Endoscopic Removal of a Long Intragastric Foreign Body with an Overtube

Abstract

Purpose: Ingestion of foreign bodies is a common occurrence, and accidental ingestion of long foreign bodies with pointed tips, such as a ballpoint pen, is a particular challenge for endoscopic removal. These long foreign bodies may predispose patients to intestinal obstruction, mucosal injury, hemorrhage and perforation. Patients with prior multiple abdominal surgeries are at particularly high risk for these complications due the altered anatomy. Case Report: A 31 year old Iraq war veteran with a history of multiple abdominal surgeries following war injuries, who came to the emergency department about 4 hours after accidently swallowing a 6 inch long ballpoint pen. Plain abdominal and chest x-ray showed a radiolucent longitudinal foreign body with a radio-opaque tip suggestive of a ballpoint pen, possibly in the body of the stomach. The patient was immediately taken to the operating room and the ballpoint pen was successfully removed endoscopically with a snare, using an overtube technique. After the procedure, the patient was stable and he was discharged the next day. Discussion: The factors that affect endoscopic management of intragastric foreign bodies are: the foreign body type and size; history of previous abdominal surgeries (as the anatomy is likely to be altered making the object unlikely to pass); and the timing of the endoscopic intervention. Objects longer than 5 cm or more than 2 cm in diameter are less likely to pass through the pylorus. Longer objects that pass from the stomach are also at risk for entrapment in many areas of the bowel. The goals of extraction are to protect the upper aerodigestive structures, and to maintain control of the object during extraction. An important principle to remember when extracting pointed objects is that the pointed end should trail, not lead. Urgent treatment is required for sharp or pointed objects due to increased risk of complications. The use of devices such as an esophageal or gastric length overtube may facilitate safer extraction of sharp or pointed objects.