Unusual Foreign Bodies in Gastrointestinal Tract – A Case Series

Introduction

Foreign body ingestion is one of the commonly encountered emergencies in emergency medical room.¹ Coins, toys or batteries are the commonest foreign bodies encountered in children,^2,3whereas food bolus impacted in the esophagus with underlying stricture/webs is the commonest in adults. Drug abusers, alcoholics or patients with psychiatric illness are commonly affected in adult population.⁴

Commonest symptoms with which patients present are dysphagia, odynophagia, chest pain, nausea & vomiting or abdominal pain.^5,6 Diagnosis is mainly derived by eliciting a proper history. In case if history cannot be properly elicited (like in pediatric population or patients with psychiatric illnesses), radiographic evaluation is the preferred initial assessment technique. In case plain radiography is negative (radiolucent foreign bodies), computed tomography or diagnostic endoscopy are preferred modalities.

Majority of the foreign bodies spontaneously pass through the digestive tract. Endoscopic intervention is recommended within 24 hours if the foreign body/food bolus of esophagus is not expelled spontaneously.¹⁹ Very rarely surgical intervention is required for foreign bodies with complications.

Case Report

Case 1:

A moderately built male patient, aged about 45years, presented to the emergency department with history of difficulty in swallowing since one day. Dysphagia was more for solids than liquids. On further enquiry, he gave history of binging on alcohol and consumption of meat the night before. Diagnostic upper GI endoscopy was performed which revealed an impacted bone piece in the mid esophagus about 30cm from upper incisors (Figure 1). The impacted bone piece was removed with the help of rat tooth forceps in the same sitting. Patient was admitted, kept nil by mouth and supportive management was done. A check endoscopy done 24hrs later was normal and did not reveal any mucosal edema/erosions/ necrosis. Patient was discharged with symptomatic treatment.

Case 2:

An elderly lady, aged about 82years, presented to the ENT department with history of drooling of saliva since morning. There was no other significant history. She had consumed food in the morning following which she had drooling of saliva. There was no history of odynophagia. Preliminary examination of oral cavity, nasal cavity was normal. An indirect laryngoscopy was also normal except for a pool of saliva in pyriform fossa. X-ray neck was done which was also normal. She was subjected to a diagnostic upper GI endoscopy which revealed an impacted green pea seed at the cricopharynx with cricopharyngeal spasm (Figure 2). Impacted pea seed was removed endoscopically and scope was passed into esophagus with ease. Patient became symptomatically better soon after the intervention.

Case 3:

A 74-year-old male patient presented to the surgical OPD with history of pain in abdomen for one week. Pain was severe, continuous, more around the umbilicus and right upper abdomen. He also gave history of fever for two days, high grade associated with chills and rigors. He was a known case of ischemic heart disease and had undergone coronary angioplasty. Preliminary investigations revealed raised WBC count. Ultrasound of abdomen showed grossly distended gall bladder with multiple calculi suggestive of calculus cholecystitis. Patient was on antiplatelets, hence was managed conservatively for three days. He was taken up for diagnostic laparoscopy after three days. It revealed a surprising finding. There was a small perforation inthe mid jejunum due to a broken toothpick, which had formed a contained inter bowel loop abscess (Figure 3). The inter bowel loop adhesions were released, abscess drained and the tooth pick was extracted (Figure 4). Perforation closure was done. Gall bladder was normal in appearance. After further probing in detail in the postoperative period, patient revealed history of habit of keeping a toothpick in his mouth after meals which he might have accidentally swallowed. Patient was put on antibiotics and he improved well and was discharged after three days.

Discussion

The above mentioned three cases reveal three unusual circumstances of foreign body ingestion in adult population. The first case was a typical case following a binge of alcohol; however, the size of the bone piece swallowed was surprising. Second case was unusual as it was due to a small pea which caused near total obstruction of cricopharynx. Third case was surprising for the treating doctor as well as the patient’s attendants as both didn’t expect to encounter a foreign body intraoperatively. Foreign body ingestions are one of the most common presenting symptoms in the emergency room.

Foreign body ingestion is encountered more in males as compared to females with an approximate ratio of 1.5:1 male to female ratio.7,8 The most common sites of lodgment of foreign body in descending order includes upper esophagus, mid esophagus, stomach, pharynx, lower esophagus, duodenum and terminal ileum.^8,9

Children make up to 80% of patients who ingest foreign bodies. Adults without mental illness/ drug abuse presenting with foreign body ingestion are very less. Most of the instances in which adults ingest foreign bodies are due tofood boluses with fish bone impaction.^7,8

Nearly 80% of all foreign bodies pass without any intervention¹⁰ and only 1% cases require surgical intervention.¹¹ Commonest complications due to foreign bodies depend on the type of foreign body ingested. Button battery may cause chemical burns, stricture formation, where as sharp foreign bodies like fish bone can cause perforation, peritonitis, abscess formation.^12,13,14,15

A detailed history clinches the diagnosis in most of the cases of foreign body ingestion. If history cannot be elicited, as in case of pediatric population or patients with psychiatric illnesses, a plain X-ray of chest and abdomen must be obtained^7,8,11 which can confirm the position, size and number of foreign bodies. However, plain radiographs may fail to detect radiolucent foreign bodies, in which case computed tomography or diagnostic endoscopy can be performed.

Majority of patients with ingested foreign bodies will not have complications. Acute abdomen due to intestinal perforation is seen in nearly 1% of patients,²⁰ which needs intervention. Other complications include impaction of the foreign body in the esophagus leading to pressure necrosis and perforation, corrosive injuries due to ingested button batteries.

Management depends on the position, size and number of foreign bodies as well as the presenting symptoms. If the foreign body has crossed stomach, majority will pass out of the body within next 4 to 6 days.¹¹

Endoscopic intervention is required if the patient is presenting with any symptoms of obstruction of upper GI tract. Assessment of patient’s airway is very much essential before endoscopic intervention. Endotracheal intubation must be considered almost always in pediatric population and in patients with proximal GI tract foreign bodies and multiple foreign bodies. An overtube may be used to prevent slipping of foreign body into airway and also to ease the process of removing multiple foreign bodies.¹¹ A flexible endoscope is used routinely to remove the foreign bodies with use of additional tools like polypectomy snares, grasping forceps, magnetic probes orsnare nets.^16,17 It is recommended to remove the sharp foreign bodies like needles/ pins before they pass into the stomach as there is very high risk of perforation.^11,18 Only 1% of patients require urgent surgical exploration in case of any complications like perforation, abscess formation or peritonitis.

Foreign body ingestion is one of the most common emergency problems. Thorough history, plain radiographs and CT scans are required to establish the diagnosis. Majority of foreign bodies pass out of the digestive system without any complication. Flexible endoscopy should be used both as diagnostic and as therapeutic intervention modality. Very rarely surgical management is required for foreign bodies with complications.

Conflict of Interest

None