Swallowed foreign bodies

What is a swallowed foreign body?

Virtually any object small enough to pass through the pharynx may be swallowed.

The objects most frequently ingested by younger children are coins, but also include small toys, pencils, pen lids, button batteries, safety pins, needles, buttons and hairgrips. These are often radio-opaque.

Food-related items, such as chicken and fish bones, are more often ingested by older children and adults and tend to be radiolucent. It is rare to see adults with accidental non-food related foreign body ingestion - rarely, dentures can be swallowed. Intentional foreign body ingestion can occur in psychiatric patients, prisoners or "drug mules". ¹

Trichobezoar is a rare condition where hair ingestion leads to formation of a hair ball in the stomach.

More than 80% of ingested foreign bodies will pass without any need for intervention. However, 10-20% will need endoscopic removal and up to 1% require surgical management. ¹

• Mouthing and tasting environmental objects is a normal developmental stage in young children and this can result in accidental ingestion. ²

• The ingestion of foreign bodies is most commonly a problem in young children aged 6 months to 3 years.² The most common age is between 1-2 years.

• Coins have been the foreign body most commonly ingested in infants and children but, with the reduction in coin usage, these have decreased and magnets have become more common. ²

• It occurs much less frequently in older children and adults but does affect these groups rarely. It usually occurs accidentally but can result from deliberate ingestion.

• Patients with psychiatric illness, or intellectual disability, or those who are prisoners or are 'drug-mules'/'body-packers' (involved in the smuggling of illicit drugs concealed in the GI tract) are prone to problems caused by purposeful ingestion of foreign bodies.

• Data from the United States has shown an increase in foreign body ingestion in adults from 3 per 100,000 people to 5.3 per 100,000 between 1995 and 2017. 14% of these were reported to be deliberate and 86% accidental. ³

• A study in the United States showed that there are as many presentations to EDs with swallowed foreign bodies as there are presentations with STEMIs. ⁴

• This is highly variable and depends on whether it is a child or an adult. In children, the event is usually witnessed, or reported by the child.

• It is common for there to be no symptoms and for parents to bring in a child where they have witnessed the ingestion.

• Symptoms can include stridor, pain, drooling, fussiness, chest pain, abdominal pain, fever, feeding refusal, wheezing, and respiratory distress. ⁵

Oropharyngeal foreign bodies

• This is a common finding with coins or small toys being the most typical in children, and fish bones in adults. ⁶

• Patients usually have a clear sensation of something being trapped that is relatively well localised.

• There is usually discomfort which can range from mild to quite severe.

• Drooling and an inability to swallow may be present.

• Airway compromise may occur if large objects are trapped.

• A delayed presentation with infection or perforation may occur with foreign objects that become stuck at this level. ⁶

• However, complications are less common with foreign bodies in this region. ⁷
  

Oesophageal foreign bodies

• In adults, there is usually an acute presentation following ingestion of an object or food item that becomes stuck.

• There tends to be a vague sensation of something being stuck in the centre of the chest or epigastric region, indicating that the object is probably at the level of the aortic cross-over or the lower oesophageal sphincter.

• There may be dysphagia for the remainder of the meal, prompting presentation or salivary pooling/drooling if there is complete oesophageal obstruction.

• Children with oesophageal impaction tend to have a less clear-cut presentation, although there may have been a witnessed swallowing event.

• Gagging, vomiting, retching, neck and/or throat pain are more common presentations in children with oesophageal foreign bodies.¹

Sub-oesophageal foreign bodies

• These may present with a range of symptoms, depending on the degree of progression of the foreign body through the gut.

• Vague symptoms, such as abdominal distension and discomfort, fever, recurrent vomiting, passing rectal blood/melaena and/or other symptoms of acute or subacute intestinal obstruction, may be present.

Symptoms due to GI perforation

• A foreign body can perforate the gastro-intestinal tract. This needs urgent referral for surgical assessment.

• Symptoms depend on where in the GI tract the perforation occurs.

• Bowel perforation tends to cause pain, frequently accompanied by a sensation of abdominal distension and bloating, often accompanied by nausea, vomiting, anorexia, fever, and obstipation. ⁸

• Pain can sometimes be followed by a pain-free interval followed by worsening pain again, representing decompression of an injured bowel segment immediately after the perforation. ⁸

• Gastric perforation most commonly results in abdominal distension and pain; other symptoms can include ileus, respiratory distress, fever, emesis, hematemesis, PR bleeding, refusal to feed, vomiting, and decreased activity. ⁹

• Oesophageal perforation from a swallowed foreign body is rare but critical and potentially life-threatening. It tends to cause acute mediastinitis with chest pain, dyspnoea, and severe odynophagia (pain associated with swallowing), along with signs of pneumonitis/pleural effusion.¹⁰

• Crepitus in the neck or chest walls is a sign of oesophageal perforation.

Examination of the patient with definite or suspected foreign body ingestion/entrapment

Examination does not always result in clear findings but remains an important part of the assessment. Examination includes:

• Assessment of the airway and respiratory function to exclude or highlight any compromise.

• Checking the vital signs to exclude impending catastrophic presentation due to airway obstruction or acute GI perforation, or fever in case of delayed presentation.

• Examining the mouth and the oropharynx with a bright light.

• Gentle palpation of the neck to assess the tracheal position.

• Respiratory examination.

• Cardiovascular examination.

• Abdominal examination.

• Consideration of indirect laryngoscopy and/or fibre-optic examination of the pharynx - this is unlikely to be available in general practice but may be possible in an emergency care setting if the appropriate equipment and a sufficiently experienced practitioner is available.

• This clinical scenario is unlikely to be confused with another illness.

• There may be an underlying cause, for example a space-occupying oesophageal pathology - eg, oesophageal carcinoma - causing obstruction of a normal food bolus.

• Always consider the possibility that a foreign body has been inhaled, particularly if a patient presents acutely with respiratory compromise.

• An acute presentation of mediastinitis may be due to perforation by a swallowed foreign body, or the primary form of the disease.

• Retropharyngeal abscess can cause similar symptoms to impacted objects in the upper oesophageal area.

• Pneumomediastinum can present similarly, where there is a pneumothorax into the mediastinal portion of pleura.

• Underlying oesophageal conditions including eosinophilic oesophagitis (10% in adults, up to 50% in children), motility disorder, stenosis and diverticula are frequent. ¹

Blood tests are usually unhelpful, with the exception of chronic presentations or febrile patients where FBC/ESR may provide useful clues as to the cause of symptoms.

Plain X-rays

• Plain x-rays remain a useful first-line imaging modality for suspected airway, oesophageal, or gastric foreign bodies. Metallic foreign bodies are readily visible and can be roughly localised on plain films, as can glass and even some plastic toys.²

Other imaging

• Contrast x-rays, CT scans, or MRI scans may be more useful than plain x-rays for visualisation of radiolucent objects.²

Studies have shown that most foreign bodies pass without the need for intervention. A study looking at 117 adults with ingested foreign bodies, where the most common foreign body was a razor blade, confirmed that size and sharpness of the foreign body was not a predictor for need for intervention.¹³

Studies have shown that removal of foreign bodies by experienced hands, at well-equipped endoscopy units and under conscious sedation, in most cases leads to high success rates, with complications (if they do occur) tending to be minor.¹⁴

Emergency management

• Patients with airways obstruction should be seen urgently in ED.

• Act quickly to locate and remove any foreign object that may be causing acute upper airway obstruction.

• Where airway obstruction is life-threatening and a foreign object cannot be removed then obtain urgent senior A&E/anaesthetic/ENT advice and/or consider cricothyroidotomy as a life-saving procedure.

• Children with upper GI obstruction and/or airway compromise should be allowed to stay in their parent's arms whilst being transferred to, or assessed in, hospital, to reduce anxiety and worsening airway embarrassment.¹¹

• Indications of the need for urgent transfer to hospital include:

  • Airway compromise.

  • Drooling.

  • Inability to swallow fluids.

  • Sepsis.

  • Suspicion of intestinal perforation.

  • Evidence of active bleeding.

  • Clear history of ingestion of a button battery.

Conservative management

• Stable patients who have swallowed small, smooth objects, who have no evidence of oesophageal entrapment, otherwise negative imaging, and no evidence of damage, can often be managed conservatively with follow-up at 24 hours or so to check that they remain well; passage of objects in stool may take days to weeks and parents should observe for their presence. More than 75% of foreign bodies will pass spontaneously.²¹

• Patients who have swallowed items that are over 2.5 cm in diameter or 6 cm in length should be considered for endoscopy.¹⁵

• Button batteries seen in the oesophagus will need emergency removal as they often contain lithium and can cause serious harm or death within hours. ¹⁵

• Button batteries seen in the stomach or further along the gastro-intestinal tract may be suitable for observation.

• If more than one magnet has been ingested, or a magnet plus a metal object, then this will usually require an urgent endoscopy due to the risks of bowel necrosis.¹⁵ However, observation may sometimes be suggested.²

Interventional management

Those with foreign objects lodged in the oesophagus will usually require some form of intervention to prevent ulceration and/or other complications; although options include endoscopy, laparoscopy, laparotomy and oesophagotomy, endoscopy is the most commonly used intervention.³

• Both flexible and rigid endoscopy remove oesophageal foreign bodies successfully.¹⁶

• Endoscopic removal of foreign bodies generally has a low probability of complications, including impaction, perforation and obstruction.¹⁷

• Adult patients with oesophageal entrapment of food bolus or other food-related objects should be considered for referral to a gastroenterologist, as there is a significant incidence of oesophageal lesions such as carcinoma in these patients.

• Patients with signs of small bowel obstruction or peritonitis should have surgery - endoscopy should not delay surgery.

Drug trafficking

• Narcotic 'body packers'/'drug mules' should be followed up and monitored as inpatients due to the risk of drug toxicity.¹⁸ They may need surgical intervention if there is any evidence of systemic effects of leaking narcotics.^{19 20}
  

A 2019 retrospective review noted complications in 9% of paediatric cases.²¹

Oropharyngeal foreign bodies

• Scratches and lacerations of oropharyngeal mucosa.

• Perforation.

• Retropharyngeal abscess.

• Soft-tissue infection or abscess.

Oesophageal foreign bodies

• Scratches, lacerations or abrasions of mucosa.

• Oesophageal necrosis (typically seen in button batteries).

• Retropharyngeal abscess.

• Oesophageal stricture.

• Oesophageal perforation and subsequent para-oesophageal abscess.

• Mediastinitis.

• Pneumothorax and/or pneumomediastinum.

• Pericarditis/cardiac tamponade.

• Tracheo-oesophageal fistula (especially swallowed button batteries in children).

• Aorto-oesophageal fistulae or other mediastinal vascular injury.

Gastric/small-intestine foreign bodies

• Entrapment of an object within a Meckel's diverticulum.

• Perforation leading to peritonitis and advanced sepsis.

• Acute or subacute small-intestinal obstruction.

• Metal poisoning (coins).

• ²²On the whole, prognosis is good, especially with appropriate investigation, management, and follow-up.

• Complications are more likely in adults over the age of 50 years, impaction over 24 hours, bone-type foreign bodies, foreign bodies larger than 30mm, and impaction higher than the mid-oesophagus.¹

• It is difficult to prevent toddlers from examining things with their mouths as this is a normal and beneficial developmental stage. However, basic home-safety measures, such as cupboard catches and vigilance about not leaving small objects within children's reach, are helpful.

• Discussion with the parents of children who have swallowed foreign bodies is recommended to reduce the risk of repetition in the same child or siblings.