Foreign Body Extraction Extravaganza! Approach to 25 Foreign Bodies, One Patient

Abstract

Introduction: Specific characteristics of foreign bodies can present as challenges to successful endoscopic removal. Endoscopic removal is urgent in cases of sharp objects, esophageal obstruction, or battery ingestion. Case: A 45-year old Caucasian inmate with a history of bipolar disorder, self-injurious behavior (including self-mutilation creating enterocutaneous fistula), and ingestion of six AA batteries previously presented for repeat ingestion of multiple foreign bodies with diffuse abdominal pain, hemoptysis, and nausea. His vitals were stable with no significant lab abnormalities. Abdominal x-ray revealed 3 radio-opaque foreign bodies: An irregular circular object, a straightened paperclip, and a hexagonal/rectangular density. Cross-sectional imaging noted stable appearance straightened paperclip was interposed between stomach and transverse colon mesentery without perforation or inflammation. Neck and chest x-rays were negative for perforated viscus. Upper endoscopy was initially performed with moderate sedation, revealing multiple sharp razor blades in the stomach. The procedure was aborted to be performed with general anesthesia. Subsequent endoscopy resumed under general anesthesia. A blunt disc-shaped metallic object was removed with rat-toothed forceps and one AA battery was removed with a snare. A hood placed at the end of the endoscope for removal of sharp razorblades, however only partially opened at GE junction. A long esophageal overtube was placed. Subsequently, 21 razor blades were individually removed as an endoscopy technician held overtube in place to prevent migration and exposing GE junction/distal esophagus to sharp objects. Finally, two irregular circular objects, one of which became lodged into the overtube, were removed with both the snared lodged object and overtube taken out together from the mouth at the conclusion of the procedure. The patient tolerated the procedure well and was extubated without complication. Follow up abdominal x-ray did not reveal any remaining foreign bodies. The patient remained stable and discharged. Conclusions: Endotracheal intubation and general anesthesia should be considered for prolonged cases and safe endoscopic removal of multiple and/or sharp foreign bodies. A long esophageal overtube is preferred over hood for removal of sharp objects from the stomach. Future design improvements in endoscopic tools could aid in safer and more effective means of foreign body removal.1889_A Figure 1 No Caption available.1889_B Figure 2 No Caption available.1889_C Figure 3 No Caption available.