Conservative management:

This is based on the knowledge than 80-90% of the foreign bodies will pass spontaneously through the digestive system.  The categories include:

• Non complicated asymptomatic foreign bodies which are  blunt and small objects (except batteries and magnets) Objects pass usually within 4 – 6 days, or in rare cases in up to 4 weeks. Generally, objects greater than 2 – 2.5 cm in diameter will not pass through the pylorus or ileocecal valve and objects longer than 5 – 6 cm will not pass through the duodenal sweep, therefore this need to be removed.   Monitor as an outpatient can suffice , sometimes with weekly xray if approppriate. Patient should be aware of consulting medical help if any signs of perforation.  If foreign body persist in stomach after 3 -4 weeks then can be removed by upper endoscopy.
•  Drug packing: 95-98% of the body packing patients will suffice with conservative management with spontaneous passage. Even more, if we try to remove endoscopically there is high risk of ruptuting the package and cause leakage of the drug and fatal intoxication.

Medical management

The use of glucagon iv 1mg remains debatable. Despite being reported to induce relaxation of the distal esophagus, thereby allowing spontaneous bolus passage, there is a small randomized study showing no significant improvement over placebo. In general, whilst it usually no harm to attempt, it should not delay endoscopy.

Endoscopy

The timing depends on the location and the morphology of the object.

• Emergent (2-6h) :  for foreign bodies inducing complete esophageal obstruction, and for sharp-pointed objects and batteries in the esophagus. This is based on the higher risk of aspiration if complete obstruction, chemical injury in batteries and perforation (35%) in sharp objects.
• Urgent (within 24 hours)  for other esophageal foreign bodies without complete obstruction
• Urgent (within 24 hours)  for foreign bodies in the stomach such as sharp-pointed objects, magnets, batteries, and large/long objects >5-6cm. Note that ASGE recommends observation up to 48h in  Disk batteries and cylindrical batteries in the stomach without signs of GI injury.
• Nonurgent (within 72 hours) therapeutic esophagogastroduodenoscopy for medium-sized blunt foreign bodies in the stomach (2-5cm)

Technique:

Airway should be protected always.  If patient is cooperative and deemed low risk of aspiration, then concious sedation may be used, but if any doubt, anaesthetist support and orotracheal intubation should be considered.

The primary approach for treating food bolus impaction is the “push technique,” which  success of 90% with minimal complications. Before attempting to push the food bolus into the stomach, an effort should be made to bypass the bolus with the endoscope to evaluate any obstructive esophageal pathology beyond the impaction. Even if this bypass is unsuccessful, most food boluses can be safely advanced into the stomach using air insufflation and gentle pushing pressure. Positioning the endoscope on the right side of the bolus may facilitate easier and safer passage into the stomach, as the gastroesophageal junction angles to the left. However, if significant resistance is encountered, pushing should be stopped immediately, as it often indicates the presence of underlying esophageal pathology. Be mindful not to apply force in such cases increases the risk of esophageal perforation. Food boluses that cannot be safely pushed, particularly those containing bones or sharp edges, should be removed either in one piece (en bloc) or in fragments.

For larger boluses, endoscopic accessories can be used to break the impaction into smaller pieces, allowing for safer advancement into the stomach.

This can be done using various tools, including grasping forceps, polypectomy snares, retrieval nets, or a Dormia basket

Retrieval forceps come in various jaw configurations, including rat-tooth, alligator-tooth, and shark-tooth designs. While graspers with two to five prongs are effective for retrieving soft objects, they may not provide a secure enough grip for harder or heavier objects. Polypectomy snares are widely available, cost-effective, and useful in many cases. Endoscopic baskets are helpful for removing round objects, while retrieval nets or bags offer a more secure grip for certain foreign bodies, such as coins, batteries, magnets, and for en bloc removal of food boluses. When removing sharp objects, it is important to grasp the foreign body in such a way that the sharp or pointed end trails behind the endoscope. This reduces the risk of mucosal damage or perforation during extraction. For long objects, the object should be gripped at its distal end to allow for smooth retrograde removal through the esophagus. Grasping it near the middle can cause the object to rotate, positioning it radially across the lumen, which would prevent it from passing through the sphincters and esophagus.

The use of a protecting device such as an overtube or bell is recommended when dealing with sharp, pointing or cutting objects (pins, needles, razors…) An overtube is a  sleeve-like device with is placed in the oesophagus till past the cardia and  then endoscope is introduced inside this tube, to  protect the digestive mucosa from injury and limit the risk of aspiration  ). the transparent cap or latex rubber hood is an attachable device that grasp to the tip of the endoscope that unrolls when scope is withdrawn at the cardia and protects the mucosa when removing sharp objetcs.

Endoscopic removal success rates are usually greater than 95 % and complication rates of 0 % – 5 % (mainly perforation or abcesses) If unable to extract, a case based approach should be taken (discuss with surgeons and other colleagues) .

In esophageal food bolus, always consider underlying pathology (75% of cases, being peptic stricture 50 % and eosinophilic esophagitis  about 40 %- this one can be manifested as linear furrows or rings, hoever in 10% of the cases mucosa might apppear normal and biopsies are recommended in the same setting). It is normal to see some underlying trauma and erythema from the object, (for this PPI might be prescribed) it is important to assess well the  mucosa to rule out deep injury , fistula or perforation.

Bibliography

Sleisenger and fordtran’s gastrointestinal and liver disease 12th edition

Birk M, Bauerfeind P, Deprez PH, Häfner M, Hartmann D, Hassan C, Hucl T, Lesur G, Aabakken L, Meining A. Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016 May;48(5):489-96. doi: 10.1055/s-0042-100456. Epub 2016 Feb 10. PMID: 26862844.

Steven O. Ikenberry, Terry L. Jue, Michelle A. Anderson, Vasundhara Appalaneni, Subhas Banerjee, Tamir Ben-Menachem, G. Anton Decker, Robert D. Fanelli, Laurel R. Fisher, Norio Fukami, M. Edwyn Harrison, Rajeev Jain, Khalid M. Khan, Mary Lee Krinsky, John T. Maple, Ravi Sharaf, Laura Strohmeyer, Jason A. Dominitz,0  Management of ingested foreign bodies and food impactions, Gastrointestinal Endoscopy, Volume 73, Issue 6,  2011,0  https://doi.org/10.1016/j.gie.2010.11.010.