Esophageal Foreign Body

Quick Reference

Critical Alerts

• Button batteries in esophagus = EMERGENT removal: Liquefactive necrosis begins within 2 hours; potentially fatal aortoesophageal fistula by 6-12 hours [1,2]
• Sharp objects = Emergent endoscopy: 15-35% perforation risk if lodged in esophagus [3]
• Complete obstruction (unable to swallow saliva) = Urgent: Endoscopy within 6 hours due to aspiration risk [4]
• Airway compromise takes priority: Proximal impaction may require emergent intubation before endoscopy
• Most foreign bodies pass spontaneously once in stomach: 80-90% passage within 4-6 days [5]
• Food impaction at any level: Consider underlying pathology (eosinophilic esophagitis most common in young adults, malignancy in elderly) [6,7]

Timing for Endoscopy

Emergency Management Algorithm

---

Definition

Overview

Esophageal foreign body (FB) ingestion occurs when a swallowed object becomes lodged in the esophagus, typically at one of three anatomic narrowing points. The presentation ranges from asymptomatic incidental findings to life-threatening airway compromise or vascular injury. Management is highly time-sensitive, with button batteries and sharp objects representing true emergencies requiring intervention within 2-6 hours. [3,4]

Food bolus impaction is the most common presentation in adults, affecting approximately 13 per 100,000 population annually, with underlying esophageal pathology present in 75-90% of recurrent cases. [6,7] Eosinophilic esophagitis (EoE) has emerged as the leading cause in young adults, accounting for 50-80% of food impactions in this demographic. [7,9]

Classification

By Object Type

By Location of Impaction

The esophagus has three anatomic narrowing points where foreign bodies most commonly lodge:

Epidemiology

• Incidence: Approximately 100,000-120,000 emergency department visits annually in the United States for foreign body ingestion [11]
• Age distribution:
  • "Pediatric (0-17 years): 75-80% of all FB ingestions (coins, toys, batteries)"
  • "Adults (18-64 years): 15-20% (food bolus most common)"
  • "Elderly (≥65 years): 5-10% (dentures, pills, food bolus)"
• Food impaction epidemiology: 13 per 100,000 population per year; male predominance (2:1); peak age 40-50 years [6]
• Button battery ingestions: Increasing incidence (9.5-fold increase from 1990-2009); larger 20mm lithium batteries associated with more severe outcomes [1,2,12]
• Geographic variation: Higher rates in developed countries correlate with increased availability of processed foods and consumer products

Etiology and Risk Factors

Risk Factors for Food Impaction

High-Risk Populations for Non-Food Foreign Bodies

---

Pathophysiology

Mechanisms of Injury

1. Mechanical Obstruction and Pressure Necrosis

Timeline of Injury:

• 0-6 hours: Mucosal edema and hyperemia at contact points
• 6-24 hours: Mucosal ulceration and ischemia from sustained pressure
• 24-72 hours: Full-thickness pressure necrosis; perforation risk increases significantly [13]
• > 72 hours: High risk of perforation (25-50% depending on object) [3,13]

Factors Increasing Perforation Risk:

• Sharp or pointed objects (15-35% perforation rate) [3]
• Object length > 5-6 cm
• Prolonged impaction > 24 hours
• Pre-existing esophageal pathology (malignancy, stricture)
• Location at aortic arch (risk of aortoesophageal fistula)

2. Button Battery Injury: Multi-Mechanism Catastrophe

Button batteries cause tissue injury through four concurrent mechanisms [1,2,12]:

Critical Timeline for Button Battery Impaction [1,2]:

• 2 hours: Significant mucosal injury and necrosis evident
• 4-6 hours: Full-thickness esophageal injury possible
• 6-12 hours: Perforation into mediastinum or major vessels (trachea, aorta)
• > 12 hours: High risk of delayed aortoesophageal fistula (even after removal, can occur 3-21 days later)

Size Matters: 20mm lithium 3-volt "coin cell" batteries (CR2032) are most dangerous due to:

• Higher voltage (3V vs. 1.5V)
• Larger diameter → more likely to lodge in esophagus
• Greater surface area → more extensive injury [2,12]

3. Sharp Object Injury

Mechanism:

• Direct laceration or perforation of esophageal wall
• Most perforations occur at anatomic narrowings or areas of pre-existing pathology
• Perforation rate: 15-35% for sharp objects in esophagus [3]
• Timing: Can occur immediately or develop over 24-48 hours

Complications of Perforation:

1. Cervical perforation (UES region):
   • Cervical subcutaneous emphysema
   • Retropharyngeal abscess
   • Mediastinitis (if descends)
2. Thoracic perforation (mid-esophagus):
   • Mediastinitis (high mortality: 20-40% if delayed > 24h) [13]
   • Empyema
   • Aortoesophageal fistula (catastrophic hemorrhage; > 90% mortality)
3. Abdominal perforation (distal esophagus/GEJ):
   • Mediastinitis
   • Subphrenic abscess
   • Peritonitis

4. Food Bolus Impaction

Mechanism:

• Food bolus (typically meat) exceeds effective esophageal luminal diameter
• Underlying pathology reduces luminal diameter to less than 13-15mm (symptomatic threshold) [6]
• Esophageal spasm and edema compound obstruction

Complete vs. Partial Obstruction:

---

Clinical Presentation

Symptoms

Cardinal Symptoms

Red Flag Symptoms (Suggest Complications)

History Taking

Key Historical Questions

Screening Questions:

1. What was swallowed? (Food? Object? Intentional?)
2. When did it happen? (Time-sensitive for button batteries, sharp objects)
3. Can you swallow saliva? Liquids? Nothing? (Complete vs. partial obstruction)
4. Any breathing difficulty or chest pain? (Airway compromise, perforation)
5. Previous episodes? (Suggests underlying esophageal pathology—EoE, stricture)
6. Any known esophageal problems? (GERD, dysphagia, prior endoscopy/surgery)

Focused History by Scenario:

Food Bolus Impaction:

• Type of food (meat > bread > other)
• Chewing adequacy (dentures, dentition)
• Prior episodes of food "sticking" (EoE, stricture)
• GERD symptoms (stricture risk)
• Atopic history: asthma, allergies, eczema (EoE risk) [7,9]
• Progressive vs. episodic dysphagia

Button Battery / Small Object:

• Battery size if known (20mm lithium CR2032 most dangerous)
• Witnessed ingestion or suspected?
• Time since ingestion (CRITICAL for batteries)
• Child access to batteries/devices

Sharp Object:

• Type (bone, toothpick, razor, needle)
• Intentional vs. accidental
• Presence of symptoms (pain, hematemesis)

Behavioral / Psychiatric:

• Psychiatric history (self-harm, psychosis, personality disorder)
• Substance use
• Prior ingestions (high recidivism in this population)
• Incarceration status

Physical Examination

Systematic Examination

General Appearance:

• Level of distress (drooling, restlessness suggests complete obstruction)
• Respiratory distress (stridor, tachypnea, use of accessory muscles)
• Vital signs: Fever (perforation, mediastinitis), tachycardia (pain, dehydration, sepsis)

Head and Neck Examination:

Chest Examination:

Abdominal Examination:

• Usually normal unless distal esophageal perforation or intra-abdominal complication
• Peritoneal signs rare unless GEJ perforation with peritonitis

---

Red Flags and Emergent Conditions

Tier 1: Immediate Life Threats (Minutes to Hours)

Tier 2: Urgent Conditions (Hours)

Tier 3: Non-Urgent but Timely Intervention (Hours to 24 Hours)

---

Differential Diagnosis

Differentiating True Foreign Body from Mimics

Clinical Pearl: Always consider cardiac etiology in patients > 40 years presenting with chest discomfort. Obtain ECG in this population.

---

Diagnostic Approach

Initial Evaluation Algorithm

Patient presents with suspected esophageal FB
↓
STEP 1: Assess for immediate threats
- Airway compromise? → Secure airway
- Hemodynamic instability? → Resuscitate
- Complete obstruction (drooling)? → Urgent endoscopy
↓
STEP 2: History and physical examination
- Type of object, timing, symptoms
- Complete vs. partial obstruction
- Signs of perforation (crepitus, fever, severe pain)
↓
STEP 3: Imaging (based on object type and clinical scenario)
- Radiopaque object suspected → Plain films (AP/lateral chest + neck)
- Button battery → Plain films → Emergent endoscopy if in esophagus
- Perforation suspected → CT chest with IV contrast
- Food bolus, no complications → No imaging needed; proceed to endoscopy [4]
↓
STEP 4: Risk stratification and management plan
- Emergent (less than 2h): Button battery in esophagus
- Emergent (less than 6h): Sharp object, complete obstruction, multiple magnets
- Urgent (less than 24h): Partial obstruction, blunt esophageal FB
- Observation: Blunt object in stomach (less than 5cm), asymptomatic

Imaging

1. Plain Radiographs (First-Line for Radiopaque Objects)

Indications [4]:

• Suspected ingestion of radiopaque object (coins, batteries, bones, metal)
• Assessment of location and number of FBs
• Rule out complications (free air, mediastinal air)

Technique:

• AP and lateral chest X-ray (essential—lateral view distinguishes esophageal from tracheal location)
• AP and lateral neck X-ray (if proximal impaction suspected)
• Abdominal X-ray (if suspect object has passed into GI tract)

Key Findings:

Complications on X-ray:

• Pneumomediastinum: Air outlining mediastinal structures (suggests perforation)
• Subcutaneous emphysema: Air in soft tissues of neck
• Pleural effusion or pneumothorax: Suggests perforation
• Prevertebral soft tissue swelling: Suggests retropharyngeal inflammation or abscess (normal prevertebral soft tissue at C6: less than 7mm adults; > 10mm abnormal)

2. Computed Tomography (CT) Chest

Indications [4,13]:

• Suspected perforation (fever, crepitus, severe pain, shock)
• Radiolucent FB not visible on X-ray (food bolus, plastic, wood)
• Pre-operative planning for complex or sharp objects
• Delineate anatomy for surgical intervention

Protocol:

• IV contrast (unless contraindicated): Enhances mediastinal structures, helps identify inflammation/abscess
• Oral contrast: Controversial; water-soluble (Gastrografin) preferred if used, but may interfere with endoscopy visualization
• Thin slices (1-3mm) with coronal and sagittal reconstructions

Key Findings:

• Foreign body location and relationship to surrounding structures
• Esophageal wall thickening, enhancement (suggests inflammation)
• Pneumomediastinum, mediastinal air (perforation)
• Mediastinal fluid collections, abscesses
• Pleural effusion, empyema
• Vascular involvement (aortoesophageal fistula extremely rare but catastrophic)

Sensitivity for perforation: 95-100% for CT; far superior to plain films [13]

3. Contrast Esophagram (Barium or Water-Soluble Contrast Swallow)

Indications:

• Radiolucent FB when CT not available
• Assessment of esophageal anatomy after FB removal (identify underlying stricture, Schatzki ring)

Contraindications / Cautions [4]:

• Complete obstruction (aspiration risk)
• Suspected perforation: Use water-soluble contrast FIRST (Gastrografin); barium contraindicated in free perforation (mediastinitis risk)
• Interferes with endoscopy: Barium coats mucosa and obscures visualization; if endoscopy planned, defer contrast study or use water-soluble only

Technique:

• Water-soluble contrast (Gastrografin) first: Detects perforation; less harmful if aspirated
• Dilute barium if Gastrografin negative: Higher sensitivity for subtle findings

Sensitivity:

• Radiolucent FB detection: 70-80%
• Perforation detection: 50-80% (lower than CT)

Current Practice: Contrast esophagram largely replaced by CT in modern practice for suspected complications; role limited to post-procedural assessment of anatomy.

Laboratory Studies

Routine Labs for Esophageal FB

Clinical Pearl: Labs are adjunctive; diagnosis relies on history, examination, and imaging. Do not delay emergent endoscopy for laboratory results.

---

Treatment and Management

Principles of Management

1. Triage by urgency: Button battery in esophagus (less than 2h) > Sharp object/complete obstruction (less than 6h) > Partial obstruction (less than 24h) > Observation [1-4]
2. NPO (nil per os): All esophageal FBs to prevent aspiration
3. Airway takes priority: Secure airway before endoscopy if compromised
4. Endoscopy is gold standard for esophageal FBs: Success rate 95-98% [4,15]
5. Address underlying pathology: Prevent recurrence (EoE workup, stricture management) [6,7,9]
6. Surgical consultation: For perforation, failed endoscopic removal, or complex cases

Initial Stabilization

Universal Measures for All Esophageal FBs

Airway Management (If Compromised)

Indications for Immediate Airway Intervention:

• Stridor, severe respiratory distress
• Inability to maintain oxygenation (SpO2 less than 90% on supplemental O2)
• Altered mental status with inability to protect airway

Approach:

1. High-flow oxygen (non-rebreather mask or high-flow nasal cannula)
2. Position upright (optimize airway patency)
3. Prepare for intubation:
   • Consider awake fiberoptic intubation if proximal FB (avoid blind intubation—may dislodge FB into airway)
   • Have cricothyrotomy kit available
4. Coordinate with endoscopy: May remove FB during intubation or immediately after airway secured

Endoscopic Management (Definitive Treatment)

Flexible endoscopy is the gold standard for esophageal FB removal, with success rates of 95-98% and complication rates less than 5%. [4,15]

Timing of Endoscopy (Evidence-Based Guidelines) [4]

Endoscopic Technique

Pre-Procedure:

• Informed consent: Discuss risks (perforation 0.5-1%, bleeding less than 1%, aspiration)
• Anesthesia: Conscious sedation (midazolam + fentanyl) vs. general anesthesia (preferred for sharp objects, high-risk patients, uncooperative patients)
• Airway protection:
  • "Consider endotracheal intubation for: airway-compromising FBs, sharp objects, uncooperative patients, high aspiration risk"
  • "Overtube (esophageal protective tube): For sharp objects (prevents injury during extraction)"

Endoscopic Accessories and Techniques:

Post-Procedure:

• Inspect esophagus thoroughly after FB removal: Assess for perforation, ulceration, stricture, rings, or other pathology
• If perforation suspected: CT chest; surgical consult; broad-spectrum antibiotics; NPO
• If button battery impacted > 2 hours: Consider repeat endoscopy in 24-48h to assess tissue injury; warn patient about delayed aortoesophageal fistula (3-21 days post-removal) [2]

Success and Complication Rates

Endoscopic Removal Success Rate: 95-98% [4,15]

Complications [4,15]:

• Perforation: 0.5-1% (higher for sharp objects, prolonged impaction > 24h)
• Bleeding: less than 1% (usually minor mucosal trauma)
• Aspiration: 1-2% (higher with "pull" technique for food bolus)
• Failed removal requiring surgery: 2-5%

Medical Management (Food Bolus Only)

Medical therapies for food bolus impaction are controversial with limited high-quality evidence. Most guidelines recommend proceeding directly to endoscopy rather than delaying for medical trials. [4,16,17]

Glucagon

Mechanism: Relaxes lower esophageal sphincter (LES) by reducing smooth muscle tone.

Evidence:

• Meta-analysis (2024): Glucagon showed no significant benefit over placebo for esophageal FB or food impaction (OR 0.90, 95% CI 0.69-1.17, p=0.42) [17]
• Systematic review (2019): Similar findings—glucagon success rate 30.2% vs. control 33.0% (no difference) [18]
• Conclusion: Not recommended as primary therapy; may consider trial while arranging endoscopy in select cases [4,17,18]

Dosing (if used):

• 1-2 mg IV push over 1-2 minutes
• May repeat once if no response in 20 minutes

Contraindications:

• Complete obstruction (ineffective; delays definitive care)
• Pheochromocytoma
• Insulinoma
• Known hypersensitivity

Adverse Effects:

• Nausea, vomiting (60-80%—may worsen obstruction or cause aspiration)
• Hyperglycemia
• Hypotension (rare)

ESGE Guideline Recommendation: "Pharmacological treatment is not recommended because of insufficient evidence of efficacy and because of adverse events." [4]

Carbonated Beverages / Effervescent Agents

Mechanism: Gas production increases intraluminal pressure, theoretically propelling FB distally.

Evidence: Very limited; mostly case reports; no RCTs; concerns about aspiration risk and esophageal rupture (rare). [4]

ESGE Recommendation: Not recommended [4]

Papain / Meat Tenderizer

Mechanism: Enzymatic digestion of protein (meat).

Evidence: NOT RECOMMENDED—case reports of esophageal perforation, mediastinitis, and death. [4]

Current Status: Contraindicated [4]

Button Battery Management (Special Considerations)

If Button Battery Confirmed in Esophagus [1,2,12]

EMERGENT protocol:

1. Immediate actions (do NOT wait for endoscopy preparation):
   • NPO
   • IV access
   • Call endoscopy team and surgeon STAT
   • Activate emergent endoscopy (less than 2 hours from presentation)
2. Do NOT induce vomiting (may cause further injury)
3. Do NOT delay for any reason (no medical management trials)
4. Remove battery endoscopically:
   • Assess for tissue injury (may see black eschar, ulceration)
   • Document location (especially if at aortic arch level—vascular injury risk)
5. Post-removal management:
   • If impacted less than 2 hours: Observation, repeat imaging if symptoms
   • If impacted > 2 hours:
     • Consider repeat endoscopy in 24-48h to assess tissue injury
     • CT chest with IV contrast if concern for deep injury or vascular involvement
     • Admit for observation (risk of delayed perforation or aortoesophageal fistula up to 21 days post-removal) [2]
     • Warn patient/family about delayed fistula (sentinel bleed followed by massive hemorrhage days to weeks later)
   • Outpatient follow-up: GI clinic in 1-2 weeks; return immediately if hematemesis, chest pain, dysphagia, fever

If Button Battery in Stomach [1,2]

• If asymptomatic and battery less than 20mm diameter:
  • Repeat X-ray in 4-7 days to confirm passage
  • Most pass within 48-72 hours
  • Removal if no progression beyond pylorus in 48h
• If symptomatic OR ≥20mm diameter:
  • Endoscopic removal (may not pass through pylorus)
• Once in small bowel: Usually passes uneventfully; serial X-rays every 3-4 days; remove if no progression or symptoms

Sharp Object Management [3,4]

Sharp Object in Esophagus

EMERGENT endoscopic removal less than 6 hours:

• General anesthesia preferred (airway protection)
• Overtube essential (protect esophagus during extraction)
• Grasp blunt end first if possible; if not, withdraw with pointed end trailing
• Transparent distal cap or hood on endoscope (shields mucosa)
• Surgical backup available
• Post-removal: thorough inspection for perforation; low threshold for CT chest if any concern

Perforation Risk: 15-35% if sharp object in esophagus > 24h [3]

Sharp Object in Stomach or Beyond

• If in stomach and less than 6cm, asymptomatic: May observe with serial imaging (X-rays every 24h)
  • 90% pass spontaneously if reach stomach [5]
  • Endoscopic removal if no progression in 72h or if symptoms develop
• If in duodenum/small bowel: Usually passes; serial imaging; surgery if peritoneal signs or no progression
• If > 6cm or unable to pass pylorus: Endoscopic removal

Multiple Magnets or Magnet + Metal Object [8]

EMERGENT removal less than 6 hours:

• Risk: Magnets attract across bowel loops → pressure necrosis → perforation and fistula formation
• If in esophagus or stomach: Endoscopic removal
• If beyond stomach: Surgical consultation; may require laparotomy if signs of obstruction or perforation

Surgical Management

Indications for Surgery:

1. Failed endoscopic removal (2-5% of cases)
2. Esophageal perforation (especially if delayed > 24h or mediastinitis) [13]
3. Sharp object not amenable to endoscopy
4. Aortoesophageal fistula (catastrophic; usually fatal; emergent surgery if any chance of survival)
5. Large or complex denture causing obstruction/perforation
6. Retained FB with ongoing complications (abscess, fistula)

Surgical Approaches:

• Cervical esophagotomy: For proximal esophageal FBs or perforation
• Thoracotomy or thoracoscopy: For mid-esophageal FBs or perforation
• Laparotomy or laparoscopy: For distal esophageal/GEJ or gastric FBs
• Esophagectomy: Rarely required; reserved for extensive necrosis, malignancy, or irreparable perforation

Outcomes:

• Mortality for uncomplicated FB removal: less than 1%
• Mortality for esophageal perforation: 20-40% if delayed > 24h [13]
• Mortality for aortoesophageal fistula: > 90%

Post-Removal Management

Immediate Post-Procedure

All Patients:

1. Assess tolerance: NPO initially; advance diet gradually (sips of water → clear liquids → soft diet → regular diet)
2. Monitor for complications: Chest pain, fever, subcutaneous emphysema (perforation)
3. Pain management: Acetaminophen; avoid NSAIDs (bleeding risk if mucosal injury)
4. Discharge criteria (if uncomplicated):
   • Tolerating oral intake
   • No signs of perforation
   • Stable vital signs
   • Follow-up arranged

Evaluate for Underlying Pathology [6,7,9]

ALL food bolus impaction patients should be evaluated for underlying esophageal disease:

Key Point: In retrospective studies, 75-90% of adults with food bolus impaction have underlying esophageal pathology. [6,7] Failure to investigate leads to recurrence.

Eosinophilic Esophagitis (EoE) Workup [9]

Who to test:

• Young adults (especially males) with food impaction
• Recurrent food impaction
• Atopic history (asthma, allergies, eczema)

Diagnostic Criteria:

• Symptoms of esophageal dysfunction (dysphagia, food impaction)
• ≥15 eosinophils per high-power field on esophageal biopsy
• Exclusion of other causes (GERD, achalasia, infection)

Management if diagnosed:

• Proton pump inhibitor (PPI) therapy: Omeprazole 20-40mg BID
• Topical corticosteroids: Fluticasone swallowed or budesonide viscous suspension
• Dietary elimination (six-food elimination diet or elemental diet)
• Endoscopic dilation for strictures
• Refer to gastroenterology for ongoing management

---

Disposition and Follow-Up

Discharge Criteria

Safe for discharge if ALL of the following:

• Foreign body successfully removed (or confirmed passage to stomach with low-risk profile)
• Tolerating oral intake (liquids at minimum)
• No signs of perforation (no fever, severe pain, crepitus)
• Stable vital signs
• No significant comorbidities requiring admission (e.g., aspiration pneumonia)
• Reliable for follow-up
• Appropriate social situation (not intentional ingestion requiring psychiatric evaluation)

Admission Criteria

Admit if ANY of the following:

• Esophageal perforation (confirmed or suspected)
• Failed endoscopic removal (may require repeat attempt or surgery)
• Significant mucosal injury (especially button battery > 2h impaction—risk of delayed perforation/fistula)
• Unable to tolerate oral intake
• Aspiration pneumonia
• Mediastinitis, abscess, or other complication
• Intentional ingestion requiring psychiatric evaluation
• Significant comorbidities (elderly, frail, multiple medical problems)
• Button battery in esophagus for > 2 hours (even after removal—risk of delayed aortoesophageal fistula) [2]

Follow-Up Recommendations

---

Prevention and Patient Education

Patient Education After Food Bolus Impaction

Explanation of Condition:

• "You had a piece of food stuck in your esophagus (food pipe)."
• "We removed it successfully with an endoscopy (camera procedure)."
• "It's important to find out why this happened to prevent it from happening again—most people who have food stuck have an underlying condition in the esophagus."

Preventing Recurrence:

1. Chew food thoroughly: Take small bites; chew well
2. Eat slowly: Avoid rushing meals; sit down to eat
3. Cut food into small pieces: Especially meat
4. Avoid distractions while eating: No talking, watching TV, or walking while eating
5. Denture care (if applicable): Ensure proper fit; see dentist regularly
6. Avoid hard, dry, or large pieces of food until underlying condition evaluated

Follow-Up Essential:

• "You need to see a gastroenterologist (stomach specialist) to evaluate your esophagus. Many people with food impaction have conditions like eosinophilic esophagitis, strictures, or narrowing that need treatment."

Button Battery Safety (Especially for Parents/Caregivers)

Prevention:

• Store button batteries in child-proof containers, out of reach
• Secure battery compartments in devices (use tape if compartment loose)
• Dispose of used batteries immediately in secure trash
• Educate family members about danger

If Ingestion Suspected:

• Call Poison Control immediately: 1-800-222-1222
• Go to emergency department immediately—do NOT wait for symptoms
• Bring the battery package if available (identify size and type)
• Do NOT induce vomiting

Warning Signs to Return to Emergency Department

Provide written and verbal instructions to return immediately if any of the following:

• Difficulty breathing or stridor
• Fever (temperature > 100.4°F / 38°C)
• Severe chest pain or pain that worsens
• Vomiting blood (hematemesis) or black tarry stools (melena)
• Inability to swallow liquids or saliva
• Coughing up blood
• Swelling of the neck
• Any new or worsening symptoms

Special Warning for Button Battery Patients: "Even though the battery was removed, there is a very rare but serious risk of delayed bleeding from the esophagus in the next few weeks. If you have ANY blood in vomit or stools, or sudden chest pain, call 911 immediately."

---

Special Populations

Children

Epidemiology:

• 75-80% of all FB ingestions occur in children (peak age 6 months to 3 years) [11]
• Coins are most common object (60-70% of pediatric FB)
• Button batteries: Increasing incidence; 20mm lithium batteries most dangerous

Clinical Differences:

• May be asymptomatic (30-40% of pediatric FB—contrast with adults who are usually symptomatic)
• Lower threshold for imaging and intervention
• Airway smaller: Higher risk of respiratory compromise from proximal FB

Management Pearls:

• ALWAYS consider FB in child with unexplained respiratory or GI symptoms
• Button battery in esophagus: Emergent removal less than 2h (same as adults) [1,2]
• Coins in esophagus: Remove within 12-24h (many pass if observed, but removal safer)
• Coins in stomach: 90% pass; observe with serial X-rays; remove if no progression in 4 weeks
• Magnets: Remove if multiple magnets or magnet + metal object (bowel necrosis risk) [8]

Elderly

Risk Factors:

• Dentures: Impaired palatal sensation → inability to assess food texture; may swallow large pieces
• Poor dentition: Inadequate mastication
• Cognitive impairment: Dementia, stroke → swallowing dysfunction
• Medications: Pills (especially large or esophagitis-inducing medications like bisphosphonates, potassium, NSAIDs)
• Underlying esophageal pathology: Malignancy, peptic stricture (GERD common in elderly)

Clinical Pearls:

• Higher incidence of malignancy: New-onset dysphagia or food impaction in elderly → malignancy until proven otherwise
• May have atypical presentation: Less pain, delayed presentation, vague symptoms
• Higher comorbidity burden: Increased surgical and anesthesia risk
• Polypharmacy: Consider pill esophagitis in patient on multiple medications with dysphagia/odynophagia

Management:

• Lower threshold for admission (less reserve, higher complication risk)
• Thorough evaluation for malignancy (endoscopy with biopsy)
• Address denture fit, dentition, swallowing safety
• Consider speech pathology evaluation for swallowing dysfunction

Psychiatric Patients and Intentional Ingestion

Epidemiology:

• Intentional FB ingestion occurs in 10-20% of adult cases
• High recidivism: 75-90% re-ingest within 1 year without psychiatric intervention

Common Objects:

• Sharp objects (razors, needles, knives, pens)
• Multiple objects
• Bizarre objects (batteries, utensils, glass)

Underlying Psychiatric Diagnoses:

• Personality disorders (borderline, antisocial)
• Psychosis (schizophrenia)
• Substance use disorders
• Intellectual disability
• Malingering (especially in prisoners)

Management:

• Safety first: Assess suicide risk, self-harm risk
• Medical management: Same principles as accidental ingestion (but often more complex, multiple objects)
• Psychiatric evaluation MANDATORY before discharge
• Multidisciplinary approach: Medicine, surgery, psychiatry, social work
• Address underlying psychiatric disorder: Hospitalization, medication, therapy
• High index of suspicion for multiple FBs: Often ingest more than one object; full GI tract imaging

Challenges:

• Poor historian (intentional concealment)
• Uncooperative with procedures
• High recidivism despite intervention
• Ethical dilemmas (repeated ingestions, limited psychiatric resources)

Prisoners and Detainees

Motivations:

• Secondary gain: Transfer to hospital, access to pain medications
• Self-harm: Psychological distress, isolation
• Concealment: Smuggling contraband (body packing—drugs)
• Attention-seeking

Management:

• Security concerns: Coordination with correctional staff; restraints if needed
• Body packing (drug smuggling): Separate entity from FB ingestion
  • Do NOT attempt endoscopic removal (packet rupture → fatal overdose)
  • Observe for passage vs. surgical removal if obstruction/perforation
• Medical management same as other intentional ingestions
• Psychiatric and social evaluation
• Communication with correctional facility: Recidivism prevention strategies

Body Packing vs. Body Stuffing:

• Body packing: Intentional concealment of well-wrapped drug packets (smuggling); packets designed to withstand GI transit
  • "Management: Observation for passage; surgery if obstruction or signs of rupture; do NOT use laxatives (may cause rupture)"
• Body stuffing: Hastily swallowing unwrapped or poorly-wrapped drugs (evade police); high risk of packet rupture and toxicity
  • "Management: Consider activated charcoal; whole bowel irrigation (polyethylene glycol) to hasten passage; ICU monitoring; antidotes for specific drugs"

---

Complications

Early Complications (Hours to Days)

Delayed Complications (Days to Weeks)

Clinical Pearl: Always warn patients about delayed aortoesophageal fistula after button battery impaction > 2 hours. This is a rare but catastrophic complication that presents with a "sentinel bleed" (minor hematemesis) followed hours later by massive hemorrhage and death. Instruct patient: "If you vomit ANY blood in the next 3 weeks, call 911 immediately." [2]

---

Evidence-Based Guidelines Summary

ESGE (European Society of Gastrointestinal Endoscopy) 2016 Guidelines [4]

Key Recommendations (Strong Recommendations):

1. Timing of Endoscopy:

   • Emergent (less than 2-6 hours): Button battery in esophagus, sharp objects, complete obstruction
   • Urgent (less than 24 hours): Other esophageal FBs without complete obstruction
   • Observation: Blunt objects in stomach (less than 5cm)

2. Imaging:

   • Plain radiography for radiopaque objects
   • CT for suspected perforation or complications
   • Do NOT use barium swallow (aspiration risk, interferes with endoscopy)

3. Pharmacological Treatment:

   • Not recommended: Insufficient evidence for glucagon, papain, or other agents
   • May worsen condition (vomiting, aspiration)

4. Endoscopic Technique:

   • Food bolus: "Push" technique preferred (advance into stomach) vs. "pull" (higher aspiration risk)
   • Sharp objects: Use protective overtube; general anesthesia
   • Button batteries: Emergent removal; assess for tissue injury

5. Body Packers (Drug Smuggling):

   • Observe for passage
   • Do NOT attempt endoscopic removal (packet rupture → fatal)
   • Surgery if obstruction or perforation

ASGE (American Society for Gastrointestinal Endoscopy) Guidelines [15]

Similar recommendations to ESGE; emphasize:

• Emergent removal of button batteries (less than 2h)
• Urgent removal of sharp objects (less than 6h) and complete obstruction (less than 6h)
• Non-urgent removal of other esophageal FBs (less than 24h)
• Most blunt objects in stomach pass spontaneously (observation)

Button Battery Task Force Recommendations [1,2]

• Esophageal location: Emergent removal less than 2 hours
• Post-removal monitoring: If impacted > 2h, monitor for delayed perforation/fistula (up to 21 days)
• Patient education: Warn about delayed aortoesophageal fistula

---

Quality Metrics and Performance Indicators

Emergency Department Performance

Documentation Requirements

Essential Documentation:

1. History: Type of object, timing, symptoms, prior episodes, known esophageal disease
2. Physical examination: Vital signs, drooling, stridor, crepitus, abdominal exam
3. Imaging: X-ray or CT findings; location of FB
4. Endoscopy report (if performed): Type of object, location, retrieval technique, complications, post-removal findings (ulcer, stricture, rings, malignancy)
5. Complications: Perforation, bleeding, aspiration
6. Disposition: Admission vs. discharge; follow-up arranged
7. Patient education: Provided verbal and written instructions; warned about red flags

---

Key Clinical Pearls

Diagnostic Pearls

1. Button battery = EMERGENT: Tissue necrosis within 2 hours; aortoesophageal fistula possible days later [1,2]
2. Sharp objects in esophagus = EMERGENT: 15-35% perforation rate [3]
3. Drooling (cannot swallow saliva) = complete obstruction: Urgent endoscopy less than 6 hours [4]
4. Most food boluses pass if partial obstruction: But underlying pathology in 75-90% requires evaluation [6,7]
5. Recurrent food impaction in young adult = EoE until proven otherwise: Biopsy for ≥15 eos/hpf [9]
6. New-onset food impaction in elderly = malignancy until proven otherwise: Endoscopy with biopsy
7. X-ray lateral view essential: Distinguishes esophageal (coronal plane) from tracheal (sagittal plane) location
8. Cervical crepitus = perforation: CT chest; surgical consult; antibiotics
9. "Double-halo" sign on AP X-ray = button battery: Not a coin; emergent removal if in esophagus

Treatment Pearls

10. NPO for all esophageal FBs: Prevent aspiration [4]
11. Endoscopy is gold standard: 95-98% success rate [4,15]
12. Glucagon for food bolus is NOT effective: Meta-analyses show no benefit over placebo [17,18]
13. Do NOT delay endoscopy for medical management trials: Especially for high-risk objects
14. "Push" food bolus into stomach: Safer than "pull" technique (less aspiration) [4,16]
15. Use overtube for sharp objects: Protects esophagus during extraction [3,4]
16. Button battery impacted > 2h: Monitor for delayed aortoesophageal fistula for 3 weeks; warn patient [2]
17. Body packers (drug smugglers): Do NOT endoscope; observe for passage; surgery if complication [4]
18. Address underlying pathology: Prevents recurrence (EoE, stricture, GERD) [6,7,9]

Disposition Pearls

19. Most uncomplicated FBs can be discharged after removal: If tolerating PO, no perforation
20. Admit button battery patients if impacted > 2h: Risk of delayed catastrophic complications [2]
21. GI follow-up essential for all food impaction patients: Underlying pathology common [6,7]
22. Psychiatric evaluation before discharge for intentional ingestion: High recidivism without intervention
23. Warn ALL patients about red flags: Hematemesis, chest pain, fever, dysphagia → return immediately

---

Prognosis and Outcomes

Overall Outcomes

Recurrence

Food Impaction Recurrence [6,7]:

• Without treatment of underlying pathology: 25-50% recurrence
• With appropriate treatment (EoE therapy, stricture dilation, GERD management): less than 10% recurrence

Intentional Ingestion Recurrence:

• Without psychiatric intervention: 75-90% re-ingest within 1 year
• With psychiatric treatment and social support: Variable; depends on underlying disorder and compliance

---

References

1. Litovitz T, Whitaker N, Clark L, White NC, Marsolek M. Emerging battery-ingestion hazard: clinical implications. Pediatrics. 2010;125(6):1168-1177. doi:10.1542/peds.2009-3037

2. Mubarak A, Benninga MA, Broekaert I, et al. Diagnosis, Management, and Prevention of Button Battery Ingestion in Childhood: A European Society for Paediatric Gastroenterology Hepatology and Nutrition Position Paper. J Pediatr Gastroenterol Nutr. 2021;73(1):129-136. doi:10.1097/MPG.0000000000003048

3. Syamal MN. Adult Esophageal Foreign Bodies. Otolaryngol Clin North Am. 2024;57(4):609-621. doi:10.1016/j.otc.2024.01.003

4. Birk M, Bauerfeind P, Deprez PH, et al. Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016;48(5):489-496. doi:10.1055/s-0042-100456

5. Ikenberry SO, Jue TL, Anderson MA, et al. Management of ingested foreign bodies and food impactions. Gastrointest Endosc. 2011;73(6):1085-1091. doi:10.1016/j.gie.2010.11.010

6. Longstreth GF, Longstreth KJ, Yao JF. Esophageal food impaction: epidemiology and therapy. A retrospective, observational study. Gastrointest Endosc. 2001;53(2):193-198. doi:10.1016/s0016-5107(01)70384-x

7. Ko HH, Enns R. Review article: esophageal food bolus impaction—evidence-based management. Aliment Pharmacol Ther. 2019;49(3):253-262. doi:10.1111/apt.15062

8. Hussain SZ, Bousvaros A, Gilger M, et al. Management of ingested magnets in children. J Pediatr Gastroenterol Nutr. 2012;55(3):239-242. doi:10.1097/MPG.0b013e3182639592

9. Muir A, Falk GW. Eosinophilic Esophagitis: A Review. JAMA. 2021;326(13):1310-1318. doi:10.1001/jama.2021.14920

10. Webb WA. Management of foreign bodies of the upper gastrointestinal tract: update. Gastrointest Endosc. 1995;41(1):39-51. doi:10.1016/s0016-5107(95)70274-0

11. National Capital Poison Center. Button Battery Ingestion Statistics. Accessed January 9, 2026. [Epidemiological data]

12. Smetak MR, Wilcox LJ. Button-Battery Ingestion. N Engl J Med. 2024;391(12):1139. doi:10.1056/NEJMicm2310606

13. Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR, Kucharczuk JC. Evolving options in the management of esophageal perforation. Ann Thorac Surg. 2004;77(4):1475-1483. doi:10.1016/j.athoracsur.2003.08.037

14. Ngan JH, Fok PJ, Lai EC, Branicki FJ, Wong J. A prospective study on fish bone ingestion: experience of 358 patients. Ann Surg. 1990;211(4):459-462. doi:10.1097/00000658-199004000-00012

15. ASGE Standards of Practice Committee. Management of ingested foreign bodies and food impactions. Gastrointest Endosc. 2011;73(6):1085-1091. doi:10.1016/j.gie.2010.11.010

16. Vicari JJ, Johanson JF, Frakes JT. Outcomes of acute esophageal food impaction: success of the push technique. Gastrointest Endosc. 2001;53(2):178-181. doi:10.1016/s0016-5107(01)70381-4

17. Ismail A, Beran A, Saadat S, Veraza DI, Guardiola JJ. Glucagon for Esophageal Foreign Body Impaction: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Am J Ther. 2024;31(5):e605-e607. doi:10.1097/MJT.0000000000001747

18. Peksa GD, DeMott JM, Slocum GW, Burkins J, Gottlieb M. Glucagon for Relief of Acute Esophageal Foreign Bodies and Food Impactions: A Systematic Review and Meta-Analysis. Pharmacotherapy. 2019;39(4):463-472. doi:10.1002/phar.2236

19. Dellon ES, Liacouras CA, Molina-Infante J, et al. Updated International Consensus Diagnostic Criteria for Eosinophilic Esophagitis: Proceedings of the AGREE Conference. Gastroenterology. 2018;155(4):1022-1033. doi:10.1053/j.gastro.2018.07.009

20. Athanasios J, Tsarouhas K, Tsitsimpikou C, et al. Button battery ingestion in children: A review of 663 cases. Drug Chem Toxicol. 2018;41(4):465-468. doi:10.1080/01480545.2017.1393127

21. Eisen GM, Baron TH, Dominitz JA, et al. Guideline for the management of ingested foreign bodies. Gastrointest Endosc. 2002;55(7):802-806. doi:10.1016/s0016-5107(02)70407-0

22. Yasrab M, Crawford CK, Chu LC, Kawamoto S, Fishman EK. CT of the esophagus in the ER: what you need to know and what you need to remember. Emerg Radiol. 2025;32(3):447-455. doi:10.1007/s10140-025-02339-0