Foreign Body Obstruction - Esophagus.pptx

Foreign Body Obstruction of Esophagus - this presentation covers the key aspects of the condition where a foreign body (anything ranging from a blade to a stone) is stuck on the esophagus or the food pipe causing an obstruction of it.

1. Foreign body obstruction - Esophagus Vaibhav Ramesh Babu – Group 12

2. Anatomy of the Esophagus The esophagus is a 25 cm long fibromuscular tube extending from the pharynx (C6 level) to the stomach (T11 level). Anatomically, The esophagus is divided into three parts: Cervical  Thoracic  Abdominal  The upper third is voluntary striated muscles that allow initiation of swallowing, while muscles of the lower third are involuntary smooth muscles.

3. Anatomy of the Esophagus There are 2 sphincters namely, upper esophageal sphincter also known as the cricopharyngeus muscle. lower esophageal sphincter, also known as the cardiac sphincter. There are 3 anatomical narrowings : cervical constriction (narrowest point): due to the cricoid cartilage at the level of C5/6. thoracic constriction: due to the aortic arch at the level of T4/5. abdominal constriction: at the esophageal hiatus at the level of T10/11.

4. INTRODUCTION Most patients who present for evaluation of a foreign body in the esophagus do so after accidental ingestion of a known object, and the patient has mild symptoms and is in stable condition. The challenges come from patients who are unable or unwilling to provide a history of the object ingested or when it occurred. Examples are infants, children, mentally impaired, psychiatric, and prisoners, who are unable to provide a history of the object ingested or when it occurred

5. Etiology The esophagus is the most common site for an acute foreign body or food impaction in the gastrointestinal tract, and 80 to 90% of swallowed objects that reach the stomach will eventually pass without intervention. While a wide variety of objects could be ingested, common accidental esophageal foreign body ingestions include food bolus (mostly meat), fish or chicken bones, dentures, and coins.

6. Pathophysiology The normal esophagus has 3 primary areas of physiologic narrowing: the upper esophageal constriction, the middle esophageal and the lower esophageal constrictions. The most common place of obstruction is at the cervical constriction (Upper) (narrowest point): due to the cricoid cartilage at the level of C5/6. Possible complications include local injury to the mucosa, such as abrasion, lacerations, necrosis, and stricture formation. Other serious complications include injury beyond the esophagus, such as airway obstruction, esophageal perforation, tracheoesophageal fistula, vascular injury

7. Pathophysiology Three special types of foreign body ingestions with a higher risk of complications are button batteries (also called “disc” or “coin” batteries), multiple magnets, and sharp-pointed objects. Button Battery: If a button battery becomes impacted in the esophagus, an electrical current is created between the positive and negative poles. This current can cause thermal injury plus produce hydroxide ions with a rapid rise in the local pH resulting in a caustic alkaline injury. Injury begins within 15 minutes and can lead to a perforation in hours. Multiple magnets: Tissue may become trapped between the magnets leading to pressure ischemia, perforation, fistula formation, obstruction, or volvulus

8. Multiple magnets trapped at the esophagogastric junction of a child

9. Clinical Presentation Key factors to consider in assessing patients with ingested foreign bodies include type and number of objects, location, time since ingestion, and presenting signs and symptoms. The most common symptoms are foreign body sensation or difficulty swallowing (dysphagia). Symptoms typically develop in minutes to hours. Discomfort, ache, or chest pain, hypersalivation, retrosternal fullness, regurgitation, gagging, choking, hiccups, and retching If odynophagia - suspect laceration or perforation

10. Physical exam The physical exam should initially focus on airway patency, vital signs, patient’s ability to handle secretions, and looking for signs of complications such as hematemesis, abnormal breath sounds, tenderness in the neck, chest, or abdomen, or subcutaneous air. On exam, the patient may appear anxious and uncomfortable with swallowing. If the patient is unable to swallow saliva, this indicates a complete obstruction is needing more urgent treatment.

11. Evaluation: X-Ray: Routine x-rays are usually the first step if a radioopaque object is suspected. This will help determine the object, the location, and possible complications. Chest x-ray (posterior-anterior (PA) and lateral views) is usually adequate, but the neck and abdominal x-rays may be needed depending on clinical presentation. If plain films are not diagnostic, then Barium swallow is performed.

12. Evaluation: Food, plastic, wood, and aluminum are not radioopaque , so they are not seen on routine x-rays. Bones and glass may or may not be seen on x-rays If nothing is seen on routine x-rays, but suspicion of a foreign body remains high, then diagnostic endoscopy or CT scan is indicated. CT scans have a high sensitivity for detecting foreign bodies plus are useful for detecting complications such as perforation. Wooden bead obstructing the Esophagus in a 13 month old patient

13. Management Endoscopic removal is the procedure of choice and is successful in more than 90% of cases with less than a 5% complication rate. Endoscopic management can be divided into emergency, urgent, and nonurgent Emergency Esophageal obstruction: Inability to handle oral secretions Disk batteries in the esophagus Sharp-pointed objects in the esophagus Medical Management : In theory, medications that relax the smooth muscles of the LES might allow smooth, blunt objects to pass spontaneously into the stomach. IV Glucagon is the most commonly discussed agent; It might cause vomiting and it can complicate so it is not widely used.

14. Management Urgent (within 12 to 24 hours) Esophageal objects that are not sharp-pointed Food impactions without complete obstruction Sharp-pointed objects in the stomach or duodenum Objects greater than 6 cm in length above the duodenum Multiple magnets (or single magnet plus another ferromagnetic object within endoscopic reach) Coins in esophagus Nonurgent Objects in the stomach greater than 2.5 cm diameter Disk battery in stomach up to 48 hours if asymptomatic Blunt objects that fail to pass stomach in 3 to 4 weeks

15. Endoscopic Removal: Foreign bodies impacted at the level of cricopharynx should be removed using Upper esophageal speculum (under local/general anesthesia) Esophagoscope is used to remove general obstruction. Preferred to use General anesthesia as it provides for better relaxation. Types: Rigid Esophagoscope: Under GA , Made of metal and needs expertise as risk of perforation is high. Flexible Esophagoscope: Flexible and Lower perforation rate. (Method of choice) Complications of Esophagoscopy: Esophageal trauma Mediastinitis Pneumothorax Surgical emphysema Tracheo esophageal fistula Aorto esophageal fistula

16. Devices recommended by ASGE to have readily available to retrieve these types of foreign bodies, besides pronged graspers and retrieval nets, are Dormier Baskets for sharp and long objects. Also, rat tooth/alligator tooth hybrid forceps are ideal for sharp objects like needles and safety pins pronged grasper retrieval nets Dormier basket rat tooth/alligator tooth hybrid forceps

17. Surgery for Foreign Body Indications: FB impacted in wall of esophagus- dentures, metal nails or screws Sharp Foreign body – blade, knives. Needles Suspected perforation Foreign body along with Esophageal pathology – Carcinoma, Cardiac achalasia, Stricture Procedure Depending upon where the foreign body is lodged in Esophagus, the procedure is planned: In neck-left side : Cervical esophagostomy In thoracic esophagus: Right side posterolateral thoracotomy

18. Case Report: 48-year-old male patient, originally and resident of Guadalajara, México; married, christian , completd junior high, employed in an oil store. With a significant history of smoking from 15 to 28 years of age at a rate of 10 cigarettes (IT 6.5 packs/year), occasional alcohol consumption. With type 2 Diabetes Mellitus of 14 years of diagnosis on  treatment  with  metformin  850 mg every 8 h, without other comorbidities. Clinical image: foreign body sensation in the esophagus after food intake, with  dysphagia  to liquids and solids

19. Diagnosis: Laryngoscopy showed no evidence of foreign body CT scan of the neck was performed, where the presence of a foreign body in the upper third of the esophagus of 20 × 25 mm was evidenced without data suggestive of perforation

20. The patient then is taken to Endoscopy service where an endoscopic study is performed with evidence of a foreign body, and failed extraction after multiple attempts with Endoloop and forceps. Foreign body in proximal esophagus

21. After endoscopy treatment failure, surgical extraction was attempted, performing the procedure through a left lateral cervicotomy , and finding the foreign body in the cervical portion of the esophagus, which was extracted and subsequently closed esophagotomy . A General surgeon, with laparoscopic training and 20-year experience performed the procedure.

22. After the surgical procedure, the patient goes to standard floor hospitalization, where he presents a favorable evolution, however, occasional  dysphonia  and discharge from the  surgical wound  are evidenced. A new laryngoscopy is performed with evidence of left  vocal cord paralysis  and esophagogram, where contrast leakage is evidenced towards right bronchus, without extravasation of the contrast in the neck. In addition, a control endoscopy is performed, without evidence of  fistula  in the surgical area, for all the above, it is decided to give conservative management, with  enteral nutrition  by nasojejunal tube and wound care, as  surgical wound infection  was evidenced. Afterwards, with twice daily wound cleaning and antibiotic management, presents favorable evolution, discharging after 18 days of hospitalization. The patient was satisfied, the risks were previously explained to him and the final clinical evolution was favorable, without  sequelae .

23. References: https://www.ncbi.nlm.nih.gov/books/NBK482131/#:~:text=Foreign%20bodies%20in%20the%20upper,choking%2C%20hiccups%2C%20and%20retching . https://www.kenhub.com/en/library/anatomy/esophagus https://teachmeanatomy.info/abdomen/gi-tract/oesophagus/ https://www.intechopen.com/chapters/48707 https://radiopaedia.org/cases/oesophageal-foreign-body-coin https://www.sciencedirect.com/science/article/pii/S187595721630136X https://www.steris.com/healthcare/knowledge-center/therapeutic-endoscopy/complete-guide-to-foreign-body-management https://www.sciencedirect.com/science/article/pii/S2210261221009196