Adults with psychiatric illnesses are also at an increased risk of foreign body ingestion, which can occur accidentally or intentionally, and many of these patients often present multiple times with recurrent foreign body ingestions. Psychiatric patients frequently present after ingesting multiple ingested foreign bodies, as described by a case report where a 15-year-old male with mental retardation and psychiatric disorder was found to have 15 foreign bodies lodged in the stomach and lower esophagus and in numerous other reports. Psychiatric patients have also been known to swallow foreign objects as a response to stress and a result of poor impulse control directed at their caregivers. Incarcerated individuals may ingest foreign bodies as a method of obtaining secondary gain. A careful history should be taken when assessing these patients due to increased risk associated with ingesting multiple foreign bodies.

Individuals under the influence of drugs and/or alcohol often present to emergency departments after ingesting multiple foreign bodies. The types of foreign bodies ingested tend to be spontaneous, and frequently patients do not remember swallowing the object. There have been cases reported in the literature in which patients have ingested crack-cocaine pipes in an effort to evade detection by police.

Accidental ingestion by adults, the geriatric population, and patients with decreased palate sensitivity is far less prevalent than in the aforementioned groups of individuals, but it does occur nevertheless with several notable patterns. 20% of adults that ingest foreign bodies do so while eating, and most foreign bodies discovered are from food boluses due to fish bone impaction. The most common esophageal foreign body in the western world is impacted food, and meat in particular. In adults, a food bolus impaction is commonly due to an underlying structural abnormality such as eosinophilic esophagitis or a stricture. Less common etiologies include dentures, chicken bones, crab shells, wires, and bread bag clips.

 Complications of Foreign Body Impaction

The majority of foreign bodies pass through the digestive system spontaneously without causing any further harm, symptoms, or necessitating any further intervention. Occasionally, complications will arise from ingested and impacted foreign bodies. These complications are directly related to the type of foreign body and the location of impaction within the gastrointestinal tract.

A complication frequently reported associated with foreign body ingestion is intestinal perforation, which is predominantly caused by fish bones, yet <1% of foreign bodies are actually known to cause perforation. Perforations often present with erythema, crepitus, or tenderness. Fish bones are easily swallowed unnoticed and have sharp, pointed ends that predispose them to impaction at intestinal areas of acute angulation or narrowing, such as the duodenal loop, duodenojejunal junction, appendix, and ileocecal valve. Studies have shown that perforation most often occurs in the ileocecal region and colon, especially in the appendix and Meckel’s diverticulum. Perforations in gastric and duodenal regions of the gastrointestinal tract are not encountered as frequently, and their presentations are more chronic and innocuous in nature. Esophageal perforation has been reported at an incidence of 9.1% in patients with foreign body impaction of the esophagus. Other foreign bodies known to cause perforation are animal bones from cow or chicken, crab shells, and wires. Intestinal perforation further predisposes to hepatic abscess, sepsis, retroperitoneal hematoma, and hydronephrosis. One case report described a 61-year-old patient who presented with liver abscess after enterohepatic migration of an ingested fish bone.

Button batteries have been reported to cause chemical and electrical damage to mucosal tissues. Beyond physical damage from the battery, complications have arisen where the battery was found to cause an esophageal stricture with the foreign body lodged in the esophagus surrounded by a mucus membrane, and, moreover, they have even been reported to pass through the esophageal wall and remain lodged within the mucosa. Batteries can cause continuous injury for weeks in pediatric patients, predisposing them to aortoesophageal fistulas in addition to strictures.

Ingested objects that are larger in size and round in shape are able to lodge in the appendix and have an increased risk of causing appendicitis, appendiceal abscesses, and appendiceal perforation. The prevalence of acute appendicitis due to foreign body ingestion is 0.0005%. Appendicitis secondary to foreign object ingestion has been reported in cases of swallowed air gun pellets, razorblades, screws, and other metallic objects. Rounded objects may lay dormant in the appendix for a long time asymptomatically and suddenly present as right lower quadrant abdominal pain years later, requiring surgical intervention.

Diagnosis

A thorough history is imperative in the diagnosis of foreign body ingestion and impaction. If history is unable to be obtained, as is the case of young children, psychiatric patients, or adults with physical limitations, a plain film radiograph of the chest and abdomen should be obtained. An initial radiographic assessment is usually the preferred initial step in foreign body management. Radiographs can confirm the size, location, shape, and number of ingested foreign bodies. However, many foreign bodies are radiolucent and plain films appear negative. Objects that are opaque are typically made of glass, metals, animal bones (except for fish), and medications. It is important to note that aluminum, although it is a metal, is radiolucent on plain films. Objects such as most foods, fish bones, wood, and thorns are radiolucent.

If a patient is unable to provide a satisfactory history and radiography studies are negative, other modalities of diagnosis may be used. Computed tomography (CT) scanning and diagnostic endoscopy are generally the preferred modalities. CT scanning without contrast is superior to plain radiography and identifies foreign bodies in 80–100% of cases. Barium swallow studies are contraindicated in these patients due to possible mucosal perforation, and, likewise, these contrast agents may interfere with endoscopic evaluation. Therefore, a CT scan without contrast should generally be performed. The sensitivity of CT scan may be improved with 3D reconstruction. After a CT scan is performed, endoscopic intervention can be performed.

Endoscopic Management and Surgical Intervention

If a patient is unable to pass a foreign body spontaneously, endoscopic intervention is recommended within 24 hours of ingestion. The risk of complications associated with removal of foreign bodies is low and includes impaction, obstruction, and perforation.

In managing patients with ingested foreign bodies, it is essential to assess the patient’s airway. Patients that have increased secretions are at an increased risk and require urgent management. In some cases, endotracheal intubation is necessary and this is particularly beneficial in patients with proximal foreign bodies, patients who have ingested multiple objects, and patients with difficulty in removing foreign bodies. The use of an overtube should also be considered to prevent an object from accidentally being dropped into the patient’s airway. In addition, a laryngoscope should be immediately available in the event of airway obstruction.

Conclusions

Food bolus impaction above a preexisting esophageal stricture or ring is the most common cause of foreign body impaction in the western world. Most foreign bodies pass through the digestive system spontaneously without causing any further harm or necessitating any intervention. A thorough history, plain films, and 3D CT scans are useful in assessing patients with foreign body ingestion. Flexible endoscopy should be used for definitive treatment and timing of endoscopy varies depending on the type of foreign body ingested. Various tools can be used to remove foreign bodies and endoscopic treatment is safe and effective if performed by a skilled endoscopist.

Materials and methods

This retrospective study was conducted at the Tropical Medicine Department, Zagazig University Hospitals, Sharkia Governorate, Egypt over a 5-year period from September 2008 to October 2013, following its approval by the Institutional Review Board of Faculty of Medicine, Zagazig University. Our hospital is a tertiary referral center for cases of liver and gastrointestinal diseases. Our department is equipped with two endoscopy units: one for cases in the emergency unit and the other for patients in the elective unit. All cases to be scoped were reviewed by a resident after verbal and written consents had been obtained from each patient.

The study subjects included male and female patients of all ages who were admitted to our units with a suspected or confirmed ingested FB. Patients with incomplete files and those with a history of FB ingestion but with none identified at endoscopic examination were excluded from the study. All patients with a history of FB ingestion in GIT were subjected to endoscopic examination.

We reviewed all patients’ files with full notations on the following data: age, sex, type of FB, anatomical location of the FB, treatments, and outcomes (complications, success rates, and mortalities).

Statistical analysis

Collected data were analyzed using SPSS computer software, version 15 (SPSS Inc., Chicago, IL, USA) and expressed as a number and a percentage for qualitative variables and as mean ± standard deviation for quantitative variables.

Discussion

Endoscopic removal of FBs is not an infrequent indication of upper gastrointestinal endoscopy. Consequently, endoscopic societies have set guidelines for safe endoscopic removals. Experienced endoscopists and well-equipped theaters are required to perform these maneuvers.

Our endoscopy units fulfill both requirements, and this is reflected by the high rate of success in this study (95.6%), which is similar to other studies. Furthermore, we believe that cases of failure reported in this study were not related to the endoscopic maneuvers. In fact, it was impossible to remove the huge gastric bezoar via endoscopy. Furthermore, it was not wise to remove the penetrating surgical towel. Laparotomy was needed not only for the towel retrieval but also for the possible repair in situ based on the situation at hand.

FB ingestion or trapping can affect individuals of any age, but it bears particular importance in very young patients due to matters related to the complete obstruction of the aerodigestive tract, and also in the elderly and patients with mental disablities. Our results were somewhat similar to these findings. Although the most common age group was 18–60 years, the second most common age group was <10 years, and the third was >60 years.