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Managing
GI emergencies
Food impactions, ingestion of foreign objects and
caustic substances
By
Diana Swift
NEW
ORLEANS, LA-With
a prevalence of 16 cases per 100,000 of population, food impactions
and foreign-body ingestions are a common GI emergency. "Though
the majority resolve spontaneously, 10 to 20 per cent will require
non-surgical interventions and one per cent will require surgery,"
Gregory G. Ginsberg, MD, said. From is a litigious area, he noted.
The ingestion of foreign objects occurs mainly in children aged
six months to three years, but also affects adults with compromised
mentation, mental retardation or inebriation, incarcerated individuals
looking for special treatment, and people with decreased tactile
sensation due to dental prosthetics, said Dr. Ginsberg, Associate
Professor of Medicine and Director, Endoscopic Services, University
of Pennsylvania, Philadelphia, PA.
While food impactions are sometimes due to underlying pathologies
such as esophageal motility disorders, they usually strike either
the "young and the restless"--those who gobble improperly
chewed food while talking on cellphones--or the "old and the
toothless"--those with compromised dentition or ill-fiiting
dentures that inhibit mastication.
In people with normal anatomy, impactions occur in locations of
physiologic narrowing and areas of acute articulation such as anastomatic
sphincters, the hypopharynx, the upper esophageal sphincter, the
pylorus, the duodenal sweap, the ileocecal valve, and the anorectum.
In pathological anatomy, the most affected areas are Schatzki's
ring, peptic strictures, esophageal webs, surgical anastomases,
tumours and congenital malformations of the gut.
Objects are categorized as blunt (coins, small toys, bottle caps),
long (pens, pencils, toothbrushes, cutlery), sharp and pointed (bones,
toothpicks, razors, glass, dental bridgework), and miscellaneous
(narcotic packs and disc batteries).
Food impactions are most commonly caused by meats such as chicken,
beef, pork, and hot dogs (which contain fillers that plump up when
they take in moisture). Another cause is vegetables cooked al dente.
Starchy foods rarely cause impactions. Dr. Ginsberg has named a
new impaction-risk scenario "Ginsberg's Triad": cocktails,
conversation and finger food.
When taking histories from children and those with compromised mentation,
the physician may have to rely on signs and symptoms of choking
such as refusal to eat and respiratory distress. "Be sure to
ask patients about previous episodes and the status of their dentition.
Assess their mental status to see if you can trust the information
they provide," he said, noting that one mental patient he treated
volunteered that she had placed a spoon in her rectum but not that
she had first broken it in two first. It is also important to establish
whether there is airway compromise and risk of aspiration. "Such
cases must be addressed immediately and may require anesthesia or
intubation assistance from your ER staff."
The gastroenterologist must carefully examine the neck, looking
for swelling, erythema, tenderness and crepitus. "You must
assess whether perforation has already occurred before inserting
the endoscope," he said. "And it is important to document
that you have done all these things."
Most food impactions are radiopaque, with the exception of fish
and chicken bones. Other exceptions to radiopacity are wood, plastic
and glass. It is a wise practice to get biplanar radiographs of
the head, neck and chest areas, said Dr. Ginsberg, referring to
a patient who had ingested metal wire while eating pasta, but whose
abnormality showed up only on the lateral X-ray view.
"There is no role for contrast studies in these patients. These
absolutely increase the risk of aspiration because you are filling
the esophagus with a column of contrast medium. And if a patient
tells you he can't swallow his own secretions, you don't need this
type of X-ray to prove there's an obstruction. It will only compromise
your endoscopy."
After the history and physical exam, flexible endoscopy to locate
the object is the first line of management, and the gastroenterologist
must individualize the timing according to risk of aspiration and
perforation and the location and duration of the obstruction. "There
is an increased risk of morbidity and mortality once the objects
go beyond the lower esophageal sphincter. So the golden rule is
to use the endoscope sooner rather than later." There is no
role for meat tenderizers, like papain, fizzies and carbonated beverages
or motility agents.
Typically, patients can be sedated, and in those with a compromised
airway or compromised mentation that may inhibit safe and effective
sedation, there is a role for general anesthesia and intubation.
Dr. Ginsberg highly recommended taking a "dry dock" run
and practising the extracorporeal retrieval of various foreign objects
beforehand. Tools should include a variety of forceps such as the
rat tooth and alligator type. There should also be graspers, snares,
baskets and overtubes, aspiration vacuum cap and protector hoods.
He noted that the esophagus does not easily release objects but
grasps them tightly and is programmed to push them forward. Overtubes
are effective for times when the physician needs to repeat insertions
of the endoscope for food impactions or to remove sharp objects
or long ones such as toothbrushes.
Most sharp objects will pass through the digestive tract spontaneously
within a week, so weekly radiographs are a good idea. The exceptions
are round objects at least 2.5 cm in diameter which have trouble
clearing the pylorus, and long objects of more than 10 cm which
have difficulty traversing the duodenal C-loop. "If you can
do so safely, remove the object, but you have to embrace Chevalier
Jackson's axiom: 'a leading point punctures; a trailing point does
not.'"
In some cases the endoscopist will have to re-orient the object
for proper grasping. "You don't need to do this at 2 a.m. You
can make sure an emergency patient is stable and then do the procedure
in the endoscopy unit the next morning with proper sedation and
your best staff."
Dr. Ginsberg's advises clinicians to: inspect with endoscopy; note
the location of the foreign body sensation; make sure the esophagus
is clear of secretions; provide appropriate airway protection; and
intubate if necessary. When feasible, it is best to try to steer
around a food impaction and see what lies beyond, then gently nudge
the morcilized food bolus into the stomach. "Do not blindly
advance dilators past the narrowed area," he said. Patients
with prior GI surgery are of special concern, and some patients
may need an ENT specialist to do a laryringoscopy when objects are
lodged at the level of the laryngopharynx.
In the miscellaneous category, the ingestion of disc-shaped batteries
is increasingly common. These should be pushed from the esophagus
into the stomach and retrieved. "As for narcotic packets, there
is no role for endoscopy here; these require the attention of your
surgical colleagues."
For objects lodged in the colorectum due to sexual assault or erotic
misadventure, the gastroenterologist should attempt flexible endoscopy.
"One trick here to eliminate the vacuum effect of a large foreign
object is to place a chest tube or nasogastric tube up beyond it."
As for caustic substances, children most commonly ingest these.
Acids cause coagulative necrosis and alkalis cause liquefaction
necrosis. The most important thing in this situation is to manage
the airway, breathing and circulation, which may involve resuscitation
and support. "Call your regional poison centre and acknowledge
that there is little you can do to reverse the extent of injury."
Endoscopy should be done in 24 to 48 hours to assess the degree
of damage. Mild injury usually resolves spontaneously, while deep
injury is apt to cause stricture and require dilation. Third-degree
injury is likely to cause perforation. "Do not attempt to neutralize
with mild acids or bases and do not attempt to intubate a necrotic
laryngopharynx," Dr. Ginsberg said, adding that there is insufficient
evidence to support the use of corticosteroids in these cases.
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