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Video Endoscopic Sequence 1 of 9.
Endoscopy of Dental Prothesis Found in the Jejuno
This 63 year-old woman, inadvertently ingested her dental
bridge at midnight, 12 hours later ask for medical
assistance, a plain abdominal Rx suggest that this foreign
body is located immediately after the Treitz angle.
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All endoscopic images of this atlas contain a video clip.
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Video Endoscopic Sequence 2 of 9.
Patient underwent endoscopic procedure
An enteroscope was used to manipulate this prothesis
using a diathermy loop.
Guideline for the management of ingested foreign bodies
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Video Endoscopic Sequence 3 of 9.
Foreign bodies in the upper GI tract are usually swallowed, purposefully or accidentally.
Undigestible objects may be intentionally swallowed by
children and demented adults. Denture wearers, the
elderly, and inebriated people are prone to accidentally
swallowing inadequately masticated food
(particularly meat ), which may become impacted in the
esophagus. Smugglers who swallow drug-filled balloons,
vials, or packages to escape detection (body packers or
body stuffers) may develop intestinal obstruction. The
packaging may rupture, leading to drug overdose.
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Video Endoscopic Sequence 4 of 9.
A variety of foreign bodies may enter the GI tract. Many
pass spontaneously, but some become impacted, causing
symptoms of obstruction. Perforation may occur. The
esophagus is the most common (75%) site of impaction.
Nearly all impacted objects can be removed endoscopically,
but surgery is occasionally necessary.
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Video Endoscopic Sequence 5 of 9.
The video clips shows the extraction from jejuno to the
mouth, here the image shows that foreign body is at the
esophagus.
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Video Endoscopic Sequence 6 of 9.
The prothesis was a successful management endoscopically
Observe at the right of the dental bridge has a sharp edge.
The typical cause of swallowed GI foreign bodies is accidental.
To be considered: Intestinal perforation by a foreign body is uncommon, and normally affects the ileocecal and rectosigmoid regions, in which it is unusual to find pneumoperitoneum preoperatively. It must be considered in the differential diagnosis of such conditions as acute appendicitis and diverticulitis.
To enlarge the image click here
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Video Endoscopic Sequence 7 of 9.
The most common cause of GI foreign bodies in adults
involves food that does not pass through the esophagus
because of underlying mechanical problems. In adults,
accidental swallowing involves toothpicks, dentures, and
other objects. Psychiatric patients may swallow a wide
variety of objects, including multiple objects, large objects,
and bizarre items. Prisoners may swallow objects either to
hide them from authorities or to seek medical care. In the
case of razor blades, they often tape the sharp edge to
avoid injury. People who smuggle drugs may swallow
multiple condoms (usually double wrapped) filled with
cocaine or heroin. This is called "body packing," as
opposed to "stuffing," which occurs when the patient
attempts to elude arrest by swallowing packets of drugs in
their possession.
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Video Endoscopic Sequence 8 of 9.
Abdominal Rx suggest that this foreign body is located immediately after the Treitz angle.
Sharp objects should be retrieved from the stomach because 15 to 35% will cause intestinal perforation, but small round objects (eg, coins and button batteries) can simply be observed. The patient's stools should be searched, and if the object does not appear, x-rays are taken at 48-h intervals. A coin that remains in the stomach for > 4 wk or a battery showing signs of corrosion on x-ray that remains in the stomach for > 48 h should be removed. A hand-held metal detector can localize metallic foreign bodies and provide information comparable to that yielded by plain
x-rays.
To enlarge the image click here
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Video Endoscopic Sequence 9 of 9.
A close up of this ingested dental prothesis
Most foreign objects that have passed into the small
intestine usually traverse the GI tract without problem,
even if they take weeks or months to do so. They tend to
be held up just before the ileocecal valve or at any site of
narrowing, as is present in Crohn's disease. Sometimes
objects such as toothpicks remain within the GI tract for
many years, only to turn up in a granuloma or abscess.
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Video Endoscopic Sequence 1 of 7.
Foreign Body Ingestion.
Coins are probably the most commonly ingested foreign
bodies in children. This 20 month-old girld had a penny,
stuck in her esophageal inlet.
A coin in the esophagus appears as a round metallic object
on an AP projection.
As children explore the world, they will inevitably put
foreign bodies into their mouths and swallow some of them.
Most swallowed foreign bodies pass harmlessly through the
gastrointestinal (GI) tract. Foreign bodies that damage the
GI tract, become lodged, or have associated toxicity must
be identified and removed. Children with preexisting GI
abnormalities (eg, tracheoesophageal fistula, stenosing
lesions, previous GI surgery) are at an increased risk for
complications.
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Video Endoscopic Sequence 2 of 7.
The coin has been lodged immediately below the upper esophageal sphincter.
Most complications of pediatric foreign body ingestion are
due to esophageal impaction, usually at 1 of 3 typical
locations. The most common site of esophageal impaction
is at the thoracic inlet. Defined as the area between the
clavicles on chest radiograph, this is the site of anatomical
change from the skeletal muscle to the smooth muscle of
the esophagus. The cricopharyngeus sling at C6 is also at
this level and may "catch" a foreign body. About 70% of
blunt foreign bodies that lodge in the esophagus do so at
this location. Another 15% become lodged at the mid
esophagus, in the region where the aortic arch and carina
overlap the esophagus on chest radiograph. The remaining
15% become lodged at the lower esophageal sphincter
(LES) at the gastroesophageal junction.
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Video Endoscopic Sequence 3 of 7.
Because many patients who have swallowed foreign bodies
are asymptomatic, physicians must maintain a high index
of suspicion. The majority of ingested foreign bodies pass
spontaneously, but serious complications, such as bowel
perforation and obstruction, can occur. Foreign bodies
lodged in the esophagus should be removed endoscopically,
but some small, blunt objects may be pulled out using a
Foley catheter or pushed into the stomach using
bougienage. Once they are past the esophagus, large or
sharp foreign bodies should be removed if reachable by
endoscope.
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Video Endoscopic Sequence 4 of 7.
Foreign body ingestion endoscopic removal.
Foreign body ingestion often requires endoscopic removal,
but the majority of the foreign body may pass through the
whole gut without creating any problem to the patient.
However, any foreign body which is large and impacted,
any sharp foreign body should be removed immediately.
Foreign bodies less than 2.5cm in diameter usually pass
through gastrointestinal tract without difficulty. The
common sites of impaction of foreign body in esophagus
are postcricoid region, level of aortic arch, left main
bronchus and the diaphragm. But there is one more site of
impaction especially in cases of flat objects like coin which
is at level of T1 i.e., thoracic inlet. Rarely foreign body not
large in size may be impacted in esophagus in cases of
strictures, or smooth muscle spasm.
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Video Endoscopic Sequence 5 of 7.
Sharp foreign body can get impacted from base of tongue
to lower end of esophagus. If they are not removed at the
earliest can cause erosion, perforation, abscess or
mediastinitis. Objects that have passed the esophagus
generally do not cause symptoms unless complications,
such as bowel perforation or obstruction, occur. Patients
with objects lodged in the esophagus may be asymptomatic
or may present with symptoms varying from vomiting or
refractory wheezing to generalized irritability and
behavioral disturbances
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Video Endoscopic Sequence 6 of 7.
Foreign body ingestion is a potentially serious problem that
peaks in children aged six months to three years. It causes
serious morbidity in less than one percent of all patients.
An estimated 40 percent of foreign body ingestions in
children are not witnessed, and in many cases, the child
never develops symptoms.
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Video Endoscopic Sequence 7 of 7.
A penny has been removed endoscopically.
Gastrointestinal tract ingested foreign bodies are common
problems, particularly in children. The most common
ingested foreign bodies are coins.
Longstanding esophageal foreign bodies may cause failure
to thrive or recurrent aspiration pneumonia. Esophageal
perforation may result in neck swelling, crepitations, and
pneumomediastinum. If perforation occurs in the stomach
or intestines, fever and abdominal pain and tenderness may
develop. Bowel obstruction by a foreign body may cause
abdominal distension, pain, and tenderness. Common sites
for obstruction by an ingested foreign body include the
cricopharyngeal area, middle one third of the esophagus,
lower esophageal sphincter, pylorus, and ileocecal valve.
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Video Endoscopic Sequence 1 of 3.
Foreign body of the stomach that resemble a snake.
from time to time the endoscopist get some surprise
performing a gastrointestinal endoscopy.
30 year-old woman that had been complaining of severe
halitosis that is worse in the morning.
The endoscopy was performed in 1990 with the old
fiber optics endoscopes (Olympus pre-oes 1T).
Therefore the video clips are dark.
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Video Endoscopic Sequence 2 of 3.
We observed the shape that resemble a snake’s head.
Most swallowed foreign bodies pass harmlessly through
the gastrointestinal (GI) tract. Foreign bodies that damage
the GI tract, become lodged, or have associated toxicity
must be identified and removed.
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Video Endoscopic Sequence 3 of 3.
A tooth brush that was found in her stomach.
Impacted foreign bodies.
A foreign body lodged in the GI tract may cause local
inflammation leading to pain, bleeding, scarring, and
obstruction, or it may erode through the GI tract.
Migration from the esophagus most often leads to
mediastinitis but may involve the lower respiratory tract or
aorta and create an aortoenteric fistula. Migration through
the lower GI tract may cause peritonitis.
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Photography Sequence 1 of 12
Multiple Foreign bodies in the GI tract
Psychiatric patients may swallow a wide variety of objects, including multiple objects, large objects, and bizarre items.
The treatment of patients with suspected radiopaque
foreign bodies is usually straightforward because these can
be easily localized on plain radiographs.
For nonradiopaque foreign objects, plain radiographs are
not helpful. Studies such as barium swallows or CT
scanning may help to confirm or localize a foreign body,
but often they only delay definitive care.
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Photography Sequence 2 of 12
Pathophysiology
Foreign bodies may involve the entire upper GI tract. The
oropharynx is well innervated, and patients can typically
localize oropharyngeal foreign bodies. Scratches or
abrasions to the mucosal surface of the oropharynx can
create a foreign body sensation. Chronic foreign bodies or
perforations can cause infections in surrounding soft
tissues of the throat and neck.
Click on the image to enlarge in a new windows
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Photography Sequence 3 of 12.
The esophagus is a tubular structure approximately 20-25
cm in length. Patients can usually localize foreign bodies in
the upper esophagus but localize them poorly in the lower
two thirds of the structure. The esophagus has 3 areas of
narrowing where foreign bodies are most likely to become
entrapped: the upper esophageal sphincter (UES), which
consists of the cricopharyngeus muscle; the crossover of
the aorta; and the lower esophageal sphincter (LES).
Structural abnormalities of the esophagus, including
strictures, webs, diverticula, and malignancies, increase
the risk of foreign body entrapment, as do motor
disturbances such as scleroderma, diffuse esophageal
spasm, or achalasia.
Click on the image to enlarge in a new windows
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Photography Sequence 4 of 12.
After reaching the stomach, a foreign body has greater
than a 90% chance of passage. Coins reaching the
stomach are very likely to pass into the small bowel.
Objects larger than 2 cm in diameter are less likely to pass
the pylorus, and objects longer than 6 cm may become
entrapped at either the pylorus or the duodenal sweep.
Objects reaching the small bowel occasionally are impeded
by the ileocecal valve. Rarely, a foreign body may become
entrapped in a Meckel diverticulum.
Click on the image to enlarge in a new windows
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Photography Sequence 5 of 12.
Multiple objects are seen as key, nails, screws, plastic syringes, plastic spoon, coins etc.
Dollar coins are currency as this is the currency used in
the Republic of El Salvador
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Photography Sequence 6 of 12.
Multiple Foreign bodies in the GI tract
At the left of the image are plastic syringes that were
swallowed during hospitalization in a psychiatric hospital.
The image below is a pvc pipe fitting, also are observed
coins, nails screws and paper clips
Click on the image to enlarge in a new windows
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Photography Sequence 7 of 12.
Gastrointestinal (GI) foreign bodies present a diverse set
of challenges to the emergency physician. Presentations
range from the obvious to the occult, from the mundane to
the bizarre, and from the benign to the life-threatening.
Management options are accordingly diverse as well,
ranging from watchful waiting to emergent endoscopy or
surgery.
Physicians must be familiar with the signs and symptoms of
ingested foreign bodies, especially in small children or
psychiatric patients who have no obvious history of
ingestion. They must have a good understanding of various
removal techniques for foreign bodies in the esophagus or
rectum. They must also know which situations require
emergent intervention and whom to consult when
intervention is necessary.
Click on the image to enlarge in a new windows
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Photography Sequence 8 of 12.
Children account for about 80% of cases of ingested
foreign bodies and tend to ingest coins, toys, and other
small objects left within their reach. Adult patients at
highest risk include psychiatric patients, prisoners, those
with impaired mental status or intoxication, those with
underlying esophageal abnormalities such as strictures,
and denture wearers, who have reduced sensation of the
palate. Adults most commonly have trouble with boluses of
meat and animal bones, although psychiatric patients and
prisoners may intentionally ingest unusual objects such as
razor blades or open safety pins.
Click on the image to enlarge in a new windows
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Photography Sequence 9 of 12.
Ingested foreign bodies frequently become lodged in the
esophagus, often requiring urgent removal. Much more
rarely, objects fail to pass the pylorus or the ileocecal
valve. More than 80% of ingested foreign bodies that pass
into the stomach will traverse the rest of the gut
uneventfully. Objects that are less likely to pass
spontaneously are those longer than 6 cm, sharp objects
such as pins and toothpicks, and blunt objects greater than
2.5 cm wide, though many of these will still pass without
sequelae.
Of primary concern are objects lodged in the esophagus,
since these are at highest risk for complications such as
mucosal erosions, perforation, or airway compromise.
Objects typically lodge at the level of the cricopharyngeus
muscle, the level of the aortic arch, or the lower
esophageal sphincter. High esophageal impactions are
most common in children; adults most often have
obstructions at the lower esophageal sphincter . Food
boluses, particularly meat, are the most common cause of
esophageal impaction in adults, and often result from
underlying esophageal pathology. Foreign bodies with
toxic contents, such as button batteries and packages of
cocaine, represent special cases. A button battery lodged
in the esophagus is a true emergency requiring immediate
endoscopic removal.
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Photography Sequence 10 of 12.
Rectal foreign bodies are usually the result of sexual
misadventure or assault, although occasionally a patient
will present with an ingested foreign body, such as an
animal bone, that passes through the entire gut only to
become lodged in the rectum). Men are at least 28 times
more likely than women to present with rectal foreign
bodies. Objects inserted into the rectum include vibrators,
vegetables, broomsticks, drugs or other contraband, and
even live animals such as gerbils. Many objects are not
visible on X-rays, although most are low-lying and palpable
on rectal examination. Mucosal lacerations and rectal
perforations are fairly common, especially in assault
victims, and may result in life-threatening sepsis.
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Photography Sequence 11 of 12.
Healthy adults with ingested foreign bodies often give a
clear history of the inciting incident and may report a
foreign body sensation if the object is lodged in the upper
esophagus where somatic nerve endings are present. If a
meat bolus or other object is impacted in the lower
esophagus, they usually complain of more visceral-type
chest pain, odynophagia, and difficulty handling
secretions.
Objects that have passed into the stomach or beyond
frequently cause no symptoms, unless obstruction or
perforation has ensued.
Small children and adults with impaired mentation may not
give a clear history of foreign body ingestion. Clinicians
may have to rely on symptoms of obstruction, such as
drooling if the object is in the esophagus, or vomiting and
distention if it is impacted below the stomach. Patients may
also present with GI bleeding or signs and symptoms of
peritonitis owing to perforation. Small children often
display indirect symptoms such as gagging and choking,
refusal to eat, irritability, or respiratory distress if the
object is compressing the trachea or causing aspiration of
saliva. The possibility of foreign body ingestion should
always be considered in small children with new-onset
wheezing, especially if it does not respond to
bronchodilators.
Patients with rectal foreign bodies usually state clearly
that something is in the rectum, although they may be very
vague as to how it got there. These patients or their
partners have often made multiple attempts to remove the
object. Occasional patients may be unaware of the object if
intoxicated at the time of insertion, or may be too
embarrassed to admit to it, complaining instead of rectal
pain or bleeding. Patients with extraperitoneal rectal
perforation may present with sepsis, whereas those with
intraperitoneal perforation present with peritonitis.
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Photography Sequence 12 of 12
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