Gastrointestinal Foreign Bodies: Background, Pathophysiology, Epidemiology

Background

Patients with foreign bodies in the gastrointestinal (GI) tract commonly present to the ED. Foreign bodies in the upper GI tract are usually swallowed, purposefully or accidentally. The presentation is usually straightforward but on occasion can be extremely subtle. A foreign body in the GI tract is shown in the radiograph below.

A screw in the stomach; peristaltic action will carry the screw through the GI tract with the blunt end (head) leading and the sharp end trailing.

Most of the literature covering GI foreign bodies is anecdotal, with the exception of some recent studies on esophageal foreign body removal techniques.

Pathophysiology

Foreign bodies may involve the entire upper GI tract. The oropharynx is well innervated, and patients can typically localize oropharyngeal foreign bodies. Scratches or abrasions to the mucosal surface of the oropharynx can create a foreign body sensation. Chronic foreign bodies or perforations can cause infections in surrounding soft tissues of the throat and neck.

The esophagus is a tubular structure approximately 20-25 cm in length. Patients can usually localize foreign bodies in the upper esophagus but localize them poorly in the lower two thirds of the structure. The esophagus has 3 areas of narrowing where foreign bodies are most likely to become entrapped: the upper esophageal sphincter (UES), which consists of the cricopharyngeus muscle; the crossover of the aorta; and the lower esophageal sphincter (LES). Structural abnormalities of the esophagus, including strictures, webs, diverticula, and malignancies, increase the risk of foreign body entrapment, as do motor disturbances such as scleroderma, diffuse esophageal spasm, or achalasia.

After reaching the stomach, a foreign body has greater than a 90% chance of passage. Coins reaching the stomach are very likely to pass into the small bowel. Objects larger than 2 cm in diameter are less likely to pass the pylorus, and objects longer than 6 cm may become entrapped at either the pylorus or the duodenal sweep. Objects reaching the small bowel occasionally are impeded by the ileocecal valve. Rarely, a foreign body may become entrapped in a Meckel diverticulum.

Swallowed magnets from toys and household items have become a serious health hazard in children. Buckey-ball magnets are small round magnets in the shape of ball-bearings that are especially strong and are used to make toys of various shapes. If these small magnets are ingested, especially at various times, they can adhere across layers of bowel and lead to pressure necrosis, fistula, volvulus, perforation, infection, or obstruction.

Epidemiology

Frequency

United States

The incidence of foreign body ingestions in children and adults is unknown. Data are largely anecdotal.

A recent study suggested approximately 1671 ingested magnet injuries annually. This is expected to decrease since sales of these small toy magnets have been banned by the Consumer Protection Agency because of safety concerns.

Mortality/Morbidity

An estimated 1500 deaths occur annually from foreign bodies in the upper GI tract.

Complications

Complications of GI foreign bodies include the following:

• Potential complications of oropharyngeal foreign bodies include esophageal or pharyngeal abrasions, lacerations, and punctures, with associated abscesses (eg, retropharyngeal abscess), perforations, and soft-tissue infections.
• Esophageal foreign bodies can also cause mucosal scratches or abrasions, punctures, and perforations, with resultant injuries or infections to surrounding structures, including abscesses, pneumomediastinum or mediastinitis ; pericarditis/tamponade, pneumothorax, pneumomediastinum, tracheoesophageal fistula, or even vascular injuries to the aorta (aortoesophageal fistulas) ; or pulmonary vasculature. Additionally, button batteries can rapidly create esophageal necrosis. Esophageal strictures may also occur.
• Complications from foreign bodies in the stomach and small intestine typically involve perforation and associated infection, including peritonitis and sepsis. Small-bowel obstruction may also occur
• Swallowed toy magnets that adhere across layers of bowel can cause pressure necrosis, fistula, volvulus, perforation, infection, or obstruction.

Race

No differences in race or nationality have been noted.

Sex

In children with swallowed foreign bodies, the incidence in males and females is equal.In adults, the incidence of accidentally swallowed foreign bodies is slightly higher in men than in women, and the incidence of intentionally swallowed foreign bodies is much higher in men than in women.

Age

Patients with foreign bodies in the upper GI tract usually fall into 1 of 3 categories: (1) children, (2) psychiatric patients and prisoners, and (3) edentulous patients.

Children account for 75-85% of patients with foreign bodies in the upper GI tract, with a preponderance at age 18-48 months.

The objects involved also differ by group. Children typically ingest objects they pick up and place in their mouths, such as coins, buttons, marbles, crayons, and similar items.In contrast, adults are more prone to ingest food boluses, chicken or fish bones, fruit pits, dentures, or toothpicks.Prisoners and psychiatric patients may present with bizarre objects, as well as multiple objects.

The site of entrapment of esophageal foreign bodies also differs with age groups, with about 75% of children having entrapment at the upper esophageal sphincter (UES) and about 70% of adults having entrapment at the lower esophageal sphincter (LES).

Clinical Presentation



David W Munter, MD, MBA Associate Clinical Professor of Emergency Medicine, Eastern Virginia Medical School; Associate Professor of Emergency Medicine, Edward Via Virginia College of Osteopathic Medicine; Partner, Emergency Physicians of Tidewater, PLC; President of the DESA Consulting Group

David W Munter, MD, MBA is a member of the following medical societies: American College of Emergency Physicians, Medical Society of Virginia, Norfolk Academy of Medicine, American Association for Physician Leadership

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Steven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Society for Academic Emergency Medicine



Jerry R Balentine, DO, FACEP, FACOEP Vice President, Medical Affairs and Global Health, New York Institute of Technology; Professor of Emergency Medicine, New York Institute of Technology College of Osteopathic Medicine

Jerry R Balentine, DO, FACEP, FACOEP is a member of the following medical societies: American College of Emergency Physicians, New York Academy of Medicine, American College of Osteopathic Emergency Physicians, American Association for Physician Leadership, American Osteopathic Association

Acknowledgements

Eugene Hardin, MD, FAAEM, FACEP Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center

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Coin (quarter) lodged at the level of the cricopharyngeus muscle.

Coin lodged at the level of the aortic crossover.

Coin lodged at the lower esophageal sphincter.

A screw in the stomach; peristaltic action will carry the screw through the GI tract with the blunt end (head) leading and the sharp end trailing.