Foreign Body Ingestion

Case Study

A rapid response event was initiated by the bedside nurse after the patient threatened to kill himself and swallowed a needle with no visualization in the oropharynx. Upon the prompt arrival of the rapid response team, it was noted that the patient was a 35-year-old male with a known history of prior severe suicidal ideation, bipolar disorder, alcohol use disorder, and recent imprisonment who was admitted earlier to the psychiatric ward because of suicidal plans and thoughts. The patient had attempted to swallow other foreign bodies in the past, and after one of the prior episodes, he had an endoscopy done for concerns of esophageal perforation.

Vital Signs

Temperature: 98.2 °F, axillary
Blood Pressure: 160/92 mmHg
Pulse: 88 beats per min (bpm) – sinus rhythm on telemetry
Respiratory Rate: 22 breaths per min
Pulse Oximetry: 94% saturation on room air

Focused Physical Examination

A quick exam showed an anxious appearing young male in mild distress. Exam of the oropharynx showed erythema and hypersalivation. He had mild tenderness along the left submandibular area. No subcutaneous crepitus was palpated. No foreign objects were visualized in the oropharynx. Pulmonary, cardiac, and abdominal exams were unremarkable.

Interventions

A cardiac monitor and pads were attached. Airway, breathing, and circulation were assessed and secured. A stat chest X-ray was obtained at the bedside, which showed a metallic object in the esophagus. Stat consult was called to ear, nose, and throat (ENT) given submandibular tenderness and hypersalivation. Mild erythema was seen in the posterior oropharynx and laryngopharynx on flexible bedside laryngoscopy. No obvious evidence of perforation was seen. Once it was ensured that there was no airway compromise, a stat consult was called to gastroenterology, and the patient was transferred to the gastrointestinal (GI) lab for emergent endoscopy.

Final Diagnosis

Foreign body ingestion.

Foreign Body Ingestion

Foreign body ingestion is more commonly seen in children than adults. In the adult population, it is more frequently seen in older patients, in individuals with underlying psychiatric diseases or alcohol intoxication, in prison inmates, and for the purpose of drug trafficking. The esophagus is the most common site of obstruction in the GI tract, and this chapter will focus on esophageal symptomatology and management. Physiologic narrowing of the esophagus occurs at three sites: at the upper esophageal sphincter, at the level of the aortic arch, and the diaphragmatic hiatus. These sites are the most common spots of foreign body lodgment.

The most common symptom of foreign body ingestion is dysphagia. It can be caused by both a retained foreign body and by the trauma left by the uncomplicated passage of the foreign body through the esophagus. Symptoms such as odynophagia, hypersalivation, blood-tinged saliva, drooling, and inability to swallow can be indicative of complications. Most ingested foreign bodies pass without the need for intervention. Endoscopic intervention is required in 10%-20% of patients, and surgical intervention is needed in less than 1% of cases. Foreign body ingestions are associated with complications such as perforation, obstruction, aorto-esophageal fistula formation, and tracheoesophageal fistula formation; the presentation of these complications is discussed in Table 55.1 .

Table 55.1

Signs and symptoms of esophageal complications from foreign body ingestion

Complication	Signs and symptoms
Obstruction	Dysphagia, odynophagia, choking, chest pain, drooling
Perforation	Fever, tachycardia, tachypnea, neck pain in case of cervical perforation, chest pain in case of thoracic perforation, blood-tinged saliva, subcutaneous emphysema
Tracheoesophageal fistula	Coughing, purulent sputum, pulmonary infiltrates because of aspiration, hypoxia