Suspected esophageal foreign body or food bolus
Swallowed object, or sudden dysphagia after eating. Adult source; child points are marked 'Child'.
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GastroenterologyEmergency
Esophageal Foreign Body and Food Bolus Management (ESGE 2016)
Esophageal Foreign Body and Food Bolus Management (ESGE 2016): Suspected esophageal foreign body or food bolus → Initial assessment → Airway compromise:...
Pathway Overview
20 steps
Algorithm Steps
20 total
01Start 02Action Initial assessment
History, examination and time since ingestion
- Airway: stridor, respiratory distress, choking
- Can the patient swallow saliva? Drooling = complete obstruction
- Object: type, size, number; witnessed or not
- Perforation signs: fever, neck or chest pain, crepitus, peritonism
- Past food bolus, dysphagia, stricture or eosinophilic esophagitis (EoE)
- Nil by mouth until the plan is clear (except honey for a child with a button battery)
03Warning Airway compromise: secure the airway first
If stridor, respiratory distress or the airway is not protected: call anaesthesia and ENT now. Removal is then an emergency.
- Secure the airway; intubate if needed
- Stridor, wheeze or cough may mean an airway foreign body: ENT or bronchoscopy
- Upper esophagus or hypopharynx: rigid endoscopy (ENT) is an option
04Warning Check red flags before removal
Perforation signs: CT, nil by mouth, IV broad-spectrum antibiotics and surgical referral before endoscopy.
- Perforation: fever, severe neck or chest pain, crepitus, peritonism
- No endoscopy on site: emergency transfer for battery, sharp object, magnets or complete obstruction
- Child: involve paediatric gastroenterology, surgery or ENT early
05Action Imaging
X-ray neck, chest and abdomen (AP and lateral) if the object may be radiopaque or is unknown
- Non-bony food bolus without complications: no imaging needed
- Coin-like disc: zoom for a double rim (AP) or step-off (lateral); treat as a button battery until proven otherwise
- Button battery: X-ray must not delay removal or transfer
- No barium swallow. No MRI if a magnet, battery or metal object is possible
- CT if perforation or another complication is suspected
- Bone, glass, wood: X-ray often misses them; CT if X-ray negative
- Symptoms persist but imaging negative: endoscopy
06Decision What was swallowed?
Choose the matching step below
- Battery
08Action Endoscopic removal
Timing: see the object step. Never for drug packets (body packing).
- Intubate if aspiration risk is high (for example complete obstruction)
- Food bolus: push gently into the stomach; retrieve if pushing fails
- Sharp object: overtube or hood; grasp so the point trails
- Battery: grasper; then check depth and site of injury
- Coins, batteries, magnets: retrieval net, snare or forceps
- Upper esophagus: rigid endoscopy (ENT) is an option
09Decision Removed without perforation?
Object out and no perforation seen
- If Yes
10Action Removed, no perforation: after removal
Look for the cause and decide on admission
- Food bolus: biopsies from upper, mid and lower esophagus for EoE, even if it looks normal
- Admit after difficult removal, high-risk or multiple objects, or major mucosal injury
- Button battery: admit; CT chest within 24 to 48 h if severe injury
- Button battery: fistula or major bleeding can occur up to day 28
- Plan treatment and follow-up for EoE, stricture or ring; exclude cancer and motility disorders (achalasia)
- Uncomplicated removal: discharge
11Outcome Removed: discharge or admit as above
Treat the underlying cause; arrange follow-up
If No12Outcome Not removed or perforation: surgical team
Perforation: CT, nil by mouth, IV broad-spectrum antibiotics, PPI, surgical team. Not removed: admit; daily X-ray for sharp objects; X-ray every 3 to 4 days for batteries past the duodenum.
- Magnets
13Warning Magnets: urgent removal
Esophagus: emergency removal. Stomach: adult, remove within 24 h, even if only 1 magnet is seen.
- 2 or more magnets, or magnet plus metal: bowel wall necrosis, perforation, fistula
- Child: 2 or more magnets or magnet plus metal = emergency removal; 1 magnet alone can be managed as a blunt object
- Out of endoscopic reach: surgical team, repeat imaging; no MRI
- Path rejoins step 08Shared downstream outcome
- Sharp
14Warning Sharp or pointed object
Esophagus: emergency removal, ideally within 2 h, at latest 6 h. Stomach or duodenum: remove within 24 h if safe.
- Perforation risk up to 35%
- Fish or chicken bone, glass, wood: CT if X-ray negative
- Use an overtube or hood; surgical referral if perforation
- Path rejoins step 08Shared downstream outcome
- Food
15Action Food bolus impaction
Cannot swallow saliva: emergency endoscopy, ideally within 2 h, at latest 6 h. Can swallow saliva: endoscopy within 24 h.
- No imaging needed for a non-bony bolus without complications
- Glucagon rarely works and can cause vomiting; do not delay endoscopy for it
- Do not use meat tenderiser (papain)
- Bone in the bolus or perforation signs: CT first
- Path rejoins step 08Shared downstream outcome
- Blunt
16Action Blunt object (coin, other)
Coin: first exclude a button battery (double rim or step-off on X-ray). Esophagus: endoscopy within 24 h; within 2 to 6 h if saliva cannot be swallowed.
- Stomach: most objects <2 to 2.5 cm wide and <5 to 6 cm long pass
- Stomach, wider than 2 to 2.5 cm: endoscopy within 72 h
- Longer than 5 to 6 cm: endoscopy within 24 h
- Child: size limits are lower; paediatric GI advice
17Decision Blunt object: removal needed?
Yes if in the esophagus, symptoms, wider than 2 to 2.5 cm or longer than 5 to 6 cm: endoscopic removal. No: outpatient observation.
- If Yes
- Path rejoins step 08Shared downstream outcome
If No18Outcome Small blunt object in stomach, no symptoms: outpatient observation
Return at once for pain, vomiting, fever or bleeding. Check stools; weekly X-ray. Not passed the stomach in 3 to 4 weeks: endoscopic removal.
- Drug packets
19Warning Drug packets (body packing): no endoscopic removal
Endoscopic retrieval can rupture a packet and cause fatal overdose
- Admit; close observation for toxicity
- Toxicity: resuscitate; call Poisons Information Centre 13 11 26
- Surgical referral if rupture suspected, packets do not progress, or obstruction
20Outcome Body packing: observe until all packets have passed
Surgical referral if rupture is suspected, packets fail to progress, or obstruction
Guideline Source
ESGE Clinical Guideline: Removal of foreign bodies in the upper gastrointestinal tract in adults (Birk et al., Endoscopy 2016;48:489-496)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adult source (ESGE 2016). Child points come from ESPGHAN 2026; get paediatric gastroenterology, surgery or ENT advice for children.
- Timings assume endoscopy on site. If there is none, arrange emergency transfer for a button battery, sharp object, magnets or complete obstruction.
- Most recommendations rest on low-quality evidence.
- Suspected airway (tracheobronchial) foreign body and caustic ingestion need their own pathways.
Contraindicated Populations
Suspected airway (tracheobronchial) foreign body without esophageal objectCaustic ingestion without a foreign body
Applicable Regions
AUUSEUGlobal
AU: Poisons Information Centre 13 11 26 (24 h). Honey is the practical first option before button battery removal in a child 12 months or older; sucralfate liquid may not be stocked.
EU: ESGE 2016 (adults) and ESPGHAN 2026 (children) are the main sources.
US: ASGE 2011 foreign body guideline (Gastrointest Endosc 2011;73:1085-1091) is consistent; National Capital Poison Center button battery guideline for honey and sucralfate.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Esophageal Foreign Body and Food Bolus Management (ESGE 2016)?
The Esophageal Foreign Body and Food Bolus Management (ESGE 2016) is a emergency clinical algorithm for Gastroenterology. It provides a structured decision tree to guide clinical decision-making, based on ESGE Clinical Guideline: Removal of foreign bodies in the upper gastrointestinal tract in adults (Birk et al., Endoscopy 2016;48:489-496).
What guideline is the Esophageal Foreign Body and Food Bolus Management (ESGE 2016) based on?
This algorithm is based on ESGE Clinical Guideline: Removal of foreign bodies in the upper gastrointestinal tract in adults (Birk et al., Endoscopy 2016;48:489-496) (DOI: 10.1055/s-0042-100456).
What are the limitations of the Esophageal Foreign Body and Food Bolus Management (ESGE 2016)?
Known limitations include: Adult source (ESGE 2016). Child points come from ESPGHAN 2026; get paediatric gastroenterology, surgery or ENT advice for children.; Timings assume endoscopy on site. If there is none, arrange emergency transfer for a button battery, sharp object, magnets or complete obstruction.; Most recommendations rest on low-quality evidence.; Suspected airway (tracheobronchial) foreign body and caustic ingestion need their own pathways.. Individual patient factors may require deviation from these recommendations.
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