GI Foreign Body

Airway & Initial Assessment

Always start with ABCs

Suspect FB if:

Sudden poor feeding, drooling, dysphagia
Stridor, cough, wheezing, fever, irritability
Transient gagging/coughing followed by the disappearance of the object

Airway threatened → intubate immediately

Symptoms may overlap with aspirated FB → keep in differential

RISK GROUP ?

Children
Adults with poor dentition or esophageal disease
Prisoners
Psychiatric patients

Intentional ingestion → often multiple objects

Common Sites of Impaction

Children: Cricopharyngeus (C6 level)

Adults: Lower esophageal sphincter (LES)

Spontaneous passage:

20–25% if stuck at cricopharyngeus/aortic crossover
25–60% if at LES

Imaging

Do radiology unless complete obstruction with inability to handle secretions

CXR if aspiration suspected

X-ray technique:

AP + lateral neck (upright, neck extended, shoulders down)
Phonate “eeee” → reduces artifact, distends hypopharynx
Add chest AP/Lat, abdominal films as needed

Non-radiopaque FBs: food, plastic, wood, aluminum, some animal bones

Plane films detect only 25–55% of bones
CT preferred (without contrast unless vascular injury suspected)

Avoid oral contrast (interferes with endoscopy) unless perforation is suspected → use water-soluble media

Management by Object & Location

IN ESOPHAGUS

Coin

Remove within 24h if persistent

Button Battery

Emergency removal (first aid: honey/jam if >12 mo old)

Magnet

Remove if reachable endoscopically

Sharp Object

Emergency endoscopy

Blunt Object

Remove within 24h

IN STOMACH

Coin

Weekly X-ray. Remove if no progression in 3–4 wks

Button battery

Repeat X-ray: 2 days if in stomach, 3–4 days if past pylorus

Magnet

Daily X-ray until passed. Remove if accessible

Sharp object

If >2.5 cm wide or >6 cm long, remove urgently. Daily X-ray

Blunt object

If >2.5 cm wide or >6 cm long, remove urgently. Weekly X-ray

Procedural Options

Esophagoscopy: gold standard; required for sharp FBs. Give IV antibiotics before sharp object removal.

Magill forceps: for FB at cricopharyngeus (under sedation).

Foley catheter: only for smooth/blunt FBs <24–48 hrs, with fluoroscopy. Contraindications: total obstruction, sharp FB, perforation, airway distress, multiple FBs.

Esophageal bougienage: only for one coin, <24 hrs, >1 year old, no distress. No reported complications if correct.

Pharmacologic Maneuvers

Indication: smooth/blunt FBs only.

Glucagon (0.25–2 mg IV over 1–2 min, may repeat after 20 min):

Useful for distal esophagus.
Combine with carbonated drink or NaHCO₃ for higher success.
Avoid if sharp FB, fixed deformity, insulinoma, pheochromocytoma.

SL Nitroglycerin (0.4 mg) or Nifedipine (5–10 mg PO):

For mid/distal FB.
Avoid if sharp FB, hypotension, hypovolemia.

Avoid carbonated drinks if impaction >6 hrs or suspected injury.

Specific Foreing bodies

Coins

Flat in esophagus (AP view), on the side in the trachea (lateral view).
25% pass spontaneously.
Upper/middle esophagus → less likely to pass.
Lower esophagus → ⅓–½ pass spontaneously.
Observation with a soft diet and a repeat X-ray is reasonable if asymptomatic.

Fish/Chicken Bones

Many patients only have abrasions, not true FB.
Only 17–25% with sensation have true FB on endoscopy.
Stepwise:
- Exam tonsils & pharynx. If seen → remove.
- If symptoms persist despite a negative exam → consider a CT.
- If negative but persistent symptoms → endoscopy.
Do not ignore continuous complaints (>2–3 days risk of damage).

Sharp Objects

Always require removal.
Esophagus: remove within 2–6 hrs.
Stomach/duodenum: within 24 hrs.
Intestine: admit for surgical follow-up & serial X-rays.

Button Batteries

Esophagus: emergency.
Stomach:
- Remove urgently if <5 yrs or >2 cm.
- If otherwise, observe with 48 hr X-ray.
Give honey/jam (5–10 ml every 10 min, up to 6 doses).

Magnets

Always remove urgently if in the esophagus/stomach.
If multiple magnets are beyond reach: admit, monitor with 4–6 hr exams/X-rays, and perform surgery if symptomatic or non-progressing.