prior to Foley catheter removal of the foreign body. Sharp or irregular shaped objects can lacerate or perforate the esophagus upon removal. Known or suspected esophageal perforation is a contraindication to this technique. Patients with complete esophageal obstruction, as demonstrated by an esophageal air-fluid level on radiographs, are not candidates. Esophageal fibrosis, esophageal tumors, anatomic anomalies, or a history of prior esophageal surgery is also a contraindication.
The equipment required for the technique is minimal. This includes topical anesthetic spray, a bite block, and a size 12 to 16 Foley catheter with a 5 to 10 mL balloon. The technique may be performed ideally in a fluoroscopy suite or blindly in the Emergency Department. A water-soluble contrast agent is required if using fluoroscopy. The most dangerous and immediate complication of this technique is airway obstruction. Airway and emergency equipment must be available if this technique is to be performed.
Explain the procedure to the patient, including the sensations they will experience. The use of a topical anesthetic spray for the oropharynx is beneficial but optional. Its use may increase the risk of aspiration. The use of physical restraints, procedural sedation, and/or intubation may be required as needed on a case-by-case basis. Preinflate the Foley catheter balloon with 5 to 10 mL of water-soluble contrast material. Inspect the integrity of the balloon. Withdraw the contrast material back into the syringe to deflate the balloon. The small amount of contrast material left in the balloon will facilitate identification under fluoroscopy. Place the patient prone in 10° to 20° of Trendelenburg or in the left lateral decubitus position in 10° to 20° of Trendelenburg. The fluoroscopy technique and then the blind technique are described in the following paragraphs.
Insert the Foley catheter. Some physicians insert a bite block and place the Foley catheter through the mouth (Figure 62-1). Others use the nasal route. The oral route avoids the potential problem of lodging the foreign body in the nasopharynx with subsequent aspiration. Advance the Foley catheter under fluoroscopy until the balloon is just distal to the foreign body (Figure 62-1A). Slowly inflate the balloon with 5 mL of contrast material (Figure 62-1B). Stop inflating the balloon if the patient complains of pain; deflate the balloon, then reposition the catheter before reinflating. Withdraw the catheter with moderate and steady traction until it exits the mouth (Figures 62-1C & D). Stop withdrawing the catheter if resistance is met to prevent an esophageal tear or perforation. The balloon may occasionally slide past the foreign body as the catheter is being withdrawn. Reinsert the catheter and inflate the balloon with 7 to 8 mL of contrast material and then withdraw the catheter. Do not overinflate the balloon as it can rupture the esophagus. Do not attempt this technique more than twice. The balloon will pull the foreign body ahead of it into the hypopharynx and then the mouth. Tell the patient to spit out the foreign body; or you can grasp it with fingers, forceps, or a hemostat.
The Foley catheter technique to remove an esophageal foreign body. This illustration demonstrates the oral route for catheter insertion. The nasal route may also be utilized. A. The catheter is inserted and advanced until the balloon is just distal to the foreign body. B. The balloon is inflated. C. The catheter is withdrawn and pulls the foreign body into the hypopharynx. D. Completely withdrawing the catheter will pull the foreign body into and out the mouth. Steps (C) and (D) are performed in one smooth motion.
This technique may also be used “blindly” if fluoroscopy is not available. Estimate the distance, on the radiographs, from the mouth or nose to the foreign body. Place the Foley catheter over the radiograph with the balloon just distal to the foreign body. Mark the distance with tape on the catheter as it exits the mouth or nose. The catheter will then be inserted into the patient until the tape is positioned at their mouth or nose. Use saline rather than contrast material to inflate the balloon. Obtain repeat radiographs if the foreign body is not expelled with the catheter as it may have been pushed into the stomach. The remainder of the technique is the same as described for removal under fluoroscopy.
Complications with this technique are uncommon but do occur. This technique may not be able to remove the foreign body. Insertion of the catheter can cause laryngospasm or vomiting. The Foley catheter may enter the airway, resulting in coughing and laryngospasm. The esophagus may be lacerated or perforated if the foreign body is large, completely impacted, sharp, irregular, or has been in place for over 12 to 24 hours. Overinflation of the balloon can rupture the esophagus. Removal through the nose may result in epistaxis or impaction of the foreign body in the nasopharynx or nasal cavity. The most feared complication is complete or partial airway obstruction if the foreign body falls into the larynx.
The use of a Bougie dilator to push an esophageal foreign body into the stomach has been used in children.42–44 The technique has been successfully used in asymptomatic children who have radiographs documenting a coin in the esophagus, no history of esophageal disease, and less than 24 hours has passed from the time of ingestion. The advantages of this technique are that it is quick, simple to perform, does not require sedation, does not require intravenous access, decreases length of stay, and saves money when compared to endoscopy.55
Apply a topical anesthetic spray to the child's oropharynx. Select an appropriate size Bougie dilator. Physically restrain the patient while they are sitting upright or standing on the bed. Place the tip of the Bougie dilator at the mouth and run the rest of the dilator to the earlobe and to just below the left costal margin. Place a piece of tape on the Bougie dilator 3 to 4 cm below the costal margin. Insert the Bougie dilator through the mouth and advance it in one smooth motion until the tape is at the mouth. Remove the Bougie dilator. Obtain a repeat radiograph to confirm that the coin is now in the stomach.
Complications can occur and are avoided with proper patient selection. Esophageal perforation may occur if the patient has known esophageal disease, prior esophageal surgery or manipulation, a sharp foreign body, or an irregular shaped foreign body. A foreign body present for more than 24 hours can cause pressure necrosis to the esophagus and increase the risk of perforation.
The orogastric tube magnet (OGTM) is an orogastric tube that has a magnet sealed within the distal end. It may be used to retrieve smooth, metallic foreign bodies from the esophagus and stomach under fluoroscopy. Place the patient in the lateral decubitus position. Apply a topical anesthetic spray to the oropharynx. Insert the OGTM through the mouth. Advance the OGTM under fluoroscopy into the esophagus and directed toward the foreign body until it makes contact. Withdraw the OGTM and the foreign body out the mouth. This is a rarely used technique.