Endoscopic treatment of foreign body in upper GI tract

The module covers:

  1. How to determine the location of the foreign body
  2. How urgently the endoscopy needs to be done
  3. How to use an overtube
  4. How to grab the FB
  5. When can you wait and watch
  6. Food bolus obstruction

Location of the foreign body:

  1. Two important questions-What is it and Where  is it ( Pharynx/Larynx/trachea/oesophagus etc)
  2. Take history and get an x-ray of neck/CXR /AXR depending on the history and clinical suspicion
  3. Remember -Bones may not show on x-ray
  4. Get both coronal and sagittal views- if in doubt
  5. Beware of airway compromise

How urgent is the need for an endoscopy?

  1. Immediate if
    • Complete obstruction
    • Sharp – up to 35% perforate
    • Battery – burn within 2 hours and can perforate within 6 hours
  2. Everything else within 24hours

    3. An overtube
    Picture1: An overtube
    How to use and overtube

  3. Use overtube- prevents repeated intubation and protect airway and mucosa
  4. Thoroughly lubricate the inside and the outside of the overtube
  5. Pass the endoscope through the overtube- the thicker and corrugated end remains outside the oral cavity – then intubate and advance the gastroscope
  6. Keep the tip of the overtube in the lower oesophagus while you find the foreign body as it immediately deflates the stomach and view will be compromised
  7. Once FB is viewed and position located – do a J manoeuvre and advance the overtube – note the tip protruding through the GOJ- both overtube and the scope is black but scope has got white ring marking
  8. Next withdraw the overtube just within the GOJ and inflate the stomach again
  9. Find the foreign body and grasp it – use Roth net for battery, for razor blade use stent grabber- anything sharp – you need to grab it along its axis and not across
  10. Pull the scope very close to GOJ
  11. Advance the overtube OVER the scope to cover the sharp object – we find it more convenient than to pull the scope into the overtube
  12. Immediately the whole field will look black
  13. Withdraw the endoscope and FB together keeping the overtube in place
  14. Can go back again if more FB is to be picked
  15. Remove the overtube at the end

How to grab the FB

  1. Tool kit- snare/triprongs/Roth net/Suction cap/biliary basket/Rat toothed forceps


    2. Picture2: Capuchon hood

  2. Capuchon hood is another device which can be used instead of overtube in selected cases- it is fitted at the tip of the endoscope and looks like a rubber skirt which invaginates itself once the scope is withdrawn into the GOJ and then covers the FB
  3. Dry run outside the patient with similar objects- ensure the size of the FB is compatible with the holding size of your device
  4. Move with pointed end trailing
  5. If both ends pointed cover one with forceps
  6. For razor blades rat toothed forceps ( stent grabbers) are probably best as with other devices you can catch it across which is problematic
  7. If perforation- conservative management only in highly selected cases (endoclips or covered stents)- most require operation

When can you wait and watch

  1. If the patient is
    • Asymptomatic
    • Blunt FB
    • Inert FB
    • Not>5cm
    • Healthy gut
  2. Warn to report symptoms
  3. Check X-Ray

Food bolus obstruction:

  1. If complete obstruction with saliva drooling urgent OGD
  2. Once visualised one can either
    • Pull- Forceps/snare/net/grasper
    • Push it down in to the stomach by using
      • Air insufflations
      • Gentle pressure
      • Fragment and gentle pressure
  3. Success 97%
  4. Remember to take oesophageal biopsy particularly if young male to exclude Eosinophilic oesophagitis
  5. If narrowing is seen once the bolus is gone- e.g. benign stricture, web, schatzki’s ring or malignant stricture – that needs to be addressed then or later depending on the pathology.

Here is the link for foreign body extraction video:

  1. Video 1
  2. Video 2

Acknowledgement/Bibliography:

  1. Alhaji M et al. Razor blade removal from the stomach utilizing a novel modification of the overtube. Endoscopy. 2009;41 Suppl 2:E166. Epub 2009 Jul 23.
  2. Webb WA et al.Management of foreign bodies of the upper gastrointestinal tract. Gastroenterology. 1988 Jan;94(1):204-16.
  3. Stack LB et al. Foreign bodies in the gastrointestinal tract. Emerg Med Clin North Am. 1996 Aug;14(3):493-521.

Post a Comment