Esophageal Foreign Bodies:

Types and Techniques

for Removal
Milton T. Smith, MD*
Roy K.H. Wong, MD
Address
*Walter Reed Army Medical Center, 6900 Georgia Avenue, NW, Washington,
DC 20307-5001, USA.
E-mail: Milton.Smith@na.amedd.army.mil
Current Treatment Options in Gastroenterology 2006, 9:75–84
Current Science Inc. ISSN 1092–8472
Copyright © 2006 by Current Science Inc.

Opinion statement
Patients with esophageal foreign bodies require prompt diagnosis and therapy. The first
tasks are to determine the type of object, time since ingestion, location of the object,
and the likelihood of associated complications. Patients who have evidence of complete
esophageal occlusion or who have ingested a sharp or pointed object require urgent
treatment due to the increased risk of complications. Button batteries are particularly
injurious in the esophagus and should be removed immediately. Coins in the esophagus
should also be removed; however, a brief period of observation is appropriate for coins
in the distal esophagus, as some will pass spontaneously. Flexible endoscopy is the
therapeutic modality of choice for most patients. The key principles for endoscopic
management of esophageal foreign bodies are to protect the airway, to maintain control
of the object during extraction, and to avoid causing additional damage. Endotracheal
intubation is sometimes necessary, especially in younger children and those at higher
risk for aspiration. The use of devices such as an esophageal overtube and a latex pro-
tector hood may facilitate safer extraction of sharp/pointed objects. Patients with food
impactions usually require treatment of an associated structural lesion of the esophagus.

Introduction
Foreign body ingestions and esophageal food bolus
impactions, common problems faced by clinicians, are
a frequent reason for urgent endoscopy. True nonfood
foreign body ingestions are more common in children,
the majority of whom are aged 6 months to 6 years
[1,2]. Although 80% to 90% of ingested foreign objects
that reach the stomach will pass uneventfully without
intervention, the remainder may become lodged in the
esophagus, placing the patient at risk for development
of complications such as perforation or aspiration. The
esophagus is the most common location in the gas-
trointestinal tract for foreign body obstructions and
accounts for 75% of all impactions [3]. The true inci-
dence and overall mortality rate from ingested foreign
objects are unknown, but deaths have been reported
rarely [4,5]. The management of objects impacted in
the esophagus is influenced by several key factors,
including the type of object and its physical characteris-
tics; location of the object; age of the patient and asso-
c i a t ed m e d i c a l co n d i t i o n s; t i m e e l a p s ed si n c e
ingestion; and evidence of complications such as
complete obstruction or perforation. An assessment
should be made as to whether the patient can be opti-
mally managed with available physician skills and
whether all necessary equipment and support staff are
immediately available.
ANATOMY AND PATHOPHYSIOLOGY
Ingested foreign objects most commonly become
impacted in areas that are physiologically or pathologi-
cally narrowed. The four sites of physiological narrow-
ing are the cricopharyngeus muscle of the upper
esophageal sphincter, the aortic arch, the left mainstem
bronchus, and the lower esophageal sphincter [6••].
76 Esophageal Disease
Table 1. Risk factors for foreign body ingestion and
esophageal impaction
Childhood (peak ages 6 months to 6 years)
Impaired mentation
Psychiatric illness
Dementia
Drug-induced (alcohol, mood-altering drugs)
Impaired vision
Edentulous
Removable dentures or dental bridge
Illicit activity (eg, drug smuggling)
Prisoners (seeking secondary gain)
Esophageal pathologic narrowing
Rings (eg, Schatzki B-ring)
Webs
Strictures (peptic, caustic, radiation-induced, anasto-
motic, post-esophageal surgery)
Esophageal motility disorder (eg, achalasia)
Eosinophilic esophagitis
Caustic pills
Ingestion of large or oddly shaped objects (eg, large coins,
safety pins, toothpicks, toys)
Adults with esophageal food bolus impactions have
underlying esophageal pathology in 88% [7•] to 97%
[3] of patients evaluated. Benign esophageal stenosis
caused by Schatzki B-rings or peptic strictures are the
most common findings. Esophageal cancer presenting
with food bolus impaction is uncommon but has been
reported [8,9]. Children often do not have an under-
lying esophageal abnormality. However, they occasion-
ally have a stricture due to prior caustic ingestion or a
congenital abnormality such as esophageal stenosis, a
web, esophageal atresia, or prior esophageal surgery
[10]. The location of impaction is also influenced by
the ingested object’s size and shape. The cervical esoph-
agus is particularly prone to foreign body impaction
and has been reported to be the region of highest
involvement in some series. This is perhaps due to the
fact that the cricopharyngeal sphincter is the narrowest
point in the gastrointestinal (GI) tract, which is approx-
imately 14 mm in diameter [11••]. Although rare,
motility dysfunction should also be considered if no
mucosal abnormality is found [12–16]. Eosinophilic
esophagitis has been increasingly recognized over the
past decade as an important factor in patients present-
ing with food impaction. A recent study from a com-
munity-based practice [17•] showed that 54% of adults
who presented with esophageal food impactions had
histologic evidence of eosinophilic esophagitis. Endos-
copists should be aware of this condition, as treatment
with esophageal dilation commonly causes deep
mucosal tears in the esophagus [18]. Endoscopic fea-
tures include linear mucosal furrows, small-caliber
esophagus, tiny superficial mucosal exudates, concen-
tric rings in the esophagus, and isolated proximal
esophageal stenosis [19].
TYPES OF ESOPHAGEAL FOREIGN BODIES AND
CLINICAL SETTING
Esophageal foreign bodies may be classified as food
bolus impactions or true foreign bodies that are not
intended for ingestion. True foreign bodies are sub-
divided into blunt objects such as coins, sharp/pointed
objects, and miscellaneous. Eighty percent of true
foreign body ingestions occur in children [20], with up
to 40% being unwitnessed [21]. Coins are the objects
most commonly ingested by children [1,22]. Other fre-
quently encountered objects in children include small
toys, keys, crayons, marbles, stones, and safety pins.
Several risk factors for foreign body ingestion and
esophageal food impaction are shown in Table 1. The
risk of food bolus impaction is greater in adults who
wear dentures due to reduced oral tactile sensitivity.
Although any solid food is capable of causing obstruc-
tion, most food impactions are caused by meat.
Adults are much less likely than children to swallow
true foreign bodies, except in certain high-risk groups.
These include prisoners seeking secondary gain, drug
smugglers, and individuals with mental impairment due
to drug or alcohol use, dementia, or psychiatric illness.
Ingested pills that lodge in the esophagus may result
in caustic injury. Antibiotics are the most common
cause, although many other drugs can cause pill-induced
esophageal injury [23].
CLINICAL MANIFESTATIONS
Adults with a foreign body impacted in the esophagus
will most often present with dysphagia, odynophagia,
and chest discomfort. Patients with high-grade obstruc-
tion of the esophagus may experience hypersalivation
and be unable to swallow liquids, including their own
saliva. Bones and other pointed objects will sometimes
cause mucosal injury that results in a persistent foreign
body sensation even after the object has been extracted
or passed spontaneously. Most adults will seek atten-
tion within the first 24 hours of ingestion [24]. Approx-
imately 5% of patients with esophageal foreign bodies
will present with airway obstruction. Respiratory symp-
toms include stridor, choking, and coughing [25].
Children often have typical symptoms but are more
likely than adults to be asymptomatic [1] and have an
increased frequency of respiratory symptoms. Foreign
body obstruction should also be considered in infants and
toddlers with symptoms such as excessive drooling, refusal
to feed, unexplained gagging, or chronic aspiration.
DIAGNOSTIC EVALUATION
The fundamental elements of diagnostic evaluation are
shown in Table 2. It should be recognized that the site
 Esophageal Foreign Bodies: Types and Techniques for Removal Smith and Wong 77

should include both anteroposterior (AP) and lateral

Table 2. Diagnostic evaluation for gastrointestinal
foreign bodies and food impactions
History
Type of object, time since ingestion, type of symptoms,
prior episodes
Physical examination
Evidence of complete obstruction or perforation
Radiographic evaluation
Plain films to detect radiopaque objects
(neck, chest, abdomen)
Anteroposterior and lateral views to distinguish esoph-
ageal vs tracheal location and radiopaque objects
overlying the spine
Limited role for barium
Gastrograffin swallow if perforation is suspected
CT for objects not seen on other modalities and to
detect complications
Flexible endoscopy
Useful for diagnosis, therapy, and detecting
associated pathology
at which the patient localizes dysphagia is of limited
value [26]. In general, esophageal dysphagia is more
likely to be referred proximally rather than distally
from the site of an obstruction [27]. Therefore, patient
localization of symptoms to the subxiphoid region is
more reliable [28]. A history of gastroesophageal reflux
disease symptoms or prior impactions suggests an
underlying esophageal abnormality.
The physical examination is important primarily
to detect complications and for assessment of the
patient’s general health status. The abdomen should be
examined for evidence of peritonitis or small-bowel
obstruction [29].
Plain films of the neck, chest, and abdomen will
commonly show the location of radiopaque objects and
views. Some radiopaque objects overlying the vertebral
column may only be visible on the lateral view. The
flat surface of a coin lodged in the esophagus is usually
seen best on the AP view due to its coronal orientation
(Fig. 1). If it is lodged in the trachea, the flat surface is
usually seen best on the lateral view. The AP view of a
button battery in the esophagus will often show a
“double density” appearance caused by its bilaminar
construction. Recent studies have shown that handheld
metal detectors have a 98% to 100% sensitivity in
detecting and localizing ingested coins in the esophagus
[30,31]. Many objects, such as meat, tiny bones, alumi-
num, glass, plastic, and wood may be radiolucent and
not visualized on plain x-rays. Barium studies have a
limited role in the management of foreign bodies and
should be avoided if evidence of high-grade obstruction
or suspicion of esophageal perforation exists. Residual
barium in the esophagus often obscures visualization
during a subsequent endoscopy. Gastrograffin may be
helpful in localizing a suspected perforation but causes
severe pneumonitis if aspirated due to its hypertonicity.
CT can occasionally detect objects that are missed by
other modalities [32,33] and is useful in detecting com-
plications [34,35]. It is imperative to remember that
failure to demonstrate a foreign body radiographically
does not preclude its presence.
Flexible endoscopy has the advantage of being
highly sensitive in detecting esophageal foreign bodies
and provides the opportunity for immediate therapy
in most cases.
ACKNOWLEDGMENTS
The views expressed in this article are those of
the authors and do not reflect the official policy of
the Department of Army, Department of Defense, or
US Government.

Treatment
• Flexible endoscopy is the preferred treatment modality in the majority of
cases. It is helpful to plan ahead to assure that all necessary equipment is
readily available (Table 3).
• Successful management is influenced by the experience level and skills of
the endoscopist [36]. The timing of endoscopy is dictated by the perceived
risk of complications [37••].
• It is critical to protect the patient’s airway from inadvertent aspiration of
saliva, retained esophageal or gastric contents, and the object itself during
attempted extraction.
78 Esophageal Disease

Figure 1. (A) Anteroposterior and

(B) lateral views of a quarter lodged in
the esophagus. Note that the flat surface
is seen best on the anteroposterior view.

Table 3. Equipment checklist for endoscopic removal of upper

GI foreign bodies
Appropriate size endoscopes (standard adult, small diameter, dual channel)
Overtube (esophageal length, gastric length)
Endoscopic accessories
Polypectomy snare
Foreign body forceps (rat tooth, alligator)
Roth retrieval net
Friction fit adapter (EMR, variceal band ligator)
Dormia basket
Grasping forceps (Magill, Kelly)

Food bolus impaction

Endoscopic therapy
The goals of therapy are to clear the esophagus by either extracting the bolus or
moving it into the stomach and to prevent complications. An overall success rate
of 98% was recently reported [7•].
Standard procedure Urgent endoscopy is indicated whenever the patient is having difficulty handling
oral secretions. It is preferable to perform non-urgent endoscopy within the first
6 to 12 hours, before the meat has a chance to soften in the esophagus. Endo-
scopic intervention should not be delayed beyond 24 hours because of increased
risk of complications [37••,38]. Early endoscopy may also minimize the amount
of local pressure-induced mucosal damage caused by the food bolus.
The procedure should be performed in a setting in which the patient can be care-
fully monitored. Assistants should be available to administer sedation, provide oral
suctioning, and assist the endoscopist. The patient must be cooperative and ade-
quately sedated. After informed consent is obtained, a forward-viewing endoscope
is used to intubate the esophagus under direct visualization. The cricopharyngeal
region and proximal esophagus are carefully inspected for the food bolus. Any
retained secretions in the esophagus should be suctioned before an attempt to
remove the food bolus. The food bolus is usually located easily and can often be
removed in a single piece if the endoscopy is performed early. Once the bolus has
been identified, the endoscopist should decide which accessories are necessary and
which technique to employ (ie, extract or push into the stomach).
Extraction of the food bolus is usually attempted first, especially if the bolus
is large or firm, or if the patient is known to have significant stricture [39]. When
attempting to extract meat from the esophagus, we most often use either a polypec-
tomy snare, or more recently, a Roth retrieval net (US Endoscopy, Mentor, OH)
 Esophageal Foreign Bodies: Types and Techniques for Removal Smith and Wong 79

Figure 2. Endoscopic accessories available for foreign body

extraction. They include (left to right) Roth retrieval net,
retrieval basket, polypectomy snare, foreign body forceps
(rat tooth and alligator).

(Fig. 2). A major benefit of using the Roth net is that the bolus is totally encom-
passed within the net, so it can be grasped more securely, reducing the risk of acci-
dentally dropping the food in the trachea [25]. Once the bolus is ensnared, the
endoscope is withdrawn proximally to a level just below the cricopharyngeus. The
bolus is then pulled snuggly against the tip of the endoscope, suction is applied, and
the endoscope and ensnared food bolus are removed together as one unit. The endo-
scopist should be careful to avoid dislodging pieces of the bolus in the hypopharynx.
If this occurs they should be quickly retrieved to avoid aspiration.
Many endoscopists prefer to use an endoscopic suction technique [40,41].
A friction–fit adapter from a variceal ligation kit is fitted over the tip of the
endoscope. Continuous suctioning creates a vacuum and pulls the meat into the
adapter. This technique is highly effective for most meat impactions.
In situations in which the bolus has become soft and fragmented and repeated
intubation seems unavoidable, we prefer to insert an esophageal overtube. After
lubrication of the internal and external surfaces, a 44-Fr Maloney dilator is passed
through the tube, and the entire unit is gently guided into the esophagus; the
dilator is then removed. The overtube serves the dual function of protecting the
airway as well as facilitating esophageal intubations.
Several authors have advocated using a “push” technique to guide an esoph-
ageal food bolus into the stomach [7•,39,42,43•]. Pushing is generally considered
safe if the endoscope can be successfully guided around the bolus to evaluate the
distal esophageal anatomy. The endoscope is then withdrawn proximal to the bolus,
and gentle pressure is applied to carefully guide the bolus into the stomach. When
a hiatal hernia is present, the esophagogastric junction often takes a left turn as
it enters the stomach; therefore, gentle pushing from the right side of the bolus is
advised [25]. In situations in which the bolus cannot be passed with the endoscope,
one may still attempt to push gently as long as significant resistance is not encoun-
tered. If gentle pushing is not successful, it may be helpful to use a polypectomy
snare or biopsy forceps to fragment the meat into smaller pieces. Some authors have
also used a guidewire placed in the stomach under direct visualization to guide the
endoscope [39,42] or to pass small Savary dilators [39]. Vicari et al [43•] reported a
97% success rate using the push technique for acute esophageal food impactions.
Push methods require experience and good judgment and should probably be avoided
if multiple esophageal rings are visualized [44].
Contraindications Evidence of esophageal perforation.
Complications Aspiration, perforation, recurrent impactions. Prospective studies are lacking.
Special points Immediate dilation of an associated Schatzki ring or peptic stricture is appropriate
if there is minimal mucosal damage and the bolus has been present for a short
period [7•,43•]. Otherwise, the patient is generally placed on a proton-pump
inhibitor and a soft or liquid diet and brought back for dilation at a later date.
Patients should be instructed to chew carefully and avoid troublesome foods.
Elective endoscopy is advised in situations in which the patient experiences
food impaction but the bolus passes spontaneously.
80 Esophageal Disease

If the food bolus cannot be successfully removed with flexible endoscopy,

options include rigid endoscopy or repeat flexible endoscopy by a different, more
experienced endoscopist.
Cost effectiveness Costs are generally those associated with an elective outpatient upper endoscopy.

Pharmacologic therapy
The aim of pharmacologic therapy is to relax esophageal smooth muscle to pro-
mote passage of the food bolus. Glucagon is known to cause relaxation of the
lower esophageal sphincter (LES) [45]. In normal subjects, the resting LES pressure
decreases by up to 60% after intravenous administration of glucagon [46]. It has
little effect on the proximal esophagus.

Glucagon
Standard dosage 1 to 2 mg intravenously. May repeat the dose in 5 to 10 minutes if necessary.
Contraindications Insulinoma, pheochromocytoma, Zollinger-Ellison syndrome, and known hyper-
sensitivity to glucagon.
Main drug interactions None.
Main side effects Nausea and vomiting, especially with doses above 1 mg or with rapid injection
(less than 1 minute). Hyperglycemia.
Special points The results of using glucagon to treat food impactions have been variable, most
likely due to its inability to affect the diameter of strictures or rings.
In one series, glucagon given at the time of endoscopy was thought to relax the
esophagus to facilitate clearing the food bolus using the “push” technique [45].
Other agents such as benzodiazepines, nitroglycerin, calcium channel blockers,
and anticholinergics do not appear to offer a significant advantage over glucagon.
Cost effectiveness Available commercially as GlucaGen (Novo Nordisk, Copenhagen, Denmark). The
wholesale price for a kit containing a 1 mg dose plus sterile water for reconstitution
is $65 (price per Bedford Laboratories, November 2005).
Other treatments Other nonendoscopic, nonpharmacologic techniques used in the past have now
been largely abandoned due to potential complications and the availability of
safer techniques.
Administration of proteolytic enzyme preparations was once popular. Solutions
containing papain or chymotrypsin were given as a drink or by nasogastric instilla-
tion. Although therapeutic successes were reported in early trials, two potentially
life-threatening complications can occur, including transumural digestion of the
esophagus and hemorrhagic pulmonary edema if the solution is aspirated. Enzyme
preparations have no place in current management.
Various gas-forming agents have been used to treat acute esophageal meat
impactions. The ingested agents release carbon dioxide in the esophagus, which
raises intraluminal pressure against a closed upper esophageal sphincter, thus forc-
ing the bolus into the stomach. Agents used have included a “cocktail” of tartaric
acid and bicarbonate, Carbex effervescent granules, and carbonated beverages.
Several series reported success with this technique; however, esophageal perfora-
tion has been reported. We do not use or recommend the use of gas-forming agents.

Blunt objects
Endoscopic therapy
Coins in the esophagus are commonly encountered, particularly in children, and
should be removed to prevent damage caused by direct pressure necrosis. Perfora-
tion and tracheoesophageal fistula have been reported. Pennies manufactured in
the United States since 1982 are composed primarily of zinc and tend to be more
corrosive than older, copper pennies.
Button batteries in the esophagus are seen less frequently but require urgent
removal to prevent severe caustic damage to the esophageal mucosa.
 Esophageal Foreign Bodies: Types and Techniques for Removal Smith and Wong 81

Standard procedure Flexible endoscopy is the method of choice to extract coins from the esophagus.
Small children may be less cooperative and often require general anesthesia to
expedite removal. Because coins sometimes pass spontaneously, x-ray confirmation
is indicated prior to endoscopy if significant time has elapsed. Direct visualization
during esophageal intubation is necessary because coins are often located proxi-
mally. Once the coin is located in the esophagus at endoscopy, a choice is made
between one of several commercially available endoscopic accessories used to grasp
the object [47]. We prefer to use the Roth net for most coin extractions, provided
there is sufficient space to open the net to ensnare the coin. This may be difficult if
the coin is located within or very close to the cricopharyngeal sphincter. The net is
used to grasp the coin more securely to decrease the chance of inadvertently drop-
ping it during extraction. A standard polypectomy snare may also be used. The for-
eign body grasping forceps (rat tooth) is particularly useful in grasping the elevated
edges of a coin. Once the coin is securely grasped, it is pulled against the tip of the
endoscope, which is then slowly withdrawn. The patient should be placed in the
Trendelenberg position prior to extraction to lessen the risk of aspiration.
Button batteries may be more difficult to grasp with a snare or foreign body
forceps. A recent animal study by Faigel et al [36] showed the Roth net to be
superior to other accessories in retrieving button disc batteries.
If a smooth object cannot be securely grasped in the esophagus, it may be
possible to gently advance it into the stomach. This will usually allow reorientation
of the object for easier extraction.
Contraindications Clinical evidence of esophageal perforation.
Complications The risks are those of upper endoscopy with perhaps a greater emphasis on the risk
of aspiration.
Special points Coins located in the distal esophagus will often pass spontaneously. In a recent
prospective study, Waltzman et al [48] found that 56% of coins in the distal third
of the esophagus passed spontaneously during observation compared with 27% of
those coins in the mid or proximal esophagus. For this reason, a period of observa-
tion not exceeding approximately 12 to 16 hours is warranted.
Rigid endoscopy for coin extraction is safe and highly successful. It provides
excellent visualization of the esophagus, airway protection, and control of the
object. The major disadvantage is the requirement for general anesthesia.
Cost effectiveness Costs are generally those associated with an outpatient upper endoscopy. Costs are
higher if general anesthesia is required.
Other treatments Nonendoscopic methods used to remove coins from the esophagus include the
balloon-tipped catheter method, esophageal bougienage, and the “penny
pincher” technique.
The use of balloon-tipped catheters to extract coins from the esophagus is
controversial. Standard Foley catheters (size 14 or 16) and similar inflatable vascu-
lar catheters have been used. The use of sedation for the procedure is optional.
Under fluoroscopic guidance, the catheter is passed orally into the esophagus to
a point just distal to the object. The patient is then moved from the sitting to
oblique prone position, and the table is turned to a steep head-down position. The
balloon is inflated with contrast, and the object is withdrawn while the operator
observes on fluoroscopy. Some series have reported success rates similar to that of
endoscopy. Potential complications include nosebleeds, laryngospasm, hyperpyr-
exia, and hypoxia [11••]. Despite favorable success rates, we do not recommend
this technique because there is little control of the object, and the airway is not
protected during extractions.
The bougienage technique involves using a standard esophageal dilator to
push a coin from the esophagus into the stomach. Bonadio et al [49] reported
successful use of this technique in children who had a single coin in the esopha-
gus for less than 24 hours. The position of the coin must be confirmed by x-ray,
and there must be no prior history of foreign bodies, esophageal disease, or surgi-
cal procedures, and no respiratory compromise. When these criteria were met, they
passed a single dilator without prior sedation. A success rate of 100% was reported
in 46 patients treated in this manner, and no complications were observed.
82 Esophageal Disease

A newer method of removing coins is the “penny pincher” technique [50]. This
method involves placing an endoscopic grasping forceps through a soft rubber catheter
from which the end has been cut off. The device is passed orally through a bite block
without sedation, using fluoroscopic observation. The prongs of the forceps are then
used to grasp the edge of the coin, and the device is quickly removed. The authors
reported 100% success in 19 children and no complications.
Few centers have sufficient experience using these techniques, and all are “blind”
in that they do not allow inspection of the mucosa. Flexible endoscopy remains the
standard of care for patients with blunt foreign objects in the esophagus.

Sharp-pointed objects
Endoscopic therapy
Sharp-pointed objects lodged in the esophagus represent a medical emergency due
to the fact that the risk of a complication is as high as 35% [37••]. They are often
more challenging to remove. Unlike other foreign bodies such as coins, a sharp-
pointed object that has reached the stomach or proximal duodenum should still be
retrieved endoscopically if possible.
Special precautions should be taken to avoid causing mucosal injury during
extraction of these objects.
Standard procedure The best principle to follow when extracting a pointed object such as a metal
tack or an open safety pin from the esophagus is that the pointed end should
trail, not lead. If necessary, a pointed object may be guided into the stomach
first in order to achieve proper orientation before extraction. An open safety pin
is best removed by grasping the hinged portion and allowing the pointed end
to trail. If the pointed end is directed caudally on initial inspection, it may be
grasped without reorientation.
As with other types of foreign bodies, selecting the proper accessory device for
extraction is important. Faigel et al [36] found that the Roth net was not useful for
retrieving toothpicks (a particularly dangerous pointed object), but the polypectomy
snare, Dormia basket, and foreign body forceps were highly successful. The polypec-
tomy snare was also better than the Roth net for retrieving metal tacks [36].
There are two techniques used to protect the esophagus from injury while sharp-
pointed objects are extracted during flexible endoscopy. First, an overtube may be
placed in the esophagus. The object is then grasped and pulled into the overtube,
and the entire assembly is removed together as one unit. A longer overtube may be
needed for sharp objects in the stomach. Second, a bell-shaped latex hood can be
attached to the tip of the endoscope to retrieve sharp objects from the stomach. The
bell portion of the hood is inverted back on itself with at least 2 to 3 mm of the endo-
scope exposed during insertion. The object is then grasped and pulled against the tip
of the endoscope. As the endoscope is withdrawn through the gastroesophageal junc-
tion, the latex hood flips downward, covering the sharp object.
Toothpicks, straight pins, hat pins, and similar long, pointed objects should
be grasped close to the tip so that the longitudinal axis is approximately parallel
to the endoscope. If necessary, the object may be pulled into an overtube prior
to removal.
Contraindications Clinical evidence of perforation.
Complications The major potential complications of removing sharp-pointed objects include
mucosal laceration and puncture, bleeding, transmural perforation, and aspiration
of the object.
Special points Some sharp-pointed objects are radiolucent and may not be visualized on x-rays
(eg, glass, toothpick). In these settings, endoscopic intervention is indicated for
diagnosis and potential therapy.
Rigid endoscopy under general anesthesia is another very effective means of
removing sharp-pointed objects. The mucosa and airway are protected as the
object is withdrawn.
Despite a higher overall complication rate, most sharp-pointed objects that
reach the small intestine will pass through the GI tract without complications.
The patient should be placed on a high-fiber diet, but laxatives should be avoided
 Esophageal Foreign Bodies: Types and Techniques for Removal Smith and Wong 83

[25]. The patient should be instructed to screen the stools, and daily x-rays should
be obtained. Surgical intervention should be considered if the object has not
progressed after 3 to 4 days.
Cost effectiveness No data are available.

Surgery
Surgical intervention is more often indicated for sharp-pointed objects compared
to other types of foreign bodies. In a recent series of adult patients with upper GI
foreign bodies, three patients (1.1%) had objects that could not be removed endo-
scopically [51]. In each case, a sharp object was impacted in the cervical esopha-
gus, requiring surgery.
Potential indications for surgical intervention include the following: inability
to remove the object endoscopically; failure of a sharp-pointed object to progress
through the intestinal tract after several days of observation; evidence of perforation;
and development of other complications during observation, such as pain, fever,
bleeding, and obstruction.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as:
• Of importance
•• Of major importance
1. Cheng W, Tam PK: Foreign-body ingestion in children:
experience with 1,265 cases. J Pediatr Surg 1999,
34:1472–1476.
2. Hachimi-Idrissi S, Corne L, Vandenplas Y: Management
of ingested foreign bodies in childhood: our experi-
ence and review of the literature. Eur J Emerg Med
1998, 5:319–323.
3. Webb WA: Management of foreign bodies of the upper
gastrointestinal tract: update. Gastrointest Endosc 1995,
41:39–51.
4. Simic MA, Budakov BM: Fatal upper esophageal
hemorrhage caused by a previously ingested chicken
bone: case report. Am J Forensic Med Pathol 1998,
19:166–168.
5. Bennett DR, Baird CJ, Chan KM, et al.: Zinc toxicity
following massive coin ingestion. Am J Forensic Med
Pathol 1997, 18:148–153.
6.•• Duncan M, Wong RK: Esophageal emergencies: things
that will wake you from a sound sleep. Gastroenterol
Clin North Am 2003, 32:1035–1052.
A comprehensive review of important esophageal emergencies
encountered by endoscopists, including caustic ingestions,
foreign bodies, and esophageal perforation.
7.• Longstreth GF, Longstreth KJ, Yao JF: Esophageal food
impaction: epidemiology and therapy. A retrospective,
observational study. Gastrointest Endosc 2001, 53:193–198.
An informative study of food impactions in a large series of
adult patients. Key clinical features and outcomes of therapy
are provided.
8. Vizcarrondo FJ, Brady PG, Nord HJ: Foreign bodies of
the upper gastrointestinal tract. Gastrointest Endosc
1983, 29:208–210.
9. Nandi P, Ong GB: Foreign body in the oesophagus:
review of 2394 cases. Br J Surg 1978, 65:5–9.
10. Yeaton P, Peura D: Foreign bodies. In The Esophagus.
Edited by Castell D, Richter J. Philadelphia: Lippincott
Williams & Wilkins; 1999:340–353.
11.•• Benjamin S, Noguera E: Foreign bodies. In The Esophagus,
edn 4. Edited by Castell D, Richter J. Philadelphia:
Lippincott Williams & Wilkins; 2004:340–353.
This recently published chapter thoroughly covers the
evaluation and available treatment options for esophageal
foreign bodies.
12. Vicente Y, Hernandez-Peredo G, Molina M, et al.: Acute
food bolus impaction without stricture in children
with gastroesophageal reflux. J Pediatr Surg 2001,
36:1397–1400.
13. Shah SW, Khan AA, Alam A, et al.: Esophageal bezoar in
achalasia: a rare condition. J Clin Gastroenterol 1997,
25:395–396.
14. Katz P, Castell J: Nonachalasia motility disorders. In The
Esophagus, edn 3. Edited by Castell D, Richter J. Philadelphia:
Lippincott Williams & Wilkins; 1999:215–234.
15. Breumelhof R, Van Wijk HJ, Van Es CD, Smout AJ: Food
impaction in nutcracker esophagus. Dig Dis Sci 1990,
35:1167–1171.
16. Mazzadi S, Salis GB, Garcia A, et al.: Foreign body
impaction in the esophagus: Are there underlying
motor disorders? Dis Esophagus 1998, 11:51–54.
17.• Desai TK, Stecevic V, Chang CH, et al.: Association of eosi-
nophilic inflammation with esophageal food impaction
in adults. Gastrointest Endosc 2005, 61:795–801.
This study highlights the importance of recognizing eosino-
philic esophagitis in adults who present with acute esophageal
food impaction.
18. Croese J, Fairley SK, Masson JW, et al.: Clinical and
endoscopic features of eosinophilic esophagitis in
adults. Gastrointest Endosc 2003, 58:516–522.
19. Potter JW, Saeian K, Staff D, et al.: Eosinophilic esophagitis
in adults: an emerging problem with unique esophageal
features. Gastrointest Endosc 2004, 59:355–361.
20. Chen MK, Beierle EA: Gastrointestinal foreign bodies.
Pediatr Ann 2001, 30:736–742.
84 Esophageal Disease
21. Uyemura MC: Foreign body ingestion in children.
Am Fam Physician 2005, 72:287–291.
22. Kim JK, Kim SS, Kim JI, et al.: Management of foreign
bodies in the gastrointestinal tract: an analysis of
104 cases in children. Endoscopy 1999, 31:302–304.
23. Kikendall J: Pill-induced esophageal injury. In The Esopha-
gus, edn 4. Edited by Castell D, Richter J. Philadelphia: Lip-
pincott William & Wilkins; 2004:572–584.
24. Herranz-Gonzalez J, Martinez-Vidal J, Garcia-Sarandeses
A, Vazquez-Barro C: Esophageal foreign bodies in
adults. Otolaryngol Head Neck Surg 1991, 105:649–654.
25. Webb WA, Taylor M: Foreign bodies of the upper gastro-
intestinal tract. In Gastrointestinal Emergencies, edn 2.
Edited by Taylor M. Baltimore: Williams & Wilkins;
1997:3–19.
26. Johnston B, Castell D: Symptom overview and quality
of life. In The Esophagus. Edited by Castell D, Richter J.
Philadelphia: Lippincott Williams & Wilkins;
2004:37–46.
27. Wilcox CM, Alexander LN, Clark WS: Localization of an
obstructing esophageal lesion. Is the patient accurate?
Dig Dis Sci 1995, 40:2192–2196.
28. Roeder BE, Murray JA, Dierkhising RA: Patient localization
of esophageal dysphagia. Dig Dis Sci 2004, 49:697–701.
29. Ginsberg GG: Management of ingested foreign objects
and food bolus impactions. Gastrointest Endosc 1995,
41:33–38.
30. Bassett KE, Schunk JE, Logan L: Localizing ingested
coins with a metal detector. Am J Emerg Med 1999,
17:338–341.
31. Gooden EA, Forte V, Papsin B: Use of a commercially
available metal detector for the localization of metallic
foreign body ingestion in children. J Otolaryngol 2000,
29:218–220.
32. Takada M, Kashiwagi R, Sakane M, et al.: 3D-CT diagnosis
for ingested foreign bodies. Am J Emerg Med 2000,
18:192–193.
33. Eliashar R, Dano I, Dangoor E, et al.: Computed tomo-
graphy diagnosis of esophageal bone impaction:
a prospective study. Ann Otol Rhinol Laryngol 1999,
108:708–710.
34. Silva RG, Ahluwalia JP: Asymptomatic esophageal
perforation after foreign body ingestion. Gastrointest
Endosc 2005, 61:615–619.
35. Lim CC, Cheah FK, Tan JC: Spiral computed tomography
demonstration of aorto-oesophageal fistula from fish-
bone. Clin Radiol 2000, 55:976–977.
36. Faigel DO, Stotland BR, Kochman ML, et al.: Device
choice and experience level in endoscopic foreign
object retrieval: an in vivo study. Gastrointest Endosc
1997, 45:490–492.
37.••Eisen GM, Baron TH, Dominitz JA, et al.: Guideline
for the management of ingested foreign bodies.
Gastrointest Endosc 2002, 55:802–806.
This article is the current practice guideline published by the
American Society for Gastrointestinal Endoscopy. It is concise,
easy to read, and gives recommendations based upon large
series and reports from recognized experts on the subject.
38. Chaves DM, Ishioka S, Felix VN, et al.: Removal of a for-
eign body from the upper gastrointestinal tract with a
flexible endoscope: a prospective study. Endoscopy
2004, 36:887–892.
39. Weinstock LB, Shatz BA, Thyssen SE: Esophageal food
bolus obstruction: evaluation of extraction and modi-
fied push techniques in 75 cases. Endoscopy 1999,
31:421–425.
40. Pezzi JS, Shiau YF: A method for removing meat impac-
tions from the esophagus. Gastrointest Endosc 1994,
40:634–636.
41. Nijhawan S, Rai RR, Nepalia S, Pokharna R: Suction
retrieval of esophageal foreign bodies. Endoscopy 1998,
30:S59.
42. Kozarek R, Ball T, Belic L, et al.: Food impaction at a
regional referral center: Should we push? Pull? or
Poke? Gastrointest Endosc 1999, 49:AB113.
43.• Vicari JJ, Johanson JF, Frakes JT: Outcomes of acute
esophageal food impaction: success of the push tech-
nique. Gastrointest Endosc 2001, 53:178–181.
This study evaluates the efficacy and safety of the “push” tech-
nique for endoscopic management of food impactions. The
safety of same session esophageal dilations is also reported.
44. Gluck M, Schembre DB, Kozarek RA: A concern with
use of the “push technique” in patients with multiple
esophageal rings. Gastrointest Endosc 2001, 54:543–544.
45. Alaradi O, Bartholomew M, Barkin JS: Upper endoscopy
and glucagon: a new technique in the management of
acute esophageal food impaction. Am J Gastroenterol
2001, 96:912–913.
46. Colon V, Grade A, Pulliam G, et al.: Effect of doses of
glucagon used to treat food impaction on esophageal
motor function of normal subjects. Dysphagia 1999,
14:27–30.
47. Nelson DB, Bosco JJ, Curtis WD, et al.: ASGE technol-
ogy status evaluation report. Endoscopic retrieval
devices. February 1999. American Society for Gastro-
intestinal Endoscopy. Gastrointest Endosc 1999,
50:932–934.
48. Waltzman ML, Baskin M, Wypij D, et al.: A randomized
clinical trial of the management of esophageal coins
in children. Pediatrics 2005, 116:614–619.
49. Bonadio WA, Jona JZ, Glicklich M, Cohen R: Esophageal
bougienage technique for coin ingestion in children.
J Pediatr Surg 1988, 23:917–918.
50. Gauderer MW, DeCou JM, Abrams RS, Thomason MA:
The “penny pincher”: a new technique for fast and
safe removal of esophageal coins. J Pediatr Surg 2000,
35:276–278.
51. Mosca S, Manes G, Martino R, et al.: Endoscopic man-
agement of foreign bodies in the upper gastrointesti-
nal tract: report on a series of 414 adult patients.
Endoscopy 2001, 33:692–696.