Management of foreign bodies of the upper gastrointestinal tract: Update

0016-5107/95/4101-0039/$3.00 + 0 GASTROINTESTINAL ENDOSCOPY Copyright ® 1995 by the American Society of Gastrointestinal Endoscopy

Management of foreign bodies of the upper gastrointestinal tract: update William A. Webb, MD Opelika, Alabama

Management of 242 foreign bodies of the upper gastrointestinal tract are reported. Thirty-nine were in the pharynx, 181 in the esophagus, 19 in the stomach, and 3 in the small bowel. The flexible panendoscope was used 211 times (87.2%) to manage these foreign bodies, while the rigid esophagoscope was used 12 times (5.0%). Two hundred thirty-nine foreign bodies (98.8%) were successfully managed endoscopically. The surgery rate was 0.4%. There was no morbidity or mortality. Twenty-five percent of the cases were done under general endotracheal anesthesia. Coins in the esophagus are removed promptly if in the cervical or mid esophagus, and within 12 hours if in the distal esophagus. Once in the stomach, they will usually pass without difficulty. Meat impaction resulting in an obstructed esophagus is an urgent problem and the bolus should be removed within hours. Sharp and pointed foreign bodies can be very difficult to manage. Dry runs with a reproduction of the foreign body are essential to successful removal. Button batteries lodged in the esophagus represent an emergency and should be removed without delay. Once in the stomach, they will usually pass through the gastrointestinal tract without difficulty. The forward-viewing flexible panendoscope has become the instrument of choice in managing foreign bodies in most tertiary medical centers as well as in the community hospitals. (Gastrointest Endosc 1995;41:39-51.)

The management of 74 foreign bodies of the upper gastrointestinal tract was initially reported by this author in 1984,1 and in 1988 this experience was updated in a collective review. 2 The purpose of this paper is to further update and report the management of 242 foreign bodies and to revise treatment guidelines for specific foreign body groups. Since the author's training is with the rigid and the flexible instruments, the discussion will reflect both. MATERIAL From December 1975 to September 1993, 242 foreign bodies of the upper gastrointestinal tract were treated. Table 1 shows the location of the objects, with Received July 28, 1994. Accepted July 28, 1994. From the University of South Alabama School of Medicine, Mobile; the Department of Gastrointestinal Endoscopy, East Alabama Medical Center, and Surgical Clinic, Inc., Opelika, Alabama. Reprint requests: William A. Webb, MD, 121 North 20th Street, Opelika, AL 36801. 37/1/59452 VOLUME 41, NO. 1, 1995

39 being in the pharynx, 56 in the cervical esophagus, 125 in the mid and distal esophagus, 19 in the stomach, and 3 in the small bowel. Table 2 indicates the method of removal. The flexible forward-viewing panendoscope was used 211 times (87.2 % ); the rigid laryngoscope 16 times (6.6 % ), primarily for fish bones; the rigid esophagoscope 12 times (5.0 % ); and surgery was required once to remove a tablespoon that could not be retrieved endoscopically. Also, there was failure to remove two straight pins that were in fundal pools full of food. Ingestion of food within 6 hours prior to endoscopy was denied on history in both cases. Two hundred thirty-nine foreign bodies were removed endoscopically, for a 98.8 % success rate; three were not removed, for a 1.2 % failure rate; and the surgery rate was 0.4% (one case). There was no morbidity or mortality (Table 3). For discussion purposes, the patients are divided into two groups, pediatric (ages 3 months to 10 years) and adult (ages 11 to 91 years). There were 133 males (55 %) and 109 females (45 %). The pediatric group (Table 4) had 50 patients (21% ), while the adult group GASTROINTESTINAL ENDOSCOPY 3 9

Table 1, Anatomic location

Table 4. Foreign bodies (ages 3 months-10 years)

Pharynx Cervical esophagus Mid and distal esophagus Stomach Small bowel Total

39 56 125 19 3 242

Table 2. Method of removal Flexible endoscope Rigid laryngoscope Rigid esophagoscope Surgery (spoon) Failed (straight pins) Total

211 16 12 1 2 242

Table 3, Success and complication rates Success Failure Surgical Morbidity

Mortality

Number

Percent

239 3 1 0 0

98.8 1.2 0.4 0 0

(Table 5) had 192 (79 % ). Coins were the most common foreign body in the pediatric series (66 % of pediatric group and 13.6% of the total series). This is supported in other reported series. 3, 4 Meat impaction (115 cases) represented the most common offender in the adult group (60 %) and in the entire group (47.5 %'). Bones were the second most common foreign body in both age groups. The large number of meat impactions reported is probably related to the author's interest in peptic strictures of the esophagus. As originally reported, patients experiencing meat impaction have a 97 % yield of pathology in the esophagus, with benign strictures and esophagitis being the most common. 1 Six patients had multiple foreign bodies (2.5 % ), and eight patients had recurrent foreign bodies (3.3%). Twenty-five percent of the foreign body removals were done with the patient under general endotracheal anesthesia, including infants, children, deliberate ingestors (e.g., psychiatric patients, prisoners), and ingestions of difficult foreign bodies (e.g., 9-volt battery).

DISCUSSION In the United States, 1500 people die annually of ingested foreign bodies of the UGI tract. 5 Eighty to ninety percent of the objects will pass spontaneously, but 10 % to 20 % will have to be removed endoscopically; about 1% will require surgery. 57 Eighty percent of foreign body ingestions occur in the pediatric age group, s followed by edentulous adults, prisoners, and 40

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Coins Bones Pins Jackstones Battery Toy bell Button Marble Meat Metal clip Tack Total

33 4 4 2 1 1 1 1 1 1 1 50

Table 5. Foreign bodies (ages 11-91 years) Meat Bones Fiber Pills Coins Dental hardware Batteries Brush bristle Brazil nut Guitar pick Herb (seed) Miller-Abbott tube Pencil Popcorn husk Potato Razor blade Splinter Spoon Wrapper (ham) Total

115 35 13 6 5 3 2 2 1 1 1 1 1 1 1 1 1 1 1 192

psychiatric patients. Of all factors, the wearing of dentures is the one most commonly associated with foreign body ingestion in adults. 9,10 The presence of dentures eliminates the tactile sensitivity of the palatal surface so vital to identification of small items that may be included in an ingested bolus of food. n When a foreign body is ingested, Koch 12 believes that 80 % will enter the gastrointestinal tract and 20 % will enter the tracheobronchial tree. This author has previously reported that only 7.5% will enter the tracheobronchial tree. 1 Children most often ingest coins, toys, crayons, and ballpoint pen caps, whereas adults commonly tend to have problems with meat and bones. The possibility of a second foreign body should be considered when one is known to have been ingested. Recurrent episodes of foreign body ingestion may occur, especially in prisoners, psychiatric patients, and patients with peptic strictures. Rosenow 13 had a 10 % recurrence rate. This author previously reported a 2.7% rate, 1 and the recurrence rate in this update is 3.3%. As many as 2533 foreign bodies have been recorded VOLUME 41, NO. 1, I995

Figure 1. Anteroposterior chest film of a coin in the cervical esophagus.

in the stomach of a single patient. 14 Objects thicker than 2.0 cm and longer than 5.0 cm tend to lodge in the stomach. 12 Long foreign bodies (greater than 10 cm) tend to hang up in the duodenal sweep where perforations may involve the right kidney. 14

SPECIFIC FOREIGN BODY GROUPS

Figure 2. Lateral chest film demonstrating the edge of a coin in the esophagus. If the coin were in the more anterior trachea (arrow-aircolumn), the flat surface of the coin would be seen.

Coins One rarely sees problems with the ingestion of a dime (17 ram) or a penny (18 mm), for it is usually the larger coins (quarters: 23 mm) that lodge at the level of the cricopharyngeus muscle or just distal to it. 1 Anteroposterior (Fig. 1) and lateral (Fig. 2) radiographs of the neck and chest should be made to determine whether the coin, or any radiopaque foreign body, is in the trachea or in the esophagus. There has been debate in the pediatric literature as to whether an asymptomatic patient with a history of foreign body ingestion should have radiographs. 15,16 A metal detector has even been recommended rather than x-rays. 17 Because foreign bodies, especially coins, can be asymptomatic in the esophagus or the trachea, radiographs should be obtained. 18-21 Hodge et al. 22 reviewed the x-rays of 80 infants and children who had a history of foreign body ingestion and found that of the 14 symptomatic patients, all had positive radiographs, and 11 of 66 patients (16.6 % ) with no symptoms had positive films. Because of such findings, radiographs are always ordered when a history of coin or other foreign body

ingestion is obtained. In infants and children, x-ray films from the base of the skull to the anus should be made to determine whether more than one foreign body is present. Coins lodged in the esophagus should usually undergo extraction as soon as possible because of the serious complications, such as fistulae, that could result from a delay. 23~24 Fatalities due to aortoesophageal fistulae have been reported. 25 Chaikhouni et al.,26 in a statistical analysis of 88 patients with impacted esophageal foreign bodies, showed that the only factor that consistently correlated with major complications was the presence of the foreign body in the esophagus for more than 24 hours. The single most important consideration in managing coins and other foreign bodies at the level of the cricopharyngeus muscle or retrieving them through this area is to maintain an airway at all times. As stated earlier, the author performs 25 % of foreign body extractions using general endotracheal anesthesia, especially in infants and children. 1 The endoscopist has two choices of instruments to be used through

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the endoscope: the polypectomy snare or the foreign body grasping forceps. The Olympus alligator-type grasping forceps (Olympus America Inc., Lake Success, N.Y.) are superb and have facilitated coin retrieval. If the patient does not have an endotracheal tube, the Trendelenburg position should be used to keep the coin out of the trachea. The "through-the-scope" balloon can also be used to extract a coin, but this is rarely necessary. However, blunt foreign bodies, such as marbles, that cannot be grasped with instruments can be removed easily under direct vision by using through-the-scope esophageal dilating balloons. No fluoroscopy is needed with this technique. A new accessory, the Roth Retrieval Net (U.S. Endoscopy Group, Inc., Mentor, Ohio), which is a polypectomy snare with a net, can be used to capture round or oval-type foreign bodies with ease. This accessory should be in every endoscopist's foreign body armamentarium. It should be remembered that if one is having difficulty retrieving a foreign body from the esophagus and it is less than 2.0 cm in diameter and 5.0 cm in length, it can be gently pushed into the stomach and should pass through the gastrointestinal tract without difficulty. An alternative method for removing coins and blunt foreign bodies from the esophagus is the use of the Foley catheter. 27,2s Campbell et alo27 successfully removed blunt foreign bodies from 98 of 100 infants and children by this method. In a survey of pediatric radiologists, 2500 successful removals were recorded with only one reversible complication. 29 This procedure is performed in the radiology department under fluoroscopy, with the catheter being placed orally, rather than nasally, t o keep the foreign body out of the nasopharynx. The x-ray table is placed in a deep Trendelenburg position to minimize the chance that the foreign body will enter the larynx. The above authors, along with Ginaldi, 2s believe that Foley catheter removal is the procedure of choice for blunt foreign bodies of the esophagus that have been ingested for only a few hours. This author does not use the Foley catheter technique because it provides n o control of the foreign body as it is removed. Another disadvantage is that pathology, if present, cannot be assessed. If the foreign body has been present for longer than 24 hours, or if edema is present, this technique should not be used. The Foley catheter technique is recommended only if endoscopy is not available. Berggreen et al.,30 in a recent review of his foreign body experience, has an excellent discussion on this technique and supports this author's position. The magnet is not used for removal of metallic objects for the same reasons as indicated with the Foley catheter. Paulson and Jaffe, 31 however, have reported successfully removing metallic foreign bodies in 34 of 36 cases using this technique. 42

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If an infant or child has a coin lodged in the esophagus and it passes spontaneously, endoscopy is not necessary unless it is a recurrent episode. If more than an hour has elapsed since the last radiograph, another one should be taken to be sure the coin is still in the esophagus. This is true also if the patient's symptoms suddenly disappear. Although the coin located in the cervical or mid esophagus should be removed promptly, once it passes into the stomach it is a different matter. An asymptomatic coin in the distal esophagus may be given 12 to 24 hours to pass into the stomach. The coin(s) will usually pass through the gastrointestinal tract without difficulty. A radiograph once a week is sufficient, unless symptoms occur. One can allow 3 to 4 weeks for the coin to pass before endoscopically removing it from the stomach. Once beyond the stomach, it will pass through the remaining gastrointestinal tract without difficulty. Coins that have reached the stomach in infants or children who have had previous gastric outlet surgery, usually in the form of a pyloromyotomy, probably will not pass and will have to be removed endoscopically. 32, ~3 Although ingested coins are most often seen in children, they have also been encountered in adults in recent years. A popular game, "Quarters," has swept college campuses and towns and has necessitated removal of the quarter from the UGI tract. (In this game, the participant "chug-a-lugs" a glass of alcoholic beverage with a quarter in the bottom and attempts to catch the coin between the teeth. After repeating this act multiple times, it becomes more and more difficult to catch the quarter!)

Meat impaction Meat impaction in the upper and lower esophagus is the most common foreign body seen in adults. 1, 2, 34 Children rarely have this problem unless they have a congenital defect of the esophagus. Buchin, 35 in evaluating esophageal foreign bodies in 33 patients with esophageal abnormalities, found 15 in the pediatric age group. A symptomatic patient presenting with a history of meat impaction in the esophagus needs no radiographs or barium studies. The latter simply makes the task of the endoscopist more difficult by obscuring visualization of the foreign body and any pathology. If the patient is salivating and unable to handle his oral secretions, endoscopy should be performed immediately to prevent aspiration. If the patient can handle his saliva, emergency endoscopy is not necessary. Time and sedation will often allow the meat to pass into the stomach, and time is the more important of the two. However, the bolus should not be allowed to remain in the esophagus for longer than 12 hours, as complications may begin to arise. 26 The author has not found it useful or necessary t o u s e glucagon. 2 Even if the meat bolus passes, the adult patient should unV O L U M E 41, NO. 1, 1995

dergo endoscopy. It is only in recent years, with the use of the flexible endoscope, that the high incidence of pathology associated with meat impaction has been appreciated. 13In this author's experience, pathology is noted 97% of the time in adults. 1 Cancer, interestingly, is rarely a cause. In earlier reports, Brooks 36 and Buchen, 35 using the rigid endoscope, found no underlying pathology in 89% and 79%, respectively, of esophageal foreign body patients, including those with meat impaction. If endoscopy is performed with flexible instruments soon after ingestion, the meat can be removed as a single unit by use of a polypectomy snare. If the meat has started to fragment, however, it becomes more difficult to remove. In recent years, the push technique 2 has been very successful in dealing with the fragmenting meat bolus. An attempt is made first to bypass the meat with the flexible endoscope and assess the cause of the distal obstruction as well as the anatomic angle of the esophagus joining the stomach. If the stomach is entered, the endoscope is brought back proximal to the meat bolus and is then used to gently push it into the stomach. If the endoscope cannot be passed beyond the meat, one can still try to push it into the stomach. In a patient with no history of dysphagia or a history of only minimal dysphagia, this can usually be accomplished easily. It is important to remember that a hiatal hernia is often present and that the esophagogastric junction usually takes a left turn as it enters the hernia (patient's left side and the endoscopist's left through the endoscope). Therefore, it is important to push from the right side of the meat bolus as well as straight down the esophagus. Whether the meat bolus is being extracted or pushed forward, there is always concern about a bone spicule. To re-emphasize, gentle technique and good judgement are essential. Alternative techniques for meat extraction include the use of an overtube with the flexible endoscope to facilitate multiple passes. The overtube should be seated with a Maloney dilator (Pilling Company, Fort Washington, Pa.), rather than the endoscope, to prevent "pinch" injuries of the hypopharynx and cervical esophagus. Also, consideration can be given to the use of a rigid esophagoscope, which requires general endotracheal anesthesia. Recently, there have been reports of using the esophageal banding hood (C.R. Bard, Inc., Tewksbury, Mass.), used in rubber band ligation of varices, with the overtube to remove impacted meat boll. 37 This apparatus has been recalled by Bard and may not be available, however. One rarely needs these alternative techniques in managing impacted meat boil After the meat has been removed from the esophagus, endoscopic assessment should be completed. 3s If a peptic stricture is present and there is not too much reaction or edema from the foreign body, dilation V O L U M E 41, NO. 1, 1995

should be performed immediately. This is almost always done with a Maloney dilator. Being able to remove the foreign body, evaluate the pathology, and treat the cause are great advantages that flexible endoscopy offers over other methods of removal. Because the meat bolus is seen almost exclusively in the adult, general anesthesia is rarely necessary unless the rigid endoscope is utilized. Otherwise, conscious sedation is used. Of the three major groups of foreign bodies, coins, meat, and sharp objects, the management of meat impaction is the most controversial. Enzymatic disruption of the meat with papain (Adolph's Meat Tenderizer), glucagon, and gas forming agents are not needed. (Their use is discussed in more detail in the author's collective review article. 2) Papain is especially discouraged since deaths have been reported with its use. 39, 40 Pushing the meat bolus into the stomach blindly with a dilator should be mentioned, but is not recommended for fear of perforation. To reiterate, the best method of managing meat (or food) impaction is with the flexible endoscope, as described above. The rigid endoscope, as well as the ligator hood, are also acceptable, but other methods of management are not recommended.

Sharp and pointed foreign bodies Sharp and pointed foreign bodies, as well as elongated foreign bodies, can be very challenging and difficult to manage; fortunately they are not common. It is important to be extremely careful not to make this situation worse or to cause a complication, such as a perforated esophagus, that can be fatal. When considering sharp and pointed foreign bodies as a separate group, morbidity and mortality figures are higher.4, 41, 42 In this day of rapid transit, a patient can easily be moved to a center with an experienced endoscopist, if necessary. Moreover, it should not be considered a defeat to have to remove a foreign body surgically, for this is sometimes the safest means. The most common foreign bodies in this group are toothpicks, nails, needles, bones, razor blades, safety pins, and dental prostheses. Toothpicks and bones are the most common foreign bodies in this country requiring surgery. 23,43,44 In removing sharp and pointed foreign bodies, it is always good to remember Jackson's axiom: "Advancing points puncture, trailing do not. ''1 Objects longer than 5 cm and wider than 2 cm will rarely pass the stomach. 12 These foreign bodies can be removed from the duodenal bulb or duodenal sweep with success, 45, 46 but are more difficult. The narrow lumen and fixed position of the duodenum makes maneuvering more difficult. Glucagon given intravenously (0.4 to 0.6 mg in adults) for difficult foreign bodies in the duodenum and stomach can greatly facilitate their extraction. The open safety pin (Fig. 3) always represents a GASTROINTESTINAL ENDOSCOPY

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Figure 3. An open safety pin is of great concern to the endoscopist, but is usually easily removed (see text). major problem. If a safety pin is in the esophagus with the open end proximal, it is best managed with the flexible endoscope by pushing the pin into the stomach, turning it, and then grasping the hinged end and pulling it out first. An overtube or a rigid esophagoscope may be necessary with large open safety pins. Removal of multiple objects from the stomach is also made easier with an overtube. The closed safety pin, once in the stomach, will pass without difficulty. The ingested razor blade is a traumatic experience for both the patient and the endoscopist. Fortunately, the single-edge blade is usually seen today, rather than the double-edge blade. This foreign body can be managed with the rigid esophagoscope in both the child and adult by pulling the blade into the instrument. In this type of foreign body removal, the foreign body, the forceps, and the endoscope often have to be removed as a unit. In adults, the razor blade can also be managed with the flexible endoscope and overtube, especially if it has reached the stomach. One also can use a rubber hood (Endovations, Inc., Reading, Pa.) or a piece of rubber glove on the end of the endoscope to protect the esophagus from sharp or pointed foreign bodies. Once a razor blade has negotiated the stomach, surprisingly, it will usually pass through the lower gastrointestinal tract without difficulty.47 In removing difficult foreign bodies (Fig. 4), time 44 G A S T R O I N T E S T I N A L E N D O S C O P Y

Figure 4. Two 9 volt batteries swallowed by a prisoner (deliberate ingestor) illustrate the importance of duplicating the foreign body and making a "dry run."

spent in forethought and planning will make extraction easier and safer. If possible, the foreign body should be duplicated, studied, and evaluated with a "dry run." These patients should also be treated with intravenous antibiotics before the procedure. In a previous publication, 2 the author stated that every physician performing flexible endoscopy, especially the gastroenterologist, should have a good working relationship with an anesthesiologist and an expert in rigid endoscopy. It is now believed that only the former is necessary because the rigid endoscopist is so rarely needed in the management of foreign bodies. The use of general endotracheal anesthesia is most important when working with sharp and pointed foreign bodies and the blunt esophageal foreign body in an infant or child. A perforated esophagus in an uncooperative prisoner or a deliberate ingestor who swallows a sharp foreign body, or a fatality in an uncooperative infant from a coin that is dropped and causes airway obstruction during extraction, are unacceptable and preventable catastrophic complications. Although less than 1% of all foreign bodies perforate the gut, 4s almost all sharp and pointed foreign bodies VOLUME 41, NO. 1, 1995

should be removed before they pass from the stomach because 15 % to 35 % of this type 4, 42 will cause intestinal perforation, usually in the area of the ileocecal valve.23,49 The straight pin ingested by infants and children is an exception. It is surprising that more sharp foreign bodies do not perforate the gut. The mechanism that often prevents perforation in the intestinal tract by sharp objects seems to be the axial flow of the foreign body in the lumen, combined with reflex relaxation of the muscle wall, which tends to turn sharp objects around, making the sharp end trail, rather than lead. When foreign bodies reach the middle of the transverse colon, they become centered in the feces, and this facilitates passage of the objects through the remaining portion of the large bowel and anal canal. 5°, 51 A history of sharp and pointed foreign body ingestion is rarely available. 4s, 52, 53 Also, symptoms resulting from foreign body perforation so closely mimic other intraabdominal conditions that a diagnosis is seldom made preoperatively. 53 Maleki and Evans, 23 in reviewing 12 cases of intestinal perforations by foreign bodies, found five chicken bones, four toothpicks, two fish bones, and one hatpin--the only metallic foreign body in the group. The patient with the hatpin perforation was the only one who gave a history of foreign body ingestion. If this type of foreign body passes into the small bowel and is recognized, a high roughage diet is begun, but laxatives are not used. The author once advocated an oral antibiotic bowel preparation, ~4 but no longer does so due to the short time it is effective. Daily radiographs are necessary in this situation, as opposed to the retained coin in the stomach. If the sharp foreign body fails to progress for 3 consecutive days, surgical intervention should be considered. If the patient becomes symptomatic, surgical intervention will probably be necessary. Button batteries

Modern technology has resulted in problems with foreign bodies that did not exist 20 years ago. One of these objects is the button battery, which has come into widespread use with the introduction of miniaturized electronics. The development and sales of hearing aids, calculators, cameras, computers, watches, games, and gadgets have been rapid; almost all of these are powered by a button battery. Before 1983, there were only six cases o f button battery ingestion in the medical literature. 54-59 Now there are frequent reports, 6°86 with a retrospective analysis by Litovitz 6° of 119 cases being the largest in the world literature. Although the gastrointestinal tract is most frequently involved, the auditory and nasal passages have also been implicated. 67 Just as with coins, it is the larger button batteries, greater than 21 mm in diameter, that usually cause problems. Ten percent of ingested butV O L U M E 41, NO. 1, 1995

ton batteries become symptomatic, and children less than 5 years of age are the most common victims. 6s The three most commonly involved battery systems are the manganese dioxide, the silver oxide, and the mercuric oxide; it is the hearing aid battery and the mercuric oxide battery that are the most often ingested. 69 These three systems contain an alkaline electrolyte that is usually a 26 % to 45 % solution of potassium hydroxide, but may be sodium hydroxide. 69 This alkaline solution is strong enough to cause rapid liquification necrosis of tissue. In battery ingestion, the mechanism of injury can be caused by three different means: direct corrosive action, low-voltage burns, and pressure necrosis. 62, 69, 70 The low-voltage current generated by the battery itself in gastrointestinal tract fluid will often cause the seal to disrupt and thus leakage of the more potent alkaline base. Perforation can then result, almost always in the esophagus. When considering endoscopic management of button batteries, the gastrointestinal tract is divided into three parts: the esophagus, stomach, and intestines. Management differs for all three. A button battery lodged in the esophagus is a true emergency because of the extremely rapid action of the alkaline substance on the mucosa 61 and the probability of a catastrophic complication, such as an esophagotracheal or esophagoaortic fistula. 54 It is important to act more quickly with batteries than with coin ingestions where pressure necrosis is the major cause of complications. Radiologists should distinguish between a coin and a button battery lodged in the esophagus. 66 When viewed in an anterior projection (Fig. 5), the latter demonstrates a double density shadow (halo) due to the bilaminar structure of the battery. On the lateral view, the edges of the battery are round and again present a step-off at the junction of the cathode and anode. A coin has a much sharper edge on the lateral view. The endoscopic removal of the button battery can be a challenge. This is an important area for general endotracheal anesthesia, for the airway must be protected. In a collective review, endoscopic removal failed 62.5% of the time. 69 The battery can rarely be grasped with the foreign body forceps because it is too smooth. It can be removed from the esophagus with a through-the-scope balloon under direct vision. The balloon is passed distal to the battery and inflated, and then the balloon, battery, and endoscope are removed as a unit. Because there may be reaction between the edge of the disk and adjacent tissue, biopsy forceps may be necessary to "dissect" the battery free before removal. Under no circumstances should the battery be left in the esophagus. Removal of a button battery has been made much easier with the new accessory, the Roth Polyp ReGASTROINTESTINAL ENDOSCOPY

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Figure 5. A button battery (anteroposterior view) demonstrating the "halo sign" of a smaller disc within a larger disc.

trieval Net. The battery can be pushed into the stomach, "netted," and retrieved without difficulty. This has become the procedure of choice. One should remember to give glucagon so that the battery will not continue into the duodenum before one can retrieve it. Another alternative is to push the battery into the stomach and then retrieve it with a polypectomy snare or a Dormia basket. If it cannot be retrieved from the stomach, chances are excellent that it will pass distally and be evacuated. Once the battery has been removed, the area of involved esophagus is closely evaluated endoscopically for the amount of tissue damage. A barium swallow is obtained 24 to 36 hours after endoscopy to rule out a fistula. A second barium swallow is obtained 10 to 14 days later to rule out a stricture or a late-developing fistula. The patient is placed on antibiotics, but not steroids, if the involved area of the esophagus appears to have significant tissue damage. A Foley catheter is not used to remove a button battery without general anesthesia because of the possibility of fatal airway problems and the inability to visualize the area of impaction and the amount of tissue damage. Although emergency management of the button battery in the esophagus is well accepted, 61' 62, 69 management of this foreign body in the stomach and

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intestine is not as well standardized. Once in the stomach, the battery will usually pass without difficulty. 60'63'69'71 Daily radiographs are obtained; the battery is removed endoscopically, as described above, only if it remains longer than 36 to 48 hours or if the patient becomes symptomatic with epigastric distress. If the battery exceeds 20 mm in diameter, it is more likely than a smaller battery to require removal, just as with coins. Ipecac is not given because it is rarely successful and because one does not have control of the foreign body as it passes the epiglottis. 6°, 72 Once the button battery has moved beyond the pylorus and duodenal sweep, it cannot be retrieved from above endoscopically. As in the stomach, however, it will usually pass without difficulty. There has been only one reported complication in nearly 100 cases involving the intestine, 71 and this was a perforation from a button battery lodged in a Meckel's diverticulum. 59 In a series of 119 button batteries, 68.8% passed within 48 hours and 85.4% passed within 72 hours, with a range of 12 hours to 14 days. 6° Radiographs are obtained no more frequently than every 3 to 4 days once the battery has passed the stomach. If the battery fails to progress and the patient becomes symptomatic with abdominal pain or signs of peritoneal irritation, surgical intervention must be considered. The symptomatic patient is the strongest indication for surgery, although some investigators recommend a more aggressive approach to surgical intervention. 61, 62 H2 blockers are often administered to decrease the acid in the stomach, thus decreasing the battery reaction. Laxatives are given to hasten transit time through the intestine. However, benefits from either of these treatments have not been confirmed. 69 The management of mercuric oxide from mercury batteries must be considered. Because one cannot tell with certainty the type of battery system that has been ingested, it must be assumed that they are all mercuric oxide batteries. Mercuric oxide is toxic, but is poorly soluble and poorly absorbed by the gastrointestinal tract. Mercury poisoning has been documented in only one case, 73 and then it was a low level. Consideration must be given to measuring heavy metal levels in the blood or urine, especially if batteries are disrupted. Rarely, however, will chelation therapy be necessary. 73 Cocaine

The principles of management for cocaine ingestion have not changed since the 1988 review. 2 In recent years, drugs, most commonly cocaine, have become problems as foreign bodies. Because cocaine is a very popular drug among recreational drug users and because of the profits associated with selling it, large quantities are smuggled into this country. The "body packer" or "body bagger" syndrome has been associ-

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ated with this effort to conceal the illegal material. 74-76 Such a person may ingest multiple small packages containing cocaine. The condom is a favorite "packet, ''74 with 3 to 5 g usually put in a single condom, forming a grape-sized object. 74-76 The ingestion of 1 to 3 g of cocaine in powdered form can be fatal 77, 7s; rupture of even one package carries the risk of death. 74, 76 In one fatal case, 75 packets (condoms) had been ingested and eight had ruptured. TM When confronted with a patient with the probability of having ingested this foreign body, radiographs will demonstrate the packets 70% to 90% of the time.75, 76 A toxic screen should also be obtained. One should be careful performing a rectal examination because a packet could be disrupted. The usual methods of gastrointestinal decontamination (ipecac syrup, lavage, enema, and cathartics) should be avoided because of the possibility of packet rupture.72, 74,79, 80 The best means of removing the packets is with surgery. The endoscopist should not try to deliver the packets from above with the gastroscope or from below with the colonoscope; packet rupture has resulted from attempts at endoscopic removal. TM Patients who are at increased risk of toxicity are those (1) who have passed broken containers or demonstrate them on x-ray, (2) who are symptomatic, (3) who have gastrointestinal obstruction, (4) who have a time lapse of greater then 24 to 48 hours since ingestion, or (5) who have an abdominal x-ray demonstrating packets highly susceptible to breaking. 72, 75 This patient requires stabilization, activated charcoal, 72 and surgical removal of containers. It is difficult to know how to manage the asymptomatic patient who has ingested cocaine packets for less than 24 hours. However, if the packets seem resistant to disruption, they may be carefully monitored and managed medically. 72 If packets are passed, normal stools and follow-up radiographs should confirm successful removal. Because this patient is often uncooperative, the management of the "body bagger" can be very difficult.

Radiolucent foreign bodies Pieces of glass, bone fragments, aluminum (e.g., canned drink pop tabs), plastic, and pieces of wood can often be difficult to see in the hypopharynx and cervical esophagus on routine radiographs, sl If the patient has complained of swallowing a foreign body and it is not seen on routine radiographs, thin barium is used to try to outline the object. Barium impregnated cotton has not been helpful, in the author's experience. If the foreign body is identified radiographically, endoscopy is performed. If no foreign body is seen radiographically but the patient remains symptomatic, endoscopy is also performed. If no foreign body is seen

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radiographically and the patient has become asymptomatic, no endoscopy is necessary.

Foreign bodies at the level of the pharynx and cricopharyngeus These foreign bodies, usually in the form of fish bones or the toy jackstone, require different management. The gastroenterologist, as opposed to the otolaryngologist, has not usually received training with the indirect mirror technique for fish bones; if it becomes necessary to remove one, it is best done in the following manner. After sedation, the patient is placed in the supine position, and the endoscopist stands at the head of the stretcher. An open rigid laryngoscope (anesthesiology type) is used, along with a long surgical grasping clamp. The patient can always identify the side on which the foreign body is located, and it almost always will be anterior to the epiglottis in the base of the tongue or in the area of the tonsillar pillar. If removal is unsuccessful, the patient is placed in the left lateral position and flexible endoscopy is performed. The anatomic area anterior to the epiglottis is often unfamiliar, and a concentrated effort must be made to view it. One should remember that a scratch produced by the bone (or any foreign body) produces the same symptoms as the foreign body itself. If the foreign body is not found, the patient should be instructed to return if symptoms persist. The jackstone is difficult to remove because of its prongs. After general endotracheal anesthesia is administered, the endoscopist stands at the head of the table and elevates the epiglottis with the laryngoscope. The jackstone can usually be seen and can be grasped with the Kelly clamp and removed in an everting or obstetrical forceps delivery fashion. It is difficult to pull it out with a polypectomy snare and flexible endoscope if the sharp prongs are lodged posteriorly. Coins in this area, however, can still be best managed as outlined previously.

THE TIMING OF ENDOSCOPIC INTERVENTION While comments have been made in specific foreign body sections above on timing of removal, this important aspect of foreign body removal will be discussed as a unit. This information has not appeared in the literature previously and there is a need for guidelines in this area. (Barkin JS, written communication, May 1994)

General considerations If a child or adult arrives in the Emergency Room with airway obstruction secondary to a foreign body, it must be dealt with immediately or a fatality will result. If a patient begins to develop a compromised airway while under observation, it becomes an emergency

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and must be managed accordingly (i.e., removal of foreign body, tracheotomy). If a patient has recently ingested food, this factor must be carefully weighed against the possible complications of leaving the foreign body in place for 6 hours to allow for gastric emptying. For example, if a coin were in the distal esophagus and asymptomatic, intervention is not necessary until 6 hours have elapsed. If, on the other hand, an infant or child presents with a button battery in the esophagus and has just eaten, the patient should be placed under general endotracheal anesthesia and the battery removed. Immediate versus delayed removal of a foreign body must also be considered in inebriated and combative patients. The benefits of removal must outweigh the risk of complications.

Specific foreign bodies Coins. A coin in the upper or mid esophagus should be removed within hours of ingestion. A coin in the distal esophagus in an asymptomatic patient may be observed for up to 12 to 24 hours to see if it will pass into the stomach before removing it from the esophagus. Once in the stomach, the coin may be observed for 3 to 4 weeks before removal. I m p a c t e d m e a t b o l u s o f t h e e s o p h a g u s . This is a treacherous clinical situation. If the esophagus is obstructed and the patient cannot handle his saliva, then the bolus must be removed within hours. The patient cannot be discharged from the emergency department and he cannot be left overnight for removal in the morning. If the patient can handle his saliva, removal can be delayed for a few hours. If the patient is already at the hospital, the bolus should be removed; if the patient is at home late at night and requesting instructions, the endoscopy may be done early the following morning. S h a r p a n d p o i n t e d f o r e i g n b o d i e s . Small safety pins and tacks will usually pass through the gastrointestinal tract once in the stomach. Longer pins (corsage), sandwich toothpicks, and any long foreign body should be removed. All of these objects should be removed from the esophagus. It should be remembered that a sharp and pointed foreign body usually can be pushed from the esophagus into the stomach and removed through a gastrotomy, if necessary. Do not perforate the esophagus! B u t t o n b a t t e r i e s . As previously stated, a button battery in the esophagus is an emergency and should be removed as rapidly as possible. Once in the stomach it will usually pass through the gastrointestinal tract. If it becomes symptomatic in the stomach, it should be removed. If it is a known 23 mm battery, it should not be left in the stomach longer than 48 hours. Double A and triple A batteries do not usually present

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a problem once in the stomach and usually pass through the gastrointestinal tract without difficulty. R e c r e a t i o n a l d r u g s in p a c k e t s . Endoscopy usually plays no role in the management of this group of foreign bodies. POSTPROCEDURAL CONSIDERATIONS

Once foreign body extraction has been accomplished, one should always consider a perforation of the esophagus. If the extraction has been difficult, an immediate radiographic contrast study should be done. In the follow-up period, one should diligently watch for signs and symptoms of perforation~ such as fever, tachycardia, shortness of breath, chest pain, abdominal pain, and crepitation in the neck. The diagnosis is usually made with a chest film that shows mediastinal air. This complication must be diagnosed early for the patient to survive, s2-s5 Postprocedural respiratory problems in infants are always a consideration, and overnight observation is sometimes required. If the procedure is performed on an outpatient basis, the family or parents must be counseled. MORBIDITY AND MORTALITY

The flexible endoscope is enjoying amazing popularity at the present time, and increasing numbers of physicians are being trained to use the flexible instruments. The rigid endoscope, in the hands of an expert, is safe, s6' 87 as is the flexible instrument, ss, 89 Morbidity rates are well below 1% with both types, as they should be. Flexible morbidity rates of 0.08 % and rigid morbidity rates of 0.5 % have been reported. 9° In the hands of the average endoscopist, the flexible instrument is the safer. The training and experience of the individual endoscopist, however, must determine the instrument of choice. At East Alabama Medical Center there were two perforations in the last 100 diagnostic and therapeutic rigid esophagoscopies. In the last 10,000 flexible esophagoscopies, including diagnostic and therapeutic examinations, the author has not had an instrument perforation. Unfortunately, just as in many other areas of medicine, the true complication rate of foreign body extraction, especially perforation, will never be known. The experienced operator tends to report his complication rates, whereas the inexperienced one does not. Jackson, 91 in commenting on his large experience of more than 3000 tracheal and esophageal foreign bodies, stated that, "Any object in the esophagus can be removed esophagoscopically." Giordano et al., 92 in a review of the literature, reported an estimated incidence of 0.34% perforation and 0.05 % mortality rate for the use of rigid esophagoscopy in removal of foreign bodies from the esophagus. Chaikhouni et al. 26 suc-

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cessfully m a n a g e d 47 of 49 (96 %) patients with an esophageal foreign b o d y with the rigid esophagoscope without a complication. Brooks 36 r e p o r t e d an experience with 200 esophageal foreign bodies: 26 patients had m e a t impaction and removal with the rigid esophagoscope with t h r e e perforations (11.5%) and one d e a t h (3.8 % ). Berggreen et al. 3° reviewed 192 cases of foreign bodies in children and adults where b o t h the flexible and the rigid endoscope were used. Success rates for rigid esophagoscopy (100 %) and flexible endoscopy (96.2 % ) were not significantly different. Rigid endoscopy had a higher complication rate t h a n flexible endoscopy, 10% versus 5.1%. Using the flexible endoscope, Classen et al. 93 rep o r t e d removal of foreign bodies in 186 patients with one perforation (0.5 % ). Vizcarrondo et al. 3 r e p o r t e d 40 patients managed with the flexible endoscope with a 92 % success rate with food impaction and a 76 % success rate with other foreign bodies. T h e r e was no morbidity or mortality. Ricote et a l Y r e p o r t e d 57 foreign body extractions of the u p p e r gastrointestinal t r a c t with a success rate of 94.3 %. T h e r e was no m o r b i d i t y or m o r t a l i t y associated with the endoscopic procedures. As has been stated earlier in this p a p e r (Table 3), 242 foreign bodies were m a n a g e d by the a u t h o r with 239 being r e m o v e d successfully (98.8%). T h r e e were not r e m o v e d for a 1.2% failure rate, and the surgery rate was 0.4 % (one case). T h e r e was no m o r b i d i t y or mortality. T h e deliberate ingestor, usually a prisoner or psychiatric patient, carries a higher complication rate and surgical rate t h a n the accidental ingestor. Gracia et al. 94 reviewed 49 cases of gastric foreign bodies. T h e r e were 22 cases of deliberate ingestions with five perforations. Endoscopic failure in this group was 80 %. T h e entire group of 49 patients had surgical intervention in 19 cases (38.7 %). Although b o t h the rigid and the flexible endoscopes can be used to successfully manage foreign bodies of the u p p e r gastrointestinal tract, more physicians are being trained with flexible esophagogastroduodenoscopes and less with rigid esophagoscopes. T h e mana g e m e n t of foreign bodies will increasingly fall into the d o m a i n of the flexible endoscopist, especially the gastroenterologist. SUMMARY For special foreign bodies (e.g., fish bones, toy jackstones) at the level of the h y p o p h a r y n x or cricopharyngeus muscle, the open rigid laryngoscope (anesthesiologist type) and a surgical grasping clamp (Kelly) should be used. For all other foreign bodies of the esophagus, stomach, and d u o d e n u m the flexible endoscope is usually the i n s t r u m e n t of choice. T h e rigid endoscope is less expensive and easier to clean, b u t the

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advantages of the flexible endoscope are numerous. It is safer in average hands; it results in less postprocedural discomfort; it does not usually require general anesthesia; it has built-in air insuffiation and suction, as well as magnifying optics (most i m p o r t a n t when managing the esophageal foreign body); it makes possible examination of the stomach and at least p a r t of the duodenum; and it is more cost-effective, requiring less use of general anesthesia or the recovery room. 2 ACKNOWLEDGMENTS T h e a u t h o r t h a n k s Dr. William M o o n e y for his help in collecting data; L i n d a Jordan, RN, Carol Benson, RN, and L e r o y Jones, M T in the Gastrointestinal Endoscopy Unit; and L i n d a Webb. REFERENCES 1. Webb WA, McDaniet L, Jones L. Foreign bodies of the upper gastrointestinal tract: current management. South Med J 1984; 77:1083-6. 2. Webb WA. Management of foreign bodies of the upper gastrointestinal tract. Gastroenterology 1988;94:204-16. 3. Vizcarrondo FJ, Brady PG, Nord HJ. Foreign bodies of the upper gastrointestinal tract. Gastrointest Endosc 1983;29:208-10. 4. Rosch W, Classen M. Fiberendoscopic foreign body removal from the upper gastrointestinal tract. Endoscopy 1972;4:193-7. 5. Schwartz GF, Polsky HS. Ingested foreign bodies of the gastrointestinai tract. Am Surg 1976;42:236-8. 6. Perelman H. Toothpick perforation of the gastrointestinal tract. Journal of Abdominal Surgery 1962;4:51-3. 7. Bendig DW, Mackie GG. Management of smooth-blunt gastric foreign bodies in asymptomatic patients. Clin Pediatr 1990;29: 642-5. 8. Erbes J, Babbitt DP. Foreign bodies in the alimentary tract of infants and children. Applied Therapeutics 1965;7:1103-9. 9. Gunn A. Intestinal perforation due to swallowed fish or meat bone. Lancet 1966;1:125-8. 10. Bunker PG. The role of dentistry in problems of foreign body in the air and food passage. J Am Dent Assoc 1962;64:782-7. 11. Dick ET. Cocktail stick perforation of the large bowel. NZ Med J 1966;65:986. 12. Koch H. Operative endoscopy. Gastrointest Endosc 1977;24: 65-8. 13. Rosenow EC. Foreign bodies of the esophagus. In: Payne WS, Olsen AM, eds. The esophagus. Philadelphia: Lea & Febiger, 1974:159-70. 14. Pellerin D, Fortier-Beanlieu M, Gueguen J. The fate of swallowed foreign bodies: experience of 1250 instances of subdiaphragmatic foreign bodies in children. Progress Pediatric Radiology 1969;1:286-302. 15. Caravati EM, Bennett DL, McElwee NE. Pediatric coin ingestion. A prospective study on the utility of routine roentgenograms. Am J Dis Child 1989;143:549-51. 16. Schunk JE, Corneli H, Bolte R. Pediatric coin ingestions. A prospective study of coin location and symptoms. Am J Dis Child 1989;143:546-8. 17. Ros SP, Cetta F. Metal detectors: an alternative approach to the evaluation of coin ingestions in children. Pediatr Emerg Care 1992;8:134-6. 18. Nathman BV, Mueller CF. Asymptomatic esophageal perforation by a coin in a child. Ann Emerg Med 1984;13:627-9. 19. Morioka WT, Smith TW, Maisel RH, et aI. Unexpected radiographic findings related to foreign bodies. Annals of Otolaryngolegy 1975;84:627-30. 20. Spitz L, Hirsig J. Prolonged foreign body impaction in the esophagus. Arch Dis Child 1982;257:551-3. 21. Handler SD, Beaugard ME, Canalis RF, Fee WE. Unsuspected

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esophageal foreign bodies in adults with upper airway obstruction. Chest 1981;80:234-6. 22. Hodge D, Tecklenburg F, Fleisher G. Coin ingestion: does every child need a radiograph? Ann Emerg Med 1985;14:443-6. 23. Maleki M, Evans WE. Foreign body perforation of the intestinal tract. Arch Surg 1970;101:475-7. 24. Spitz L. Management of ingested foreign bodies in childhood. BMJ 1971;4:469-72. 25. Wu MH, Lai WW. Aortoesophageal fistula induced by foreign bodies. Ann Thorac Surg 1992;54:155-6. 26. Chaikhouni A, Kratz JM, Crawford FA. Foreign bodies of the esophagus. Am Surg 1985;51:173-9. 27. Campbell JB, Quattromani FL, Foley LC. Foley catheter removal of blunt esophageal foreign bodies. Experience with 100 consecutive children. Pediatr Radiol 1983;13:116-9. 28. Ginaldi S. Removal of esophageal foreign bodies using a Foley catheter in adults. Am J Emerg Med 1985;3:64-6. 29. Campbell JB, Condon VR. Catheter removal of blunt esophageal foreign bodies in children. Survey of the Society for Pediatric Radiology. Pediatr Radiol 1989;19:361-5. 30. Berggreen PJ, Harrison ME, Sanowski RA, Ingebo K, Noland B, Zierer S. Techniques and complications of esophageal foreign body extraction in children and adults. Gastrointest Endosc 1993;39:626-30. 31. Paulson EK, Jaffe RB. Metallic foreign bodies in the stomach: fluoroscopic removal with a magnetic orogastric tube. Radiology 1990;174:191-4. 32. Cass DT. Gastric retention of a swallowed coin after surgical treatment of pyloric stenosis. Aust Paediatr J 1989;25:299-301. 33. Stringer MD, Kiely EM, Drake DP. Gastric retention of swallowed coins after pyloromyotomy. Br J Clin Pract 1991;45:66-7. 34. Webb WA. Foreign body extraction from the upper gastrointestinal tract. In: Bayless TM, ed. Current therapy in gastroenterology and liver disease. Philadelphia: B.C. Decker, 1986:44-8. 35. Buchin PJ. Foreign bodies of the esophagus. New York State Journal of Medicine 1981;81:1057-9. 36. Brooks JW. Foreign bodies in the air and food passages. Ann Surg 1972;175:720-32. 37. Saeed ZA, Michaletz PA, Feiner SD, Woods KL, Graham DY. A new endoscopic method for managing food impaction in the esophagus. Endoscopy 1990;22:226-8. 38. Webb WA. The use of endoscopy in assessment and treatment of peptic strictures of the esophagus. Am Surg 1984;50:476-8. 39. Andersen HA, Bernatz PE, Grindlay JH. Perforation of the esophagus after use of a digestive agent: report of a case and experimental study. Ann Otol Rhinol Laryngol 1959;68:890-6. 40. Holsinger JW, Fuson RL, Sealy WC. Esophageal perforation following meat impaction and papain ingestion. JAMA 1968; 204:188-9. 41. Ricote GC, Torte LR, DeAyala VP, et al. Fiberendoscopic removal of foreign bodies of the upper part of the gastrointestinal tract. Surg Gynecol Obstet 1985;160:499-504. 42. Carp L. Foreign bodies in the intestine. Ann Surg 1927;85:57591. 43. Schwartz JT, Graham DY. Toothpick perforation of the intestines. Ann Surg 1977;185:64-6. 44. Budnick LD. Toothpick-related injuries in the United States, 1979 through 1982. JAMA 1984;252:796-7. 45. Manegold BC, Mennicken C. Gastrointestinal foreign bodies. Excerpta Medica International Congress Series 1981;555:79-85. 46. Manegold BC. Endoscopic foreign body removal including suture extraction. In: Demling L, Koch H, eds. Operative endoscopy past and future. Baltimore: University Park Press 1977: 119-27. 47. Read KE. Intestinal perforation by wood splinter. BMJ 1946;1: 315. 48. Johnson WE. On ingestion of razor blades. JAMA 1969;208: 2163. 49. Hacker JF, Cattau EL. Management of gastrointestinal foreign bodies. Am Fam Physician 1986;34:101-8. 50. Macmanus JE. Perforation of the intestine by ingested foreign body. Am J Surg 1941;53:393-400. 51. Davidoff E, Towne JB. Ingested foreign bodies. New York State Journal of Medicine 1975;75:1003-7.

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52. Cohen H. Glass gluttony and gastrointestinal gouging. JAMA 1968;206:1582. 53. Snodgrass TJ. Foreign bodies in the intestinal tract. Arch Surg 1947;55:441-56. 54. Blatnik BS, Toohill RJ, Lehman RH. Fatal complications from an alkaline battery foreign body in the esophagus. Annals of Otolaringology 1977;86:611-5. 55. Shabino CL, Feinberg AN. Esophageal perforation secondary to alkaline battery ingestion. Journal of the American College of Emergency Physicians 1979;8:360-2. 56. Barros EA, Barros AAB. Mercury battery ingestion [Letter]. BMJ 1979;1:1218. 57. Reilly DT. Mercury battery ingestion. BMJ 1979;1:859. 58. Votteler TP. Warning: ingested disc batteries [Letter]. Tex Med 1981;77:7. 59. Willis GA, Ho WC. Perforation Of Meckel's diverticulum by an alkaline hearing aid battery. Can Med Assoc J 1982;126:497-8. 60. Litovitz TL. Battery ingestions: product accessibility and clinical course. Pediatrics 1985;75:468-76. 61. Votteler TP, Nash JC, Rudledge JC. The hazard of ingested alkaline disk batteries in children. JAMA 1983;249:2504-6. 62. Temple DM, McNeese MC. Hazards of battery ingestion. Pediatrics 1983;71:100-3. 63. Maves MD, Carithers JS, Birck HG. Esophageal burns secondary to disc battery ingestion. Ann Otol Rhinol Laryngol 1984; 93:364-9. 64. Rumack BH, Rumack CM. Disk battery ingestion. JAMA 1983; 249:2509-11. 65. Yasui T. Hazardous effects due to alkaline button battery ingestion: an experimental study. Ann Emerg Med 1986;15: 901-6. 66. Maves MD, Lloyd TV, Carithers JS. Radiographic identification of ingested disc batteries. Pediatr Radial 1986;16:154-6. 67. Kavanagh KT, Litovitz TL. Miniature battery foreign bodies in auditory and nasal cavities. JAMA 1986;255:1470-2. 68. Temple AR, Veltri JC. One year's experience in a regional poi~ son control center. The IntermountainRegional Poison Control Center. Clinical Toxicology 1978;12:27-89. 69. Litovitz TL. Button battery ingestions. JAMA 1983;249:2495-500. 70. Katz L, Cooper MT. Danger of small children swallowing hearing aid batteries [Letter]. J Otolaryngol 1978;7:467. 71. Mofenson HC, Greensher J, Caraccio TR, Danoff R. Ingestion of small flat disc batteries. Ann Emerg Med 1983;12:88-90. 72. Boehnert MT, Lewander WJ, Gaudreault P, Lovejoy FH. Advances in clinical toxicology. Pediatr Clin North Am 1985;32: 193-211. 73. Kulig K, Rumack CM, Rumack BH, Duffy JP. Disk battery ingestion: elevated urine mercury levels and enema removal of battery fragments. JAMA 1983;249:2502-4. 74. Suarez CA, Arango A, Lester JL. Cocaine-condom ingestion: surgical treatment. JAMA 1977;238:1391-2. 75. Caruana DS, Weinbach B, Goerg D, et al. Cocaine packer ingestion. Ann Intern Med 1984;100:73-4. 76. McCarron MM, Wood JD. The cocaine "body packer" syndrome. JAMA 1983;250:1417-20. 77. Price KR. Fatal cocaine poisoning. J Forensic Sci Soc 1974;14: 329-33. 78. Wetli CV, Wright RK. Death caused by recreational cocaine use. JAMA 1979;241:2519-22. 79. Jonsson S, O'Meara M, Young JB. Acute cocaine poisoning. Am J Med 1983;75:1061-4. 80. Weber F, Williams G, Swartz MA. Effect of ipecac in "body packers." Ann Emerg Med 1982;11:699-700. 81. Payne SDW, Henry W. Radiolucent dentures impacted in the oesophagus. Br J Surg 1984;71:318. 82. Sawyers JL, Lane CE, Foster JH, et al. Esophageal perforation: an increasing challenge. Ann Thorac Surg 1975;19:233-8. 83. Elleson DA, Rowley SD. Esophageal perforation: its early diagnosis and treatment. Laryngoscope 1982;92:678-80. 84. Sarr MG, Pemberton JH, Payne WS. Management of instrumental perforations of the esophagus. Thorac Cardiovasc Surg 1982;84:211-8. 85. Skinner DB, Little AG, DeMeester TR. Management of esophageal perforation. Am J Surg 1980;139:760-4.

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86. Wychulis AR, Fontana RS, Payne WS. Instrumental perforations of the esophagus. Diseases of the Chest 1969;55:184-9. 87. Jones RJ, Samson PC. Esophageal injury. Ann Thorac Surg 1975;19:216-30. 88. Shamir M, Schuman BM. Complications of fiberoptic endoscopy. Gastrointest Endosc 1980;26:86-91. 89. Mandelstam P, Sugawa C, Silvis SE, Nebel OT, Rogert BHG. Complications associated with esophagogastroduodenoscopy and with esophageal dilation. Gastrointest Endosc 1976;23:16-9. 90. Borgeskov S, Struve-Christensen E. The modern treatment of oesophageal strictures using the Eder-Puestow dilators. Acta Otolaryngol (Stockh) 1978;85:456-60.

91. Jackson CL. Foreign bodies in the esophagus. Am J Surg 1957; 93:308-12. 92. Giordano A, Adams G, Boies L Jr, Meyerhoff W. Current management of esophageal foreign bodies. Arch Otolaryngol 1981; 107:249-51. 93. Classen M, Farthmann EF, Seifert E, et al. Operative and therapeutic techniques in endoscopy. Clinics in Gastroenterology 1978;7:741-63. 94. Gracia C, Frey CF, Bodai BI. Diagnosis and management of ingested foreign bodies: a ten-year experience. Ann Emerg Med 1984;13:30-4.

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