History

Obtaining an accurate history from children or noncommunicative adults can be challenging.

It is common to hear the story from parents or carers.   As a result, symptoms in children are often subtle, such as drooling, refusal to eat, and failure to thrive.

For communicative adults, the history of ingestion is usually more reliable. Patients can often describe what they ingested, when it occurred, and whether they are experiencing pain or symptoms of obstruction. Adults with esophageal food bolus impactions commonly present with symptoms of complete or intermittent obstruction, such as an inability to swallow liquids or manage oral secretions. Sialorrhea (excessive saliva production) is frequent. The ingestion of small, sharp objects, such as fish or animal bones, can cause odynophagia (painful swallowing) or a persistent sensation of a foreign body due to mucosal laceration. The nature of the symptoms can help determine whether a foreign object remains in the esophagus. For example, if the patient presents with dysphagia (difficulty swallowing), odynophagia, or dysphonia (voice changes), there is an 80% likelihood of a foreign body causing at least partial obstruction. Symptoms such as drooling and difficulty managing secretions suggest near-total esophageal obstruction. Conversely, if symptoms are limited to retrosternal chest pain or pharyngeal discomfort, there is thought than only half of these patients will still have a foreign body present.

Patient-reported localization of where a foreign object is lodged is often inaccurate. Only 30% to 40% of patients can correctly identify the location of a foreign body in the esophagus, and localization is essentially 0% accurate when the object is in the stomach. Once the foreign body has passed into the stomach, small intestine, or colon, patients typically remain asymptomatic unless complications such as obstruction, perforation, or bleeding arise.

Physical examination

Alwasy evaluate for neck swelling, erythema, tenderness, or crepitus. Clinicians must also examin for peritonitis or small-bowel obstruction

Imaging

Plain chest and abdominal X-rays are recommended for patients with suspected foreign body ingestion to determine the presence, type, number, and location of the objects. Lateral films can also reveal objects that may be obscured by the spine in an AP view.  Plain films are also useful in identifying complications such as free air, aspiration, or subcutaneous emphysema. This is not necessary when it comes to simple food bolus obstruction (such as oesophageal meat) Specifically, for food impactions, false-negative rates can be as high as 87%. 

However, radiographs have limitations. They cannot detect non-radiopaque materials such as plastic, glass, or wood, and they may miss small bones or metallic objects. The false-negative rate for plain X-rays in detecting foreign bodies is as high as 47%, with false-positive rates reaching 20% (up to 80% in food impactions)

In pediatric patients, the use of plain X-rays is more controversial due to children’s difficulty in providing a reliable history and the risks associated with radiation exposure. Some experts recommend screening from mouth to anus to detect foreign bodies in children. To reduce radiation exposure, hand-held metal detectors have been used, with a sensitivity of 89% to 95% for detecting and localizing metallic foreign bodies.

Barium studies are generally not recommended for evaluating gastrointestinal foreign bodies. Aspiration of hypertonic contrast agents in patients with near-complete or complete esophageal obstruction can lead to aspiration pneumonitis. Barium can also hinder therapeutic endoscopic interventions by obstructing clear visualization. Even if a barium study appears normal, endoscopy is recommended if symptoms persist or suspicion of a foreign body remains high.

If perforation is suspected ,CT is always indicated.  CT can assess the shape, size, location, and depth of the  foreign body and the surrounding tissue can be visualized. Also CT is very useful for specific foreign bodies, or example, in fish bone impaction, Xray has a sensitivity of 30% but CT scan can reach 90-100%.