S2218 A Multi-Specialty Approach to Foreign Body Ingestion

Abstract

Introduction: Intentional foreign body ingestion represents a challenge to treat for emergency room physicians, endoscopists, and psychiatrists alike. Time from ingestion and composition of the ingested object are often unclear on initial presentation, making it difficult for endoscopists to determine the optimal timing for attempting procedural removal. Fortunately, over 80 percent of these ingested foreign bodies pass without the need for endoscopic intervention. We present a case, however, where emergent collaborative endoscopic intervention was needed. Case Description/Methods: A 29-year-old male with a history of schizoaffective disorder presented following purposeful ingestion of a foreign body. The patient was in a cemetery when he experienced auditory hallucinations instructing him to swallow his crucifix necklace. Following ingestion, the patient immediately experienced drooling, coughing, and dysphagia. Despite his attempts to self-expel the crucifix, it remained lodged. On arrival to the emergency department, the patient was intubated for airway protection. Initial laboratory findings were unremarkable except for a urine drug screen that was positive for amphetamines. Initially, the gastroenterology team was consulted, and EGD was pursued. An Olympus endoscope was inserted into the mouth and advanced under direct visualization to the upper esophageal sphincter where a metallic tip was seen. Rat tooth forceps were used to attempt to grasp the metallic object but resistance was met, and the procedure was aborted. Otolaryngology was then consulted and performed a direct laryngoscopy using a Lindholm laryngoscope. Evaluation showed that the distal aspect of the cross was down into the cervical esophagus while the right aspect of the cross was in the patient’s hypopharynx. The otolaryngology team was able to use a grasper to grab the clasp of the cross with successful removal. Following the procedure, the patient was safely extubated and eventually was eventually transferred to an inpatient psychiatric hospital. Discussion: This case highlights the importance of a multi-specialty approach to purposeful foreign body ingestion. Flexible endoscopy has become the instrument of choice in managing foreign bodies and, with the advent of retrieval devices, it has led to more than a 90 percent success rate of retrieval. Our case highlights that even when unsuccessful the importance of working alongside our otolaryngology colleagues can ensure safe outcomes.Figure 1.: X-ray imaging of an ingested crucifix requiring procedural removal.