Oesophageal Foreign Body

An oesophageal foreign body is an ingested object or food bolus retained within the oesophageal lumen.

Most true foreign bodies occur at physiological narrowings, particularly the upper oesophageal sphincter, aortic arch level and gastroesophageal junction.

Food bolus impaction in adults frequently indicates underlying pathology such as peptic stricture, Schatzki ring, eosinophilic oesophagitis, achalasia or malignancy.

Urgency depends on airway risk, complete obstruction, object type and risk of perforation.

Patients commonly report sudden dysphagia, odynophagia, retrosternal discomfort or inability to swallow.

Inability to swallow saliva with drooling indicates complete oesophageal obstruction and requires emergency endoscopic treatment because aspiration risk is high.

Sharp objects may cause focal chest or neck pain.

Fever, severe chest pain, subcutaneous emphysema, haematemesis, dyspnoea or systemic toxicity suggests perforation or another major complication.

A clear history may be sufficient before therapeutic endoscopy.

Plain radiography detects radiopaque objects but does not identify many food boluses, plastic objects or thin bones.

CT: preferred when perforation, sharp foreign body, mediastinal complication or uncertain anatomy is suspected.

Avoid routine barium contrast studies because retained contrast can impair subsequent endoscopy and aspiration may occur.

Emergency endoscopy, ideally within 2 to 6 hours, is required for:

• Complete oesophageal obstruction
• Button battery in the oesophagus
• Sharp pointed oesophageal foreign body
• High risk magnets within the oesophagus.

Other oesophageal foreign bodies should generally be removed within 24 hours because prolonged impaction increases pressure necrosis and perforation risk.

Protect the airway with endotracheal intubation when there is complete obstruction, substantial retained food, proximal impaction, uncooperative patient or high aspiration risk.

Food boluses may be removed piecemeal, extracted en bloc or carefully advanced into the stomach after the distal oesophagus has been assessed and no dangerous structural lesion is encountered.

Do not blindly push a bolus through an uncharacterised distal stricture.

An overtube is useful for repeated withdrawal of sharp objects or fragmented food and protects the airway and mucosa.

A button battery must be removed immediately because electrical and caustic injury can rapidly produce transmural necrosis and fistulation.

Glucagon may occasionally be attempted while endoscopy is being organised:

Glucagon 1 mg IV once.

Its success rate is inconsistent and it must never delay endoscopy in complete obstruction.

After food bolus removal, investigate the underlying cause. If eosinophilic oesophagitis is possible, obtain appropriate oesophageal biopsies even when the mucosa is not dramatically abnormal.

Perforation, an irretrievable dangerous object or an object penetrating toward the airway or major vessels requires surgical management.