Brief Report

Emergency endoscopic management of dietary foreign bodies in the esophagus

Hsuan-Hwai Lin MD^a, Shih-Chun Lee MD^b, Heng-Cheng Chu MD, PhD^a,

Wei-Kuo Chang MD, PhD^a, You-Chen Chao MD^a, Tsai-Yuan Hsieh MD, PhD^a,*

^aDivision of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, Taipei, Taiwan, ROC

^bDepartment of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC

Received 4 November 2006; revised 1 December 2006; accepted 1 December 2006

Abstract

Objective: We report our experience of endoscopy in the emergency management of dietary foreign bodies.

Methods: One hundred thirty-six patients were admitted to the emergency department (ED) between January 1997 and October 2006 for the endoscopic removal of esophageal dietary foreign bodies. They had a mean age of 47.7 years, and 91 (67%) were women.

Results: Most of the ingested materials (98.5%) were successfully extracted using either flexible or rigid endoscope. The objects most frequently ingested were fish bones (48%) and chicken bones (46%). Most of the objects (84%) were lodged in the upper esophagus. Two patients with irretrievable foreign bodies or complicated perforations were taken to surgery.

Conclusion: Because most of these foreign bodies lodged in the upper esophagus, physicians should take care of this area to avoid secondary injury or complications, especially with sharp bones.

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Introduction

Ingested gastrointestinal (GI) foreign bodies are a common problem in the emergency department (ED). It is well known that conservative treatment is successful in most of these cases, with only a few (b1%) causing complications such as GI tract perforation [1-6]. Foreign body ingestion usually occurs in children [1]. However, it can happen in a variety of adults such as edentulous individuals, Psychiatric patients, prisoners, and those with alcohol dependence [1,2].

* Corresponding author. Tel.: +886 287927409; fax: +886 287927139.

E-mail address: [email protected] (T.-Y. Hsieh).

Children often ingest coins and toys, whereas adults usually ingest dietary foreign bodies such as bones and meat [7,8]. Most GI perforations in adults are caused by dietary foreign bodies [9]. Here we report our experience of endoscopy in the emergency management of dietary foreign bodies in a series of 136 adult patients at a university teaching hospital.

Materials and methods

Study design

This was a retrospective study of patients admitted through the ED for extraction of dietary esophageal foreign bodies; they were observed until hospital discharge.

0735-6757/$ – see front matter D 2007 doi:10.1016/j.ajem.2006.12.012

Setting and population

Charts for visits occurring between January 1997 and October 2006 were collected from a university teach- ing hospital.

Selection of participants

Lists of patients with codes related to esophageal foreign bodies (International Classification of Diseases, Ninth Revision) as the principal admitting diagnoses were obtained from the medical records departments at the hospital. Patients needed to fulfill the following inclusion criteria: (1) they were adults (aged 18 years or older), (2) hospital admission was through the ED for a principal diagnosis of dietary esophageal foreign bodies, and (3) they received emergency endoscopic examination within 12 hours of admission. Patients with documented malig- nancies of the esophagus were excluded.

Clinical and demographic information

The following information was recorded: demographic characteristics, underlying disorders, methods of manage- ment, duration of impaction, type and location of ingested foreign bodies, use of general anesthesia, and any associated complications.

Hospital course information

The diagnosis of a foreign body in the esophagus was confirmed by endoscopy (Fig. 1) and Plain radiography (Fig. 2). A lateral neck plain radiograph and a posteroanterior

Fig. 1 Endoscopic image of a fish bone lodged in the upper esophagus.

Fig. 2 Radiograph of a chicken bone lodged in the upper esophagus (arrow).

view that included the oropharynx, neck, chest, and abdomen were made routinely before endoscopic examina- tion. It helped in locating the site of impaction of the foreign body, determining the level of perforation, and finding the abscess or air in soft tissue [6]. Computed tomography scanning was done for those patients with suspected perforations. Either conscious sedation or general anesthesia was used in those patients who underwent rigid endoscopy or who were extremely nervous. Decisions on using a rigid esophagoscope (Karl Storz, Tuttlingen, Germany) or a flexible endoscope (GIF 200-240, Olympus, Tokyo, Japan) depended on the experience of individual physicians (gastroenterologists, thoracic surgeons, or otolaryngolo- gists). An overtube was always used to protect the airway or prevent esophageal mucosal injury while removing sharp objects using a flexible endoscope [8]. Those patients in whom the removal of the foreign body by endoscopy failed were referred to a thoracic surgeon for further management.

There are 4 regions of physical narrowing in the esophagus where a foreign body is likely to impact. These include the upper esophageal sphincter, the level of the aortic arch, the crossing of the main stem bronchi, and the Lower esophageal sphincter and gastroesophageal junction. All of these regions are regions of luminal narrowing with diameters of 23 mm or less in adults. Based on these landmarks, we can divide the esophagus into 3 parts: upper, middle, and lower esophagus.

Table 1 Methods of management: extraction successes and failures					Table 3 Time from endoscopy and incidence of esophageal perforation
	Success (%)	Failure (%)	No. of patients			Without	With	Total
Endoscopy Flexible	48 (98)	1 (2)	49		Within 24 h	perforation (%) 108 (100)	perforation 0	(%) 108
Rigid	86 (99)	1 (1)	87		More than 24 h	27 (96)	1 (4)	28
Total	134 (98)	2 (2)	136		Total	135 (99)	1 (1)	136

Data analysis

All statistical analyses were performed using SPSS software, version 10.0 (SPSS Inc, Chicago, Ill). All data are presented as means F 95% CIs. A v² test was used to analyze the relationships between categorical variables. All P values are 2-tailed, and P b .05 was considered statistically significant for all tests.

Results

One hundred thirty-six patients with dietary esophageal foreign-body impaction were enrolled in this study. They comprised 45 men (33%) and 91 women (67%), ranging in

age from 18 to 88 years (mean, 47.7 F 2.7 years). All impactions were accidental. The objects were extracted using flexible and rigid endoscopy in 49 (36%) and 87 (64%)

patients, respectively (Table 1); 111 (82%) underwent endoscopy under general anesthesia. Only 2 were taken to surgery because the extraction by endoscope was impossible (one by rigid endoscope and the other by flexible endoscope). There was no difference in this extraction failure rate between the rigid and flexible endoscopy (Table 1). One patient had an impacted chicken bone, and the other had fish-bone lodgment at the upper esophagus. The patient who had chicken-bone impaction developed a perforation 1 week after symptom onset. All the other patients were treated successfully and made good recoveries without any major complication.

The impacted dietary foreign bodies comprised fish bones (48%), chicken bones (46%), and meat (5.1%). The impacted sites were in the upper (114, 84%), middle (16, 12%), and lower (6, 4%) esophagus. Patients with fish-bone obstruc- tions were more likely to have them lodged in the upper esophagus (v² = 8.88, P = .012) (Table 2) compared with those with chicken bones or meat. One hundred eight patients

Table 2 Types of ingested objects and location in the

esophagus*

* P = .012, v² = 8.88 (excluding others).

2

2

Type	Upper esophagus (%)	Middle or lower esophagus (%)	Total
Meat	4 (57)	3 (43)	7
Chicken bones	48 (77)	14 (22.6)	62
Fish bones	60 (92)	5 (8)	65
Others	2 (100)	0	2
Total	114 (84)	22 (16)	136

(79%) underwent endoscopy within 24 hours after foreign body ingestion, whereas the other 28 patients (21%) received this procedure after more than 24 hours. The only patient with an esophageal perforation was in the latter group (Table 3).

Discussion

Ingestion of GI foreign bodies represents the second most common endoscopic emergency after GI bleeding. The type of impacted foreign body is associated with the patient’s age and the local cuisine and dietary habits. Children often ingest coins and toys; adults usually have problems swallowing bones and meat [7-9]. Fish and chicken bones represented the most commonly encountered foreign bodies in this study, consistent with other reports on Asian populations [6,9,10]. In previous reports [1,11], Intentional ingestion of potentially obstructive objects usually occurred with underlying psychiatric disorders or in prisoners. However, all these cases were accidental, and we had no psychiatric patients or prisoners in this study. Normally, such patients do not ingest dietary foreign bodies, according to our experience. Most ingested foreign bodies (80%-90%) pass through the GI tract spontaneously, 10% to 20% need endoscopic intervention, and only 1% or fewer may require surgery [1-6]. If the foreign body becomes impacted in the esophagus, it may cause serious sequelae such as inflammation, mucosal ulceration and hemorrhage, obstruction, perforation, or even death [12,13]. Most GI perforations in adults are caused by dietary foreign bodies such as fish bones or bone fragments [9]. One of our patients indeed developed an esophageal perforation be- cause of chicken-bone impaction. Therefore, when impac- tions with fish bones or bone fragments are noted, this risky complication should be taken seriously.

Historically, rigid esophagoscopy is the method of choice to remove an Esophageal foreign body [2,14]. However, a prospective study of removal of foreign bodies using flexible endoscopy has demonstrated that this is also a safe and effective method for removing foreign bodies from the upper GI tract [15]. In our study, both rigid and flexible endoscopes were used to dislodge the foreign bodies. The choice depended on the experience of individual physicians. There was no significant difference in the success rate between the 2 methods in this series (Table 1), but a prospective randomized control trial would be needed to avoid any selection bias and confirm this conclusion.

Most esophageal foreign bodies are reported to lodge in the upper esophagus [2,11,16]. Likewise, we found that 84% of our patients had an impaction in this region (Table 2). Therefore, physicians should examine the upper esophagus more carefully if an obstruction is suspected. However, we are used to passing through the upper esophageal sphincter and reaching the middle esophagus promptly during routine upper GI endoscopy. Therefore, we should slow down the procedure and be aware of the potential danger from impacted objects, or the patient’s esophagus may be at risk for secondary injury.

Significant factors that might predispose patients to complications include Delayed presentation (N24 hours after the onset of symptoms), presence of a sharp foreign body, Mental illness, wearing dentures, and multiple objects [4,8,17]. A high index of suspicion, judicious judgment, and early endoscopic intervention within 24 hours after ingestion are associated with favorable outcomes [4,5,11]. In this series, 108 patients (79%) underwent endoscopic intervention within 24 hours after ingestion. Only 1 patient who underwent endoscopic intervention after 24 hours had an esophageal perforation. Although there was no difference in the Perforation rate between the 2 groups (Table 3), this might be because of the extremely low perforation rate in our study. In our study, there were extremely low perforation rate and failure of extraction. These became our limitations in per- forming further statistical tests. In addition, this was a retro- spective study; thus, there were many biases. Therefore, we still need further prospective studies to test our observation. In summary, the ingestion of most dietary objects that cause obstruction occurs accidentally, and treatment depends on the experience of the physician. Most obstruc- tions are found in the upper esophagus. Thus, physicians should examine the upper esophagus carefully. Because most bowel perforations in adults are caused by dietary foreign bodies, especially fish bones or bone fragments, we should be more watchful in managing patients when fish

bones or bone fragments are identified by endoscopy.

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