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ADVANCES IN GERD

Section Editor: Joel E. Richter, MD

C u r r e n t D e v e l o p m e n t s i n t h e M a n a g e m e n t o f A c i d - R e l a t e d G I D i s o r d e r s

Esophageal Foreign Bodies and Food ImpactionsStanley B. Benjamin, MDChief, Division of GastroenterologyProfessor, Department of MedicineGeorgetown University Medical Center

G&H What is meant by the term esophageal foreign body as opposed to the term food impaction?

SB An esophageal foreign body is any object that does not belong in the esophagus that becomes stuck there. The type of foreign body is inuenced by a number of factors such as age and culture. For example, in toddlers, foreign bodies can consist of any object that they place in their mouth. In the past, the most common foreign body in toddlers was aluminum can tops; nowadays, it is button batteries. In contrast, in college students, com-mon foreign bodies are associated with drinking games such as quarters or other games. Food impactions com-prise the largest subset of esophageal foreign bodies and are normally handled more easily than true esophageal foreign bodies, which are potentially very dangerous and may constitute medical emergencies, particularly if sharp. Thus, esophageal foreign bodies and food impac-tions comprise a very variable and wide-ranging topic.

G&H What are the main causes of food impactions?

SB Although any type of food can become stuck in the esophagus, in the adult population, structural diseases or abnormalities of the esophagus, specically eosinophilic esophagitis, are the main causes of food impactions. Eosinophilic esophagitis causes solid food to become stuck in the esophagus intermittently. A generation ago, the most common cause of food impaction was Schatzki ring, in which patients had a classic history of intermit-tent, early-meal, solid-food dysphagia that resolved after

the rst piece of food moved through the esophagus. The usual treatment for these patients was dilation. Currently, Schatzki ring is seen quite rarely by gastroenterologists due to the widespread usage of proton pump inhibitors.

Beyond eosinophilic esophagitis, there is a long list of other causes of food impactions, ranging from, in children, vascular anomalies or other congenital abnormalities that can cause the esophagus to constrict, to other causes such as overeating or eating pieces of food that are too large, subsequently becoming stuck in an otherwise normal esophagus. Once again, the specic types of food impac-tions may depend upon age and culture. For instance, in an area located next to bodies of water, food impactions may be caused mainly by sh bones.

G&H What are the usual presenting symptoms of patients with esophageal foreign bodies and food impactions?

SB The main presenting symptom of patients with esophageal foreign bodies is the sensation of not being able to swallow. Patient history is crucial; in fact, the most important step of examining a patient, by far, is obtaining as accurate of a patient history as possible. Via patient history, the gastroenterologist may be able to determine whether the obstructing object is a food impaction or a foreign body, which drastically changes the approach of the treatment protocol. The possibility of an esophageal foreign body, particularly one that is sharp or is seen in a baby or small child, constitutes a medical and surgical emergency. If there is any suspicion at all of a sharp or dangerous esophageal foreign body, imaging tools such as computed axial tomography scans or plane or lateral

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radiographs must be obtained in order to identify the object. The dierence between a coin and a battery, for example, is important and should be determined as soon as possible; each object is treated and removed dier-ently. A chest computed tomography scan should also be obtained to exclude the possibility of a sharp object, prior to using an endoscope to explore the esophagus for the foreign body. As food impactions are not normally considered medical emergencies, gastroenterologists have more time to examine these patients.

G&H Could you expand on the standard protocol for removing food impactions and foreign bodies?

SB Endoscopy has certainly become the standard treat-ment option for removing food impactions. A generation ago, patients would sit and wait for hours in the emer-gency room, but that is no longer the case. If a patient has a known food impaction and has not responded to the use of glucagons, the gastroenterologist will utilize an endoscope to locate the food impaction and make an assessment of the amount of material, making sure to simultaneously protect the airway. Then, the gastro-enterologist will attempt to either remove the impaction by nudging around it (not blindly pushing it into the stomach) or pulling it out using graspers and an overtube. There are a number of endoscopic devices that can be uti-lized. Gastroenterologists should have a variety of proper endoscopic tools, as they may not know the specic type of impaction that they are dealing with until they enter the esophagus and they must always be able to ensure airway protection. These are the most important concerns when removing food impactions.

With foreign bodies, it is ideal to know the type of obstructing object beforehand and to practice with some similar material, if possible, in preparation for performing the actual procedure. It is important to know the dierence between handling the removal of a foreign body as opposed to the removal of a food impac-tion. Proper treatment requires appropriate endoscopic equipment and potential surgical backup for thoracic or ear, nose, and throat surgery. Factors that inuence the removal of the foreign body include the type of object, the location, and the length of time it has been lodged there. Preparation for any situation is key for removal of foreign bodies, as it is not as straightforward as removal of food impactions, which luckily comprise the overwhelming majority of foreign bodies that gas-troenterologists encounter.

As for other treatment options for removing for-eign bodies and food impactions, rigid endoscopy in an operating room is a possibility, though I believe that exible endoscopy in an emergency room is empirically

more eective. However, there are certain situations in which rigid endoscopy is required at least in combination with other procedures, particularly when a foreign body is involved.

G&H Could you expand on the role of glucagons and other medical therapies in the removal of foreign bodies?

SB Currently, it is quite common to administer glucagons whenever patients present to the emergency room with food impactions or foreign bodies, due to the suggestion in radiologic literature that glucagons occasionally help the foreign body or food impaction to spontaneously pass by relaxing the esophagus. However, it is possible that this passage is not due to the medication, but to the foreign body or food impaction passing by itself by the time the patient is examined. Although it is not clear whether glu-cagons aid in passage, it is generally thought that they are not harmful to try. The potential problem with medical therapy lies with sodium bicarbonate or other substances that have the ability to expand and create pressure; these therapies are potentially hazardous to patients with foreign bodies and food impactions and ought to be avoided.

G&H How do diagnostic and treatment protocols differ for foreign body removal in children?

SB As children are not merely small adults, there are many dierences when treating them. Children cannot recount what they swallowed, rendering the gastroen-terologist dependent upon the parents. As mentioned above, it is important to be careful and thorough when obtaining patient history, so as to oer the gastroenter-ologist at least a vague idea of what to expect. There is an entire series of situations that may occur in children that do not typically occur in adults. As mentioned above, toddlers may place anything they nd in their mouth. Standard procedure mandates that whenever danger-ous objects such as button batteries are suspected, the case must be handled emergently due to the potential consequences of leaving the object in place even for a short period of time. Aluminum top cans, which used to be the most common foreign bodies found in children, were quite problematic as they are not radiopaque. Pen-nies are known to spontaneously pass in most cases.

G&H Could you discuss the follow-up care required in patients with foreign bodies and food impactions?

SB When treating patients with food impactions, fol-low-up care is clearly necessary and important, as over

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90% of cases are caused by eosinophilic esophagitis or other structural abnormalities. However, it is important to identify whether the impaction was caused by eosino-philic esophagitis in the rst place, as patients may present with impactions again in the future. It may be possible to obtain a biopsy to conrm eosinophilic esophagitis at the time of endoscopic removal of the food impaction.

G&H Could you discuss the main complications and risks associated with foreign bodies?

SB Perforation is the main risk with foreign bodies. I recently treated a patient who had a food impaction pushed into his stomach, which caused perforation and led to thoracic surgery that ended up leaking and creating a host of problems. This case was quite unfortunate and complicated; the patient, an otherwise healthy adult, had to be fed by a jejunostomy tube for 6 months. Perfora-tion of the esophagus can certainly be life-threatening, which is one of the reasons that eosinophilic esophagitis can be a serious condition. It is important to recognize eosinophilic esophagitis and treat the patient accordingly, avoiding situations such as the use of standard-sized dilators that can create complications in these patients. Another concern in the setting of sharp foreign bodies is potentially penetrating the surrounding area, including the aorta. Thus, it is vital to work with extreme care with dealing with foreign bodies in the esophagus.

It should also be noted that as the cause of food impaction has shifted over time, so has the set of risks associated with it; eosinophilic esophagitis has a dierent set of risks associated with its management compared to Schatzki ring, which gastroenterologists from a generation ago dealt with in regard to food impaction, as mentioned above. Nevertheless, the general gastroenterology com-munity has been quite savvy when managing these issues and has emphasized appropriate care of these patients.

Suggested Reading

Straumann A, Bussmann C, Zuber M, Vannini S, Simon HU, Schoepfer A. Eosin-ophilic esophagitis: analysis of food impaction and perforation in 251 adolescent and adult patients. Clin Gastroenterol Hepatol. 2008;6:598-600.

Smith MT, Wong RK. Foreign bodies. Gastrointest Endosc Clin N Am. 2007; 17:361-382, vii.

Byrne KR, Panagiotakis PH, Hilden K, Thomas KL, Peterson KA, Fang JC. Retro-spective analysis of esophageal food impaction: dierences in etiology by age and gender. Dig Dis Sci. 2007;52:717-721.

Katsinelos P, Kountouras J, Paroutoglou G, Zavos C, Mimidis K, Chatzimavroudis G. Endoscopic techniques and management of foreign body ingestion and food bolus impaction in the upper gastrointestinal tract: a retrospective analysis of 139 cases. J Clin Gastroenterol. 2006;40:784-789.

Kay M, Wyllie R. Pediatric foreign bodies and their management. Curr Gastroen-terol Rep. 2005;7:212-218.

Al-Haddad M, Ward EM, Scolapio JS, Ferguson DD, Raimondo M. Glucagon for the relief of esophageal food impaction: does it really work? Dig Dis Sci. 2006;51:1930-1933.