Esophageal Foreign Body Management (ASGE 2020)

Algorithm Steps

1. ▶

   Start

   Suspected Esophageal Foreign Body/Food Impaction

   History of ingestion or acute dysphagia

   1. ●

      Action

      Initial Assessment

      Assess stability and type of object

      • Airway patency - can patient manage secretions?
      • Type of object ingested
      • Location symptoms (neck, chest, epigastric)
      • Time since ingestion
      • Prior history of food impaction/stricture
      1. ◆

         Decision

         Airway Compromise?

         Signs of complete obstruction

         • Inability to handle secretions
         • Respiratory distress
         • Stridor
         1. ⚠

            Warning

            ⚠️ Emergent Airway Management

            Life-threatening emergency

            • Call anesthesia/ENT
            • Prepare for emergent intubation
            • Consider rigid esophagoscopy (ENT)
            • Immediate endoscopy if stable airway
            1. ●

               Action

               Endoscopic Removal

               Flexible EGD with appropriate devices

               • Food: push technique or piecemeal removal
               • Coins: rat-tooth forceps, snare, Roth net
               • Sharp: protective overtube, orient point trailing
               • Button battery: retrieve immediately, inspect mucosa
               • General anesthesia preferred for high-risk
               1. ●

                  Action

                  Post-Removal Evaluation

                  Evaluate underlying pathology

                  • Look for stricture, ring, eosinophilic esophagitis
                  • Biopsies for EoE (even if normal appearance)
                  • Schedule follow-up dilation if stricture
                  • PPI therapy
                  1. ✓

                     Outcome

                     Successful Removal

                     Address underlying cause, follow-up

               2. ✓

                  Outcome

                  Surgical Intervention

                  If perforation, failed endoscopic removal, or inaccessible location

         2. ◆

            Decision

            Type of Object

            Determines urgency

            1. ⚠

               Warning

               ⚠️ Button Battery (Esophageal)

               TRUE EMERGENCY - removes within 2 hours

               • Causes liquefactive necrosis
               • Perforation can occur in 2-4 hours
               • Emergent endoscopy (<2 hours)
               • Do NOT wait for imaging if high suspicion
            2. ⚠

               Warning

               Sharp/Pointed Objects

               Urgent removal (<24h, ideally <6h)

               • Toothpicks, bones, needles, razor blades
               • 20-35% complication rate if not removed
               • Use protective devices (overtube, hood)
               • Surgical consult if perforation concern
               1. ●

                  Action

                  Imaging (If Indicated)

                  X-ray or CT

                  • X-ray: radiopaque objects, button battery, coins
                  • CT: if perforation suspected, multiple magnets
                  • NOT required if clear food impaction history
                  • Avoid contrast if complete obstruction
            3. ●

               Action

               Food Bolus Impaction

               Common, usually safe to wait 6-12h if managing secretions

               • Complete obstruction: EGD within 6 hours
               • Partial: may observe up to 12-24 hours
               • Glucagon 1mg IV (limited evidence, may try)
               • Avoid meat tenderizer - risk of perforation
            4. ●

               Action

               Blunt Objects (Coins, etc.)

               Less urgent if asymptomatic

               • Esophageal: remove within 24 hours
               • Gastric: may observe if <2.5cm diameter
               • Coins often pass spontaneously
               • Large objects (>6cm long or >2.5cm wide) need removal