Endoscopy Foreing Bodies
Endoscopy of Dental Prothesis Found in the Jejuno

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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Endoscopy of Dental Prothesis

Video Endoscopic Sequence 2 of 9.

Patient underwent an endoscopic procedure

An enteroscope was used to manipulate this prothesis using a diathermy loop.

 

 

Guideline for the management of ingested foreign bodies.

 

Endoscopy of Dental Prothesis

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.
 

 

 

 

Endoscopy of Dental Prothesis

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 removedendoscopically, but surgery is occasionally necessary.

 

 

Endoscopy of Dental Prothesis

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.

 

 

Endoscopy of Dental Prothesis Found in the Jejuno

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.

 

Endoscopy of Dental Prothesis Found in the Jejuno

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.

 

 

Endoscopy of Dental Prothesis Found in the Jejuno

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.

 

Endoscopy of Dental Prothesis Found in the Jejuno

Video Endoscopic Sequence 9 of 9.

A close up of this ingested dental prothesis

Sharp objects should be retrieved from the stomach becauMost 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.

 

obstruction esophagus

Video Endoscopic Sequence 1 of 4.

Severe dysphagia due to obstruction of the esophagus because of corn grains

This is a 93 year-old female, who was hospitalized for dysphagia, retro sternal pain and sialorrhea.

An endoscopy was performed finding multiple grains of corn, which had ingested three days before, causing a Pseudo obstruction of the lower third of the esophagus.

 

 

obstruction esophagus

Video Endoscopic Sequence 2 of 4.

Pseudo obstruction of the lower third of the esophagus.

Multiple grains of corn, which make a single plug causing a mechanical pseudo-obstruction, retroflexed image.

 

 

 

 

 

obstruction esophagus

Video Endoscopic Sequence 3 of 4.

Another image and video. Retroflexed view

 

 

obstruction esophagus

Video Endoscopic Sequence 4 of 4.

With special forceps of foreign body and polypectomy loop the corn fragments are manipulated some are extracted and pass into the stomach. After that patient is handled conservatively, given soda beverages (Coca Cola), the patient improves substantially.

 

Foreign Body Ingestion.

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. 

 

 

Foreign Body Ingestion.

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.

 

 

Foreign Body Ingestion.

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.

 


 

 

Foreign Body Ingestion.

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. 

 

 

Foreign Body Ingestion.

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.

 

Foreign Body Ingestion.

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.

 

Foreign Body Ingestion.

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.

 

Foreign body of the stomach that resemble a snake.

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.
 

 

 

Foreign body of the stomach that resemble a snake.

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.

 

Foreign body of the stomach that resemble a snake.

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.

 

Multiple Foreign bodies in the GI tract

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.

 

 

 

 

Multiple Foreign bodies

Photography Sequence 2 of 12.

Multiple Foreign bodies

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.

 

 

Multiple Foreign bodies

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.

 

Multiple Foreign bodies

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.

 

 

 

Multiple Foreign bodies

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

Click on the image to enlarge in a new windows.

 

 

 

 

Multiple Foreign bodies

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.

 

 

Multiple Foreign bodies

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.

 

Multiple Foreign bodies

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.

 

Multiple Foreign bodies

Photography Sequence 9 of 12.

ngested 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.

 

 

Multiple Foreign bodies

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.

 

Multiple Foreign bodies

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.

 

Multiple Foreign bodies

Photography Sequence 12 of 12.

Multiple Foreign bodies

 

 

Click on the image to enlarge in a new windows.

 

Button Battery Ingestion

Video Endoscopic Sequence 1 of 7.

Button Battery Ingestion

This is a 22-month-old male, 17 hours previous, had ingested, a battery of a toy.

General Considerations

Battery ingestion primarily involves disk or button batteries ingested by children.
Lithium button batteries of 20 mm pose a particular hazard in the esophagus where the current generated by the negative (narrower) side may cause damage within hours after ingestion so that expedited removal is best for this size and type of battery.
Alkaline batteries, those most commonly used in flashlights, tend to produce their adverse effects through release of caustic chemicals.
Their ingestion is more common in adults with a psychiatric history and is frequently intentional
Alkaline batteries can produce erosions, ulcerations and, infrequently, perforation.
Once they have passed the esophagus, most foreign bodies will pass through the GI tract with the ileocecal valve being the next most likely site of impaction.

 

Button batterie stomach

Video Endoscopic Sequence 2 of 7.

Surface erosion caused by the burning of the battery is observed.

Treatment

Button batteries 20 mm or more in diameter still lodged in the esophagus should be removed endoscopically
Once in the stomach, most button batteries will pass spontaneously.
Most larger objects will pass spontaneously.
Monitor larger batteries for their passage radiographically every 3-4 days and patient should be monitored clinically
If the object remains in the stomach, it may be removed endoscopically.
Any object that fails to exit the stomach in 3-4 weeks should be removed endoscopically.
Once past the stomach, any object that remains in the same location for more than a week should be considered for removal surgically.
If the object already is producing obstructive symptoms, it is usually removed surgically.

Complications
Overall, the risk of intestinal perforation from any ingested foreign body is less than 1%

 

 

 

Button batterie stomach

Video Endoscopic Sequence 3 of 7.

Button batteries, particularly those made of lithium and > 20 mm in diameter, are the most concerning. Lithium batteries do not cause injury because of leakage but have an irritating electrode and often have higher energy that generates more current. Many lithium batteries are 3-V batteries as opposed to 1.5 V in other types. Lithium causes electrolysis of tissue and localized hydroxide generation at the negative pole (smaller side of the button battery and without the imprint). Batteries in the esophagus can cause injury in as little as 2 hours.

Analysis of fatalities has shown many non-specific presenting symptoms including fever, emesis, lethargy, poor appetite, irritability, cough, wheezing and/or dehydration. This makes it very difficult to determine what evaluation and/or treatment is necessary particularly in unwitnessed events. Additionally, even if batteries are removed, some patients had unanticipated, uncontrolled bleeding up to 18 days later.

 

 

Button batterie stomach

Video Endoscopic Sequence 4 of 7.

The foreign body with a forceps is removed

 

Button batterie stomach

Video Endoscopic Sequence 5 of 7.

Battery is trapped.

 

 

Button batterie stomach

Video Endoscopic Sequence 6 of 7.

Make the patient is not given anything by mouth and obtain an initial radiograph of the chest and abdomen to determine the battery location.

Imaging Findings
Since all batteries are radiopaque, they can be seen on conventional radiographs
Fluoroscopy may be helpful if there is a question of a button battery masquerading as a swallowed coin


Since disk batteries (also called button batteries) have different GI consequences compared to coins, it is important to distinguish an ingested coin from a disc battery by history or radiographically. Disc batteries will often have the characteristic internal ring appearance if taken in the AP direction. If taken in the lateral position (on edge), it may show a bulge on one side (bilaminar appearance). When viewed obliquely, it may be difficult to distinguish a coin from a disc battery since none of these signs may be radiographically evident.

 

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Button batterie stomach

Video Endoscopic Sequence 7 of 7.

 

 

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