Gastrointestinal Foreign Bodies in Emergency Medicine

Author

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;
Medical Director, Emergency Medical Department, Sentara Obici Hospital; 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, American College of Physician Executives, Medical Society of Virginia, and Norfolk Academy of
Medicine
Disclosure: Nothing to disclose.

Specialty Editor Board

Jerry Balentine, DO  Professor of Emergency Medicine, New York College of Osteopathic Medicine; Executive
Vice President, Chief Medical Officer, Attending Physician in Department of Emergency Medicine, St. Barnabas
Hospital
Jerry Balentine, DO is a member of the following medical societies: American College of Emergency Physicians,
American College of Osteopathic Emergency Physicians, American College of Physician Executives, American
Osteopathic Association, and New York Academy of Medicine
Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

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
Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess
Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending
Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency
Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency
Medicine
Disclosure: Nothing to disclose.

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 and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
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 may 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.
Epidemiology

Frequency

United States

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

Mortality/Morbidity

An estimated 1500 deaths occur annually from foreign bodies in the upper GI tract.[1]

 Potential complications of oropharyngeal foreign bodies include abrasions, lacerations,

and punctures, with associated abscesses, perforations, and soft-tissue infections.
 Esophageal foreign bodies can also cause abrasions, punctures, and perforations, with
resultant injuries or infections to surrounding structures, including abscesses,
pneumomediastinum or mediastinitis;[2] pneumothorax, pericarditis or tamponade,
fistulas, or even vascular injuries to the aorta;[3] or pulmonary vasculature.[4] Additionally,
button batteries can rapidly create esophageal necrosis.
 Complications from foreign bodies in the stomach and small intestine typically involve
perforation and associated infection, including peritonitis.

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.[5, 6] 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 75-80% 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.[6] In
contrast, adults are more prone to ingest food boluses, chicken or fish bones, fruit pits,
 dentures, or toothpicks.[7] 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).[6, 7, 1]

History

 Oropharyngeal foreign bodies

o Patients with oropharyngeal foreign bodies normally present with a foreign body
sensation, especially after eating chicken or fish, although a variety of other
objects, including toothpicks, may be involved.
o They may have variable degrees of discomfort, from minor to more severe.
o Patients may complain of inability to swallow or handle secretions.
o Rarely, patients may have airway compromise, typically in delayed presentations
with subsequent infection or perforation.
o Patients can usually localize the foreign body sensation in the oropharynx.
 Esophageal foreign bodies
o Adults with esophageal foreign bodies usually present acutely, with a history of
ingestion. A foreign body sensation or vague discomfort in the epigastrium
suggests that the foreign body is entrapped at the LES.
o Dysphagia is the norm in adults. If the obstruction is complete, an inability to
handle secretions is common. The classic adult presentation is the person with
dentures who has had some alcohol and is eating meat. Incomplete chewing leads
to an impaction at the LES. Adults should be asked about the use of dentures,
alcohol intake, and circumstances surrounding the ingestion.
o In children with esophageal foreign bodies, the history may be less clear.[8] As
many as 35% of children with esophageal foreign bodies are asymptomatic; the
history is given by a parent who has seen the child with an object in his or her
mouth and suspects the child might have swallowed it. Such reports must be taken
seriously and investigated.[9] Gagging, vomiting, and neck or throat pain are
common presentations. Children with chronic esophageal foreign bodies may also
present with poor feeding; irritability; failure to thrive; fever; stridor;[10] or
pulmonary symptoms, such as repetitive pneumonias from aspiration.[11] Large
esophageal foreign bodies at the UES can cause tracheal impingement in children,
with resultant stridor or respiratory compromise.
 Stomach/small intestine foreign bodies
o Patients with foreign bodies in the stomach or small intestine may present with a
history of swallowing an object, which has passed through the esophagus.
o Patients may present with vague symptoms such as fever, abdominal pain, or
vomiting.
o
Physical

 The physical examination typically is not helpful, but the oropharynx, neck, chest, lungs,
heart, and abdomen should be carefully examined.
 Occasionally, a foreign body in the oropharynx can be visualized and removed. In
cooperative patients, indirect laryngoscopy or fiberoptic nasopharyngoscopy provides
better information than a direct examination.
 In children, tracheal compression and stridor suggest a large foreign body at the UES.
 Complete obstructions can cause drooling and the inability to swallow.
 Delayed presentations may be accompanied by signs of infection, including peritonitis.

Causes

The most common causes of GI foreign bodies are food boluses and accidental swallowing of
other objects.

 Young children often put any object they find into their mouths and may accidentally
swallow them.
 Although less common, older children also put smooth objects, such as coins or marbles,
in their mouths and swallow them. However, the larger diameter esophagus in this age
group results in fewer entrapped foreign bodies compared to young children.
 Children who are abused may present with GI foreign bodies after being forced to
swallow objects; however, this is rare.
 The most common cause of GI foreign bodies in adults involves food that does not pass
through the esophagus because of underlying mechanical problems.
 In adults, accidental swallowing often involves toothpicks and dentures.
 Psychiatric patients may swallow a wide variety of objects, including multiple objects,
large objects, and bizarre items.
 Prisoners may swallow objects either to hide them from authorities or to seek medical
care. In the case of razor blades, they often tape the sharp edge to avoid injury.
 Drug smugglers may swallow multiple condoms (usually double wrapped) filled with
cocaine or heroin. This is called "body packing," as opposed to "stuffing," which occurs
when the patient attempts to elude arrest by swallowing packets of drugs in their
possession.
Differentials

 Disk Battery Ingestion

 Esophageal Perforation, Rupture and Tears
 Foreign Bodies, Rectum
 Foreign Bodies, Trachea
 Mediastinitis
 Obstruction, Small Bowel
 Pediatrics, Foreign Body Ingestion
 Pediatrics, Gastrointestinal Bleeding
 Retropharyngeal Abscess

Laboratory Studies

 Most patients with GI foreign bodies do not require any laboratory studies. Exceptions
are patients who present with signs and symptoms consistent with infection or
complications, in which case a CBC may be indicated, and patients who require
preoperative studies.

Imaging Studies

 Radiography
o Plain radiographs are indicated for every patient with a known or suspected
radiopaque foreign body in the oropharynx, esophagus, stomach, or small
intestine. Plain radiographs are also mandated for children in whom any ingestion
of a radiopaque foreign body is suspected. Keep in mind, however, that in cases
of nonradiopaque foreign bodies, imaging studies rarely have any influence on
management, except in delaying endoscopy or CT scanning.
o In small children, a mouth-to-anus radiograph can be obtained. In older children
and adults, posteroanterior (PA) and lateral chest radiographs provide better
localization.
o Radiopaque objects are easily seen and localized on the radiograph.
o Plain radiographs typically have been used in patients who have swallowed bones,
although the yield is low, with only 20-50% of endoscopically proven bones
visible on plain radiographs. Xeroradiography does not increase this yield.
o Coins are usually seen in a coronal alignment on anteroposterior (AP), or frontal,
radiographs (examples of a lodged coin are shown in the
radiographs below).
o

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.

o Button batteries can usually be differentiated from coins on plain films.[12]

However, if any question exists as to whether the object is a button battery, urgent
intervention is indicated because of the rapidity of esophageal necrosis that can be
seen in button battery ingestion.
o If the foreign body is in the trachea, it presents in a sagittal orientation because the
tracheal rings are incomplete in the posterior aspect.
o In adults with food impactions, a plain radiograph may be indicated to search for
imbedded bony fragments if techniques, such as LES-relaxing agents or
bougienage, are being considered. If endoscopy is used to treat the patient, plain
radiographs are not indicated.
o Drug packets typically have a characteristic appearance on plain films.[13]

 Barium or Gastrografin swallow

 o Barium swallow may be indicated in cases of ingestion of nonopaque foreign
bodies, such as toothpicks or aluminum soda can tabs, although CT scanning is a
much better imaging modality and should be used as the first choice when
available.
o A barium or Gastrografin swallow, without cotton balls, can sometimes outline
the foreign body, but, again, the yield is very low.
o Barium swallow can be used for food impactions; however, most authorities
believe that it adds nothing to the evaluation and delays definitive treatment.
o Contrast studies are not useful in detecting foreign bodies in the stomach or small
intestine.
o Barium is contraindicated in cases in which esophageal perforation is suspected.
Gastrografin may be used if a study is needed.
 CT scanning
o In one study, CT scanning was superior to plain radiographs for localization and
identification of foreign bodies in 83-100% of cases. CT scanning is highly
reliable in localizing foreign bodies in the esophagus.[14, 15]
o CT scanning is now considered the imaging modality of choice to locate
nonradiopaque foreign objects in the oropharynx or esophagus. However, the
application is probably unwarranted in every case of acute bone dysphagia, as
only a minority (17-25%) of patients who sense a foreign body after eating
chicken or fish has a bone present.
o CT scanning is also the imaging modality of choice in cases of suspected
perforation or abscess.
 Metal detectors: Handheld metal detectors have been shown to be accurate in determining
if a coin has been swallowed and may be a useful noninvasive screening tool in children
with a suspected coin ingestion. However, the specificity of localization is poor,
especially in differentiating LES impaction from coins in the stomach.[16]
 Ultrasound: This may be useful in detecting ingested drug packets.[17]
Procedures

 Endoscopy
o Emergent endoscopy is indicated for patients whose airway is compromised or
who show signs of complications.
o Urgent endoscopy is indicated for patients who have swallowed aluminum soda
can tabs or toothpicks, since these objects are not visible on plain radiographs and
both have a relatively high incidence of complications. If the history is clear,
proceed to endoscopy; if unclear, CT scanning may be used to confirm the
presence of the foreign body before endoscopy.
o Endoscopy is absolutely indicated for foreign bodies that are sharp,
nonradiopaque, or elongated; for multiple foreign bodies; or for possible
esophageal injuries.
o Endoscopy is the most commonly used technique for active management of
impacted esophageal foreign bodies. Endoscopy has been traditionally used for
the visualization of the esophagus and the removal of foreign bodies.[18]
o Endoscopy is indicated for patients with foreign bodies in the stomach or
proximal duodenum if the foreign bodies are larger than 2 cm in diameter or
longer than 5-7 cm or for oddly shaped foreign bodies such as open safety pins.
o Endoscopy is safe and effective but relatively expensive.[5, 19, 20]

Prehospital Care

The patient should be transported in a comfortable position. Patients with airway compromise
may need acute airway management. Patients unable to tolerate secretions are often most
comfortable in the sitting position. A suction catheter should be provided to assist in handling
secretions.

Emergency Department Care

The treatment of patients with suspected radiopaque foreign bodies is usually straightforward
because these can be easily localized on plain radiographs.

For nonradiopaque foreign objects, plain radiographs are not helpful. Studies such as barium
swallows or CT scanning may help to confirm or localize a foreign body, but often they only
delay definitive care.

In cases involving suspected oropharyngeal foreign bodies, which usually present with a foreign
body sensation, the evaluation and treatment is complicated by the fact that the physical
examination is usually unhelpful; only a minority (26% in one study) of patients have any
pathology at all as seen on endoscopy, and imaging studies are either unhelpful (plain
radiography or barium swallow) or expensive (CT scanning).[21]
Because of the broad range of presentations of GI foreign bodies, a tiered approach is
appropriate.

 Patients in an unstable condition

o Patients with airway compromise; drooling; inability to tolerate fluids; or
evidence of sepsis, perforation, or active bleeding are considered to be in an
unstable condition.
o Treatment includes airway management as indicated, followed by urgent
endoscopy (see Procedures).
o Patients who have ingested button batteries are considered to be in an unstable
condition. The presence of a button battery in the esophagus is a medical
emergency because necrosis of the esophageal wall may occur within hours.
These button batteries must be expeditiously removed. Button batteries in the
stomach can be allowed to pass but must be monitored radiographically to
observe for disruption of the battery. Follow-up radiographs are needed in 24-48
hours. If the battery is still in the stomach, endoscopic removal is indicated.
o Patients who are drooling may be more comfortable holding a suction catheter
and using it as needed.
 Patients in a stable condition
o For patients complaining of an oropharyngeal foreign body sensation, perform
direct and indirect oropharyngeal examination or fiberoptic nasopharyngoscopy,
if available; ENT consultation may be required to assist in removing any
visualized foreign bodies.
o Radiographically localize radiopaque objects.
 If the foreign body is sharp, elongated (>5 cm in esophagus, >6 cm in
stomach or small intestine), or multiple in number, refer for endoscopy.
Sharp objects, such as pins, razor blades, toothpicks, and chicken bones,
should be removed endoscopically on an urgent basis because up to 35%
of these sharp objects perforate the bowel wall if not removed.
 Most smaller, sharp foreign bodies, such as straight pins, transit the GI
tract without difficulty, as the peristaltic action carries the blunt end first
(as in the radiograph below); however,
many authorities recommend
endoscopic removal for these as well. 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.







  If the foreign body is smooth or blunt, consider the following modalities
(endoscopy is discussed in Procedures; the other 3 techniques are
discussed in detail below): endoscopy (see Procedures), Foley catheter
removal, bougienage, and sphincter relaxation if lodged at LES.
o For patients whose history strongly suggests an ingestion of a nonopaque foreign
body such as a plastic object, toothpick, or aluminum soda can tab, consider CT
scanning and refer for endoscopy. When the history is less clear about the
definitive swallowing of a nonradiopaque foreign body, obtain CT scanning and
refer for endoscopy if the foreign body is localized in the oropharynx or
esophagus.
o Button batteries in the stomach can be allowed to pass but must be followed
radiographically to observe for disruption of the battery. Follow-up radiographs
are needed in 24-48 hours. If the battery is still in the stomach, endoscopic
removal is indicated.
o Smooth foreign bodies, such as coins or marbles, almost always transit the GI
tract without any difficulties. Coins lodged in the distal esophagus of healthy
children spontaneously pass into the stomach in up to 60-80% of cases, usually
within several hours of presentation.[22]
o Note that the use of meat tenderizer is contraindicated in patients with food
boluses at the LES, as meat tenderizer may cause necrosis of the esophagus.
o People who body pack, those who ingest carefully wrapped packets of drugs, such
as heroin or cocaine, should be admitted for observation. Whole-bowel irrigation
is frequently used to aid passage. Endoscopy is generally avoided because
instrumentation of the packets may result in rupture.
 Foley catheter removal
o Foley catheter removal is another widely used technique for the removal of single,
smooth, blunt, radiopaque foreign bodies.
o Foley catheter removal is contraindicated in patients with foreign bodies that have
been present for more than 72 hours, those with a history of esophageal disease or
surgery, those who are experiencing respiratory distress, and those who are
uncooperative.
o This procedure is performed under fluoroscopy with immediate availability of
emergency airway equipment and personnel capable of emergency airway
management.
o In this procedure, the patient is placed in a head-down position, and a #12-#16
Foley catheter is passed orally past the foreign object under fluoroscopic
guidance. The balloon is inflated, and the catheter is pulled out with the foreign
body. The success rate for this procedure has been reported as 85-100%.
Complications, including epistaxis, dislodgment of the foreign body into the nose,
laryngospasm, hypoxia, and aspiration, have been reported at rates of 0-2%.
o Foley catheter removal should be attempted only by those familiar with its use.
Until ED personnel become comfortable with this procedure, it should be
performed under controlled conditions with immediate backup available for
complications.
 Bougienage
o Smooth esophageal foreign bodies, such as coins, lodged at the LES in children
have been advanced successfully into the stomach by using bougienage.
o Indications for this procedure are a smooth foreign body, lodged less than 24
hours, with no underlying esophageal disease or respiratory distress.
o Dilator size is selected according to the patient's age; the dilator is advanced
gently through the mouth and esophagus to the stomach with the child in a sitting
position, essentially in the same manner as is used in passing a nasogastric tube.
Often, topical anesthesia is used for the oropharynx.
o A repeat radiograph is used to confirm passage into the stomach.
o Published success rates for this procedure are 83-100%, and complication rates in
limited studies are 0%.[23, 24, 25]
 Relaxation of the lower esophageal sphincter
o Foreign bodies lodged at the LES can be managed by relaxation of the LES,
although in some studies, success rates associated with this technique are no
greater than those associated with watchful waiting.
o Typically, glucagon is used, with or without a gas-forming compound. The patient
is administered 1-2 mg of glucagon intravenously (0.02-0.03 mg/kg in children,
not to exceed 0.5 mg) followed by ingestion of E-Z Gas mixed with 240 mL of
water. The use of carbonated beverages if E-Z Gas is not available in the ED has
been reported.
o The published success rates for this procedure range from 12-50%,[26] which may
not be any better than spontaneous passage with no interventions, especially with
coin ingestions in children.[27]
o Nitrates, such as sublingual nitroglycerin and nifedipine, have been used less
widely; a risk involved with this procedure is creating significant hypotension in
the patient.
o This procedure does not work in patients with structural abnormalities.
 Cost is always a consideration when selecting a procedure. In one study, endoscopy
averaged $2700; Foley catheter removal, $660; and bougienage, $614.[28] In another
study, the average cost of endoscopy was $6087, whereas that of bougienage was $1884.
[29]

 If the workup is negative for a foreign object, discharge the patient with analgesics as
needed and refer for follow-up in 24 hours. If the patient is still symptomatic at recheck,
refer for endoscopy.

 Esophageal coins
o Four generally broadly accepted approaches to management of esophageal coins
in children are as follows: endoscopic removal, Foley catheter removal,
bougienage, and "watchful waiting," which is based on the fact that up to 80% of
coins at the LES will pass spontaneously within 24-48 hours with no
 interventions.[30] The watchful waiting approach is used only in patients with
single coins, who are able to handle secretions with no difficulties, and who have
no pain or distress, and no stridor or drooling.[31] After ascertaining location of the
coin at the LES, the child is discharged with follow-up arranged in 24 hours for
repeat radiography.[32, 33] Each of the 4 modalities is relatively site or regionally
accepted based on training and experience of local practitioners.
o United States pennies are now composed of copper-clad zinc, raising the potential
for possible esophageal or gastric ulcerations if impacted. Consider follow-up
radiographs in 1-2 days if in the stomach.
 Magnets: If one magnet is ingested, the patient may be treated as any other patient with
an ingested foreign body. However, if 2 or more magnets are ingested, there is a risk that
the magnets may be in different loops of bowel and become attached via magnetic
attraction. In this case, necrosis, perforation, and peritonitis may occur. Patients who have
ingested 2 or more magnets warrant surgical consultation.[34, 35, 36]
 Press-through packaging (bubble packaging for medications): Increasingly reported,
especially in elderly patients or in those with dementia, the entire package is swallowed.
The sharp edges cause entrapment in the esophagus. These should be treated as sharp
foreign bodies and endoscopically removed.[37, 38]
 Razor blades: These are normally swallowed by prisoners or psychiatric patients. Often,
the sharp edge is taped to avoid injury. Remove the razor blade if in the esophagus or
stomach. They can usually be safely observed if past the pylorus.[39]

Medication Summary

Smooth-muscle relaxation agents may be used to relax the LES, thereby allowing the passage of
foreign bodies lodged in this location. However, there is not convincing evidence in the literature
that the use of such agents changes clinical outcomes.[26, 27]

Gastrointestinal agents

Class Summary

These agents may improve peristaltic activity in the GI tract.

View full drug information

Glucagon (GlucaGen)
 

Mechanism of action unknown.

Sodium bicarbonate, citric acid, and simethicone (E-Z Gas)

 
Neutralizes acidity and relieves functional gastric bloating.

Further Inpatient Care

 Patients in an unstable condition including drooling, stridor, inability to handle

secretions, signs of perforation or bleeding:
o Manage airway and refer for urgent endoscopy.
o Patients with button batteries in the esophagus are considered to be in an unstable
condition.
 Patients in a stable condition
o Oropharyngeal foreign bodies: If ED evaluation is negative for a foreign body,
discharge with follow-up, generally with an ear, nose, and throat (ENT) specialist
in 24 hours. If ED evaluation is positive for a foreign body that cannot be
removed under direct visualization, refer to an ENT specialist for endoscopy.
o Esophageal foreign bodies: In cases that involve sharp, elongated, or multiple
foreign bodies, refer the patient to a gastroenterologist for urgent removal. For
patients with entrapped smooth foreign bodies, if treatment in the ED does not
result in removal or passage into the stomach, refer to a gastroenterologist for
endoscopy. In children with coins at the LES, watchful waiting may be used if the
patient is stable, with follow-up and repeat radiography in 12-24 hours; if the coin
has not advanced to the stomach by that time, refer for endoscopy.
o Stomach or small intestine foreign bodies: Patients with smooth, blunt objects that
are less than 2 cm in width or 6 cm in length should be discharged to home. Serial
radiographs are generally not needed. Instruct patient to return if fever, vomiting,
or abdominal pain occurs. Those with sharp or large foreign bodies in the stomach
should be referred to a gastroenterologist for endoscopic removal. Serial
radiographs are indicated for sharp or large foreign bodies in the duodenum or
small intestine. In most cases, refer to a surgeon or gastroenterologist in 24 hours
for follow-up examinations, radiographs, and intervention.
o People who body pack should be admitted to a monitored setting and are typically
treated with whole-bowel irrigation or observation alone. If they develop signs of
drug toxicity, this indicates rupture of one of the drug-containing packages and
mandates resuscitative measures and surgical consultation for possible surgical
removal.

Further Outpatient Care

 For adults with resolved esophageal foreign bodies, referral to a gastroenterologist in 24-
72 hours is mandatory because a large percentage of these patients have underlying
structural abnormalities, including malignancies, and follow-up endoscopy is needed.
 In children with resolved esophageal foreign bodies, no follow-up is needed.
Complications

 Oropharyngeal foreign bodies - Esophageal or pharyngeal scratches, abrasions,

lacerations, or perforations; retropharyngeal abscess; soft-tissue infection or abscess
 Esophageal foreign bodies - Mucosal scratches or abrasions; esophageal necrosis;
retropharyngeal abscess; esophageal stricture; esophageal perforation leading to
paraesophageal abscess, mediastinitis, pericarditis/tamponade, pneumothorax,
pneumomediastinum, tracheoesophageal fistula, and vascular injuries, including
aortoesophageal fistulas
 Stomach and small intestine foreign bodies -Small-bowel obstruction; perforation with
intra-abdominal infection, peritonitis, and sepsis