The Straw That Got Stuck: Predicting the Course of Foreign Body Impaction
Fady G. Haddad, MD; Mayurathan Kesavan, MD; Vivek Gumaste, MD; and Stephen Mulrooney, MD
Haddad FG, Kesavan M, Gumaste V, Mulrooney S. The straw that got stuck: predicting the course of foreign body impaction. Consultant. 2017;57(7):408-410.
A 27-year-old healthy woman presented with acute epigastric pain that had started 1 hour prior to evaluation. She described the pain as being severe and sharp, with no radiation or associated symptoms. She recalled having accidentally swallowed a plastic straw while showing her 18-month-old son how to drink through a straw several days earlier. The woman denied self-induced vomiting, a history of similar symptoms, psychiatric disease, and eating disorder.
On physical examination, the patient was in no acute distress. Her temperature was 37°C, her heart rate was 95 beats/min, and her blood pressure was 150/90 mm Hg. She was normocephalic with equal and reactive pupils. No dental abnormalities were noted.
Lung examination showed adequate air entry bilaterally. Cardiac examination revealed regular rate and rhythm, with no audible murmurs. Abdominal examination revealed no distension, normal bowel sounds, and a soft abdomen with mild epigastric tenderness without guarding or rebound. Physical and emotional development were appropriate for her age.
Contrast computed tomography (CT) scan of the abdomen revealed a 13-cm cylindrical foreign body (FB) within the duodenum, with no free air detected (Figures 1 and 2). The patient was admitted to the hospital.
Figure 1. Coronal view of contrast abdominal CT scan showing a 13-cm cylindrical FB (arrows) within the duodenum. No free air wasdetected.
Figure 2. Axial view of contrast abdominal CT scan showing the FB (arrow) within the duodenum.
Upper endoscopy revealed a cylindrical plastic object with one end embedded in a shallow linear 4-cm ulcer along the base of the duodenal bulb (Figure 3). The proximal edge of the object moved freely. The FB was removed successfully using rat-tooth forceps. Inspection of the FB revealed a tubular, straw-like, plastic object measuring 13.5 cm in length and 0.6 cm in diameter, with a wall measuring 0.1 cm in thickness (Figure 4). At the second part of the duodenum, where the distal end of the FB had impacted, a deep, 2-cm, cratered mucosal ulcer was found tunneling into the retroperitoneum (Figure 5). The defect was closed successfully with 2 endoclips (Figure 6).
Figure 3. Upper endoscopy image showing a 4-cm ulcer along the base of the duodenal bulb in which the FB was embedded.
Figure 4. A photograph of the 13.5-cm long, 0.6-cm diameter tubular, straw-like, plastic object, with a wall measuring 0.1 cm in thickness, that had been embedded in the duodenal bulb ulcer and was removed using rat-tooth forceps.
Figure 5. Upper endoscopy image showing a 2-cm cratered mucosal ulcer at the second part of the duodenum, where the distal end of the FB had lodged.
Figure 6. Upper endoscopy image showing the 2 endoclips used to close the mucosal ulcer where the proximal end of the FB had lodged.
FB ingestion is a common clinical scenario in gastroenterology and is intentional, not accidental, in the majority of cases.1 FB ingestion occurs most commonly in individuals who are elderly, who are incarcerated, or who have alcoholism, dental abnormalities, developmental delay, or psychiatric disorders.2-5 The most common FBs ingested in the elderly population include dentures, fish bones, and chicken bones, whereas coins and toys are more commonly ingested in the pediatric population.6 Most ingested objects are found in the esophagus,4 whereas only 2.6% to 4.5% lodge in the duodenum.4,7 Although most FBs pass uneventfully through the gastrointestinal (GI) tract, 10% to 20% of patients require nonsurgical interventions, and 1% need surgical removal.2,8
The ability of the FB to traverse the esophagus is a key determinant in the outcome of the FB ingestion, since most FBs will traverse the GI tract without complications after crossing the gastroesophageal junction.9,10 Once past the pylorus, FBs can lead to obstruction at various locations in the bowel, usually at the junction of the second and third parts of the duodenum, the ileocecal junction, the appendiceal lumen, the cecal and ascending colonic junction, and the large intestinal flexures and haustra.1 Objects more than 2 cm wide tend to remain in the stomach due to the luminal narrowing at the pylorus, whereas objects more than 5 cm long frequently impact in the duodenal sweep.10-12 Given that the onset of symptoms can be highly variable from the time of ingestion,13,14 imaging studies are often used to detect the current FB location. Limitations in localization by radiography include failure to identify fish or chicken bones, glass, thin metals, wood, and plastic.15 CT localization is limited by its inability to detect radiolucent objects.5
In patients presenting with FB ingestion, initial management depends on the risk of complications such as perforation or vascular penetration. High-risk individuals are those with history of GI tract surgeries or congenital gut malformations.5 Multiple long and thin objects tend to cause more complications.10,16,17 In the majority of low-risk individuals, FBs pass without further complications, and simple observation is warranted.2 In cases where intervention is needed, an endoscopic approach is favored as the initial approach,4,18 and the FB can be retrieved using snares, Dormia baskets, nets, tripods or rat-tooth forceps.19
Ingestion of long or sharp objects requires special attention.5 Objects of 6 to 10 cm in length may be grasped via forceps or snare and dragged into an overtube, which facilitates the retrieval of the object and its safe passage through the stomach and esophagus while protecting the airway.2,20 Sharp objects should always be retrieved, regardless of the presence or absence of symptoms,19 due to the higher risk of complications and higher mortality.2,3,9 Such objects are usually retrieved with a snare or a retrieval forceps (rat-tooth, biopsy, or alligator jaws) and an overtube by slowly trailing their sharp end in order to avoid mucosal injury.19
In our patient’s case, the straw was a blunt, 13-cm-long cylinder, and it was successfully retrieved with rat-tooth forceps without need of an overtube. The characteristics of the object—namely, the solid, nonflexible nature of the cylinder—prevented migration beyond the proximal duodenum and resulted in the formation of a tunneled defect into the retroperitoneum, which required endoscopic closure.
Outcome of the Case
Our patient’s condition remained stable during hospitalization, and her pain resolved after the endoscopic intervention to remove the ingested FB. She was able to tolerate a diet and was discharged with no further complications.
Fady G. Haddad, MD, is in the Department of Internal Medicine at Northwell Health Staten Island University Hospital (SIUH) in Staten Island, New York.
Mayurathan Kesavan, MD, is in the Department of Gastroenterology and Hepatology at Northwell Health SIUH in Staten Island, New York.
Vivek Gumaste, MD, is in the Department of Gastroenterology and Hepatology at Northwell Health SIUH in Staten Island, New York.
Stephen Mulrooney, MD, is a clinical assistant professor of medicine at the Hofstra Northwell School of Medicine at Hofstra University in Hempstead, New York.
- Dedania B, Khanapara D, Panwala A, Dharan M. A case of mysterious impacted duodenal foreign body presenting with halitosis. Case Rep Gastroenterol. 2016;10(3):800-807.
- Eisen GM, Baron TH, Dominitz JA, et al; Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy. Guideline for the management of ingested foreign bodies. Gastrointest Endosc. 2002;55(7):802-806.
- Stiles BM, Wilson WH, Bridges MA, et al. Denture esophageal impaction refractory to endoscopic removal in a psychiatric patient. J Emerg Med. 2000;18(3):323-326.
- Li Z-S, Sun Z-X, Zou D-W, Xu G-M, Wu R-P, Liao Z. Endoscopic management of foreign bodies in the upper-GI tract: experience with 1088 cases in China. Gastrointest Endosc. 2006;64(4):485-492.
- Islam SR, Islam EA, Hodges D, Nugent K, Parupudi S. Endoscopic removal of multiple duodenum foreign bodies: an unusual occurrence. World J Gastrointest Endosc. 2010;2(5):186-189.
- Cho EA, Lee DH, Hong HJ, et al. An unusual case of duodenal perforation caused by a lollipop stick: a case report. Clin Endosc. 2014;47(2):188-191.
- Katsinelos P, Kountouras J, Paroutoglou G, Zavos C, Mimidis K, Chatzimavroudis G. Endoscopic techniques and management of foreign body ingestion and food bolus impaction in the upper gastrointestinal tract: a retrospective analysis of 139 cases. J Clin Gastroenterol. 2006;40(9):784-789.
- Nassani N, El-Charabaty E, Nasr P, Barakat I, Andrawes S. Foreign body penetration through jejunal loops causing renal artery thrombosis and renal infarct. ACG Case Rep J. 2017;4:e12.
- Vizcarrondo FJ, Brady PG, Nord HJ. Foreign bodies of the upper gastrointestinal tract. Gastrointest Endosc. 1983;29(3):208-210.
- Webb WA. Management of foreign bodies of the upper gastrointestinal tract: update. Gastrointest Endosc. 1995;41(1):39-51.
- Chang J-J, Yen C-L. Endoscopic retrieval of multiple fragmented gastric bamboo chopsticks by using a flexible overtube. World J Gastroenterol. 2004;10(5):769-770.
- Palta R, Sahota A, Bemarki A, Salama P, Simpson N, Laine L. Foreign-body ingestion: characteristics and outcomes in a lower socioeconomic population with predominantly intentional ingestion. Gastrointest Endosc. 2009;69(3 pt 1):426-433.
- Adams DB. Endoscopic removal of entrapped coins from an intraluminal duodenal diverticulum 20 years after ingestion. Gastrointest Endosc. 1986;32(6):415-416.
- Tsui BC, Mossey J. Occult liver abscess following clinically unsuspected ingestion of foreign bodies. Can J Gastroenterol. 1997;11(5):445-448.
- Cheng W, Tam PKH. Foreign-body ingestion in children: experience with 1,265 cases. J Pediatr Surg. 1999;34(10):1472-1476.
- Velitchkov NG, Grigorov GI, Losanoff JE, Kjossev KT. Ingested foreign bodies of the gastrointestinal tract: retrospective analysis of 542 cases. World J Surg. 1996;20(8):1001-1005.
- Skeik N, Jabr FI, Stark M. Unusual case of foreign-body ingestion. J Emerg Med. 2013;44(3):e307-e309.
- Ikenberry SO, Jue TL, Anderson MA, et al; ASGE Standards of Practice Committee. Management of ingested foreign bodies and food impactions. Gastrointest Endosc. 2011;73(6):1085-1091.
- Cho HJ, Kim JY, Lee HC, et al. An impacted clamshell in the duodenum mistaken for a gall stone. Korean J Intern Med. 2007;22(4):292-295.
- Chinitz MA, Bertrand G. Endoscopic removal of toothbrushes. Gastrointest Endosc. 1990;36(5):527-530.