Git F Bs.


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GIT Foreign bodies & others.

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Git F Bs.

  1. 1. Upper Gastrointestinal Foreign Bodies Dr. Mohammad Shaikhani.
  2. 2. Case history: <ul><li>13 years girl presented to the endoscopy unit with H/O ingesting a pin during trial to hold a pin between her teeth before 24 hours. </li></ul><ul><li>No previous H/O FB ingestion. </li></ul><ul><li>No H/O psychiatric diseases. </li></ul>
  3. 3. Pin during endoscopy:
  4. 4. Pin retrieved by endoscopy:
  5. 5. International j of clinical practice    2006 <ul><li>GIT FBs represent a significant clinical problem in the Emergency Department, causing a high degree of financial burden, morbidity and mortality. A large variety of foreign bodies are accidentally ingested or inserted into the GIT in different age groups. </li></ul><ul><li>This a retrospective review of 38 patients presented to ERT with GIT FBs between January 2001 and December 2004. </li></ul><ul><li>30 males/ eight females (M: F ratio of 3.75:1) with an age range of 10 months to 87 years (median age 25.5 years), accidental in 14 , deliberate in 11, for anal erotism in 11 &assault in two cases. The median time before presentation was 12 h, mean length of hospital stay was 1.7 days. </li></ul><ul><li>Treatment was conservative in 15 patients; five patients had gastroscopic retrieval; 15 patients underwent examination under anaesthetic, retrieval and proctosigmoidoscopy and three patients underwent laparotomy for impacted foreign bodies. GIT foreign body ingestion or insertion is common; however, majority of cases can be successfully managed conservatively. </li></ul>
  6. 7. <ul><li>Common >100 000 /year, 80% in children, with a peak incidence between 6 months-3 years. </li></ul><ul><li>The type/frequency varies in different geographical regions </li></ul><ul><li>& by the medical specialty reporting the ingestion. </li></ul><ul><li>Majority of ingestions are accidental in children, often witnessed by an adult caregiver. </li></ul><ul><li>Ingestions in adults are more often intentional associated with psychiatric disturbance, alcohol consumption& incarcerated adults seeking the relative comforts of medical facilities. </li></ul>
  7. 8. <ul><li>Most blunt ingested objects pass through the GIT without incident, but sharp objects, 5–30% of swallowed objects, pose a more serious threat of perforation. </li></ul><ul><li>In Asia, where the ingestion of fish is more common, fish bones may become lodged as they pass& account for a greater fraction of reported ingestions in adults &children. </li></ul><ul><li>The most common reported ingestion in children in US/Europe is coins, 80% </li></ul><ul><li>In adults, meat impaction is the most common cause of accidental ingestion, usually associated with underlying pathology such as esophageal stricture or eosinophilic esophagitis. </li></ul><ul><li>Other causes of accidental ingestions in adults include tooth brushes, used to induce vomiting in patients with eating disorders. </li></ul><ul><li>Sharp &multiple objects are typically swallowed intentionally. </li></ul><ul><li>Recent adolescent gang activity includes the practice of the ingestion of a foreign body as part of an initiation ritual. </li></ul>
  8. 9. <ul><li>80–90% pass spontaneously, 10–20% require endoscopic removal, <1% require surgical intervention. </li></ul><ul><li>Sharp objects have a much higher perforation rate, ranging from 15 to 35%. Some objects require special attention, including small magnets, which have become popular building materials in children’s toys& the ingestion of button batteries. </li></ul><ul><li>One of the most serious intentional ingestions is small packets of drugs, which are usually swallowed to transport the illegal substances from one location to another. </li></ul><ul><li>Once in the stomach, most foreign bodies pass without incident. </li></ul><ul><li>Some large objects will predictably fail to pass the pylorus, and others will fail to negotiate the duodenal sweep. </li></ul><ul><li>In these patients early endoscopic intervention is indicated to avoid later surgery. </li></ul>
  9. 10. <ul><li>The routine management of coin ingestion if it is passed into the stomach is to wait 2–3 weeks and repeat an abdominal radiograph if the coin has not been observed in the stool . </li></ul><ul><li>Alternatively, metal detectors have been used to avoid radiation exposure and monitor the passage of coins. </li></ul><ul><li>If the child remains asymptomatic, some physicians will wait an additional 2–3 weeks before removing the coins. </li></ul><ul><li>Ovoid objects >2cm by 5cm in adult-sized individuals have difficulty passing through the pylorus&are typically removed when discovered. </li></ul><ul><li>if an object is greater than 1cm by 3cm in a child we recommend removal. </li></ul><ul><li>If watchful waiting does not lead to passage within 2–3 weeks in the stomach, endoscopic removal is typically recommended. </li></ul><ul><li>If patients are symptomatic, regardless of the size of the object in the stomach, they should be retrieved. </li></ul>
  10. 11. <ul><li>Long objects have difficulty negotiating the duodenal sweep& should also be removed. </li></ul><ul><li>In adult patients, objects greater than 10 cm in length are routinely removed from the stomach rather than allow them to pass the pylorus&risk becoming lodged in the duodenum. </li></ul><ul><li>Ingested batteries are serious because they can alkaline caustic material causing mucosal ulceration,mercury poisoning, lithium absorption. </li></ul><ul><li>In symptomatic patients batteries should be removed regardless of battery size or the age of the patient. </li></ul>
  11. 12. <ul><li>Sharp foreign bodies are more likely to be associated with complications. </li></ul><ul><li>Perforation may occur anywhere in GIT, but is more common in areas of angulation, including the C loop of the duodenum&ileocecal valve. </li></ul><ul><li>Areas of congenital malformation or previous surgery are also more likely to be associated with bowel perforation after ingestion. </li></ul><ul><li>The risk of perforation rises with the number of objects ingested. </li></ul><ul><li>The ingestion of any single magnet piece presents little risk, but two or more magnets may pose a problem as they may attract across several layers of bowel leading to pressure necrosis, fistula formation, free perforation or obstruction. </li></ul>
  12. 13. Foreign bodies <ul><li>intentionally or unintentionally inserted or ingested objects </li></ul><ul><li>inadvertently ingested animal and fish bones </li></ul><ul><li>food bolus impactions </li></ul>
  13. 14. Epidemiology <ul><li>children </li></ul><ul><ul><li>80 percent of cases - pediatric population </li></ul></ul><ul><ul><li>a peak incidence : 6 months - 3 years </li></ul></ul><ul><ul><li>coins, keys, buttons, small toys, nails, pins, thumbtacks, and disc batteries </li></ul></ul>
  14. 15. Epidemiology <ul><li>Adults </li></ul><ul><ul><li>patients with psychiatric disorders and those seeking some secondary gain </li></ul></ul><ul><ul><li>the very elderly, the demented, the intoxicated. with dentures and dental bridgework </li></ul></ul>
  15. 16. Pathophysiology <ul><li>Complications </li></ul><ul><ul><li>Bowel perforation and obstruction </li></ul></ul><ul><ul><li>bleeding, respiratory compromise, fistulization, and abscess formation </li></ul></ul>
  16. 17. Pathophysiology <ul><li>Hypopharynx </li></ul><ul><li>Esophagus </li></ul><ul><li>Pylorus </li></ul><ul><li>Duodenal Sweep </li></ul><ul><li>The ligament of Treitz </li></ul>
  17. 18. Diagnosis <ul><li>History and Physical Examination </li></ul><ul><li>Radiographic Studies </li></ul><ul><li>Endoscopy </li></ul>
  18. 19. History and Physical Examination <ul><li>history of ingestion </li></ul><ul><li>onset of symptoms </li></ul><ul><li>physical examination </li></ul><ul><ul><li>unremarkable or nonspecific </li></ul></ul><ul><ul><li>recognize complications </li></ul></ul>
  19. 20. Radiographic Studies <ul><li>The plain film of the chest and abdomen </li></ul><ul><ul><li>help determine the presence, type, and location of the foreign body. </li></ul></ul><ul><ul><li>identifying possible complications </li></ul></ul>
  20. 21. Radiographic Studies Coin in esophagus
  21. 22. Radiographic Studies <ul><li>The diagnostic capabilities of plain film are limited </li></ul><ul><ul><li>not all ingested objects are radiopaque </li></ul></ul><ul><ul><li>False-negative rates 47% </li></ul></ul><ul><ul><li>To children, hand-held metal detectors </li></ul></ul>
  22. 23. Radiographic Studies <ul><li>The role of contrast studies - limited(Barium esophagrams) </li></ul><ul><ul><li>suspicion of perforation </li></ul></ul><ul><ul><li>complete esophageal obstruction </li></ul></ul>
  23. 24. Endoscopy <ul><li>diagnostic accuracy </li></ul><ul><li>safe and effective therapy </li></ul><ul><li>Endoscopy indication </li></ul><ul><ul><li>when the history suggests a GIFB, irrespective of a negative radiograph </li></ul></ul>
  24. 25. Endoscopy <ul><li>Emergent endoscopy is indicated </li></ul><ul><ul><li>high-grade esophageal obstruction </li></ul></ul><ul><ul><li>esophageal foreign object or food bolus impaction </li></ul></ul><ul><ul><li>suspected ingestion of sharp and pointed objects. </li></ul></ul>
  25. 26. Endoscopy <ul><li>Endoscopy contraindicated </li></ul><ul><ul><li>bowel perforation or small bowel </li></ul></ul><ul><ul><li>obstruction beyond the ligament of Treitz </li></ul></ul>
  26. 27. Treatment <ul><li>Indications and Timing for Therapy </li></ul><ul><li>Endoscopic Management </li></ul><ul><li>Surgery </li></ul>
  27. 28. Indications and Timing for Therapy <ul><li>symptomatic patients --- therapeutic intervention </li></ul><ul><li>asymptomatic patients --- location and characteristics </li></ul>
  28. 29. Indications and Timing for Therapy <ul><li>All GIFBs lodged in the esophagus - an urgent basis ( longer than 24 hours ) </li></ul><ul><li>Once an object has reached the stomach - management can be individualized </li></ul>
  29. 30. Indications and Timing for Therapy <ul><li>In most cases of gastric foreign body - conservative management </li></ul><ul><li>Endoscopic retrieval is indicated </li></ul><ul><ul><li>objects that fail to progress </li></ul></ul><ul><ul><li>Large objects (>2 cm in diameter) </li></ul></ul><ul><ul><li>long objects (>5 cm in length) </li></ul></ul><ul><ul><li>Sharp objects because their risk of perforation (15 - 35%) </li></ul></ul>
  30. 31. Indications and Timing for Therapy <ul><li>Surgery is indicated </li></ul><ul><ul><li>evidence of perforation, hemorrhage, fistula formation, obstruction secondary to a GIFB. </li></ul></ul><ul><ul><li>GIFBs fail to progress and/or cannot be retrieved endoscopically. </li></ul></ul>
  31. 32. Endoscopic Management <ul><li>General Considerations </li></ul><ul><ul><li>success rates ranging from 90-100% </li></ul></ul><ul><ul><li>Endoscopic extraction failures - the number and type of object(s). </li></ul></ul>
  32. 33. Endoscopic Management <ul><li>General Considerations </li></ul><ul><ul><li>lodged at the hypopharynx - laryngoscope </li></ul></ul><ul><ul><li>Rigid esophagoscopy </li></ul></ul><ul><ul><li>Extracorporral practice </li></ul></ul><ul><ul><li>Overtube or hood </li></ul></ul>
  33. 34. Food bolus impactions <ul><li>Food bolus impactions can produce obstruction. </li></ul><ul><li>Urgent management: </li></ul><ul><ul><li>severe distress </li></ul></ul><ul><ul><li>excessively salivating </li></ul></ul><ul><li>12 - 24 hours </li></ul>
  34. 35. Food bolus impactions <ul><li>Many food boluses - a gentle nudge (sedation and air-insufflation) </li></ul><ul><li>- be disrupted and debulked using a forceps </li></ul><ul><li>Using grasping forceps (rat-toothed, or alligator type) </li></ul>
  35. 36. Food bolus impactions
  36. 37. Food bolus impactions <ul><li>cannot be removed with flexible endoscopy, options include </li></ul><ul><ul><li>repeated attempt by a second endoscopist </li></ul></ul><ul><ul><li>rigid esophagoscopy </li></ul></ul><ul><ul><li>laparotomy/thoracotomy </li></ul></ul>
  37. 38. Coins and Other Small, Blunt Objects <ul><li>Blunt objects </li></ul><ul><li>esophagus gastric pass gastric </li></ul><ul><li>( urgent) (3-4w) (>1w) </li></ul><ul><li>endoscopy surgery </li></ul>
  38. 39. Sharp/Pointed and Long Objects <ul><li>the most dangerous GIFBs and the most challenging objects to remove </li></ul><ul><li>15- 35% of ingested sharp/pointed objects cause a gastrointestinal perforation if untreated. </li></ul>
  39. 40. Sharp/Pointed and Long Objects <ul><li>Sharp/pointed and long objects in the esophagus merit urgent attention </li></ul>
  40. 41. In esophagus
  41. 42. Sharp/Pointed and Long Objects <ul><li>Long objects (particularly >10 cm) in the stomach -- remove endoscopically </li></ul>
  42. 43. Sharp/Pointed and Long Objects
  43. 44. Sharp/Pointed and Long Objects <ul><li>Sharp objects that cannot be removed by endoscope - followed with daily radiographs </li></ul><ul><li>surgical intervention should be considered </li></ul><ul><ul><li>the object has failed to progress over 3 consecutive days. </li></ul></ul><ul><ul><li>acute onset of abdominal pain, fever, evidence of obstruction, and bleeding. </li></ul></ul>
  44. 45. Overtube
  45. 46. Latex hood
  46. 47. Middle aged woman with BPR:Rectal cancer.
  47. 49. Ch active DU/Severe deudenitis:
  48. 50. GERD:
  49. 51. Pre-pyloric ulcer:
  50. 52. Ch active DUs:
  51. 53. Young woman: severe nodular antral gastropathy & 2 ugly looking antral ulcers
  52. 54. Pregnant woman with ascites: Thickened diffusely infiltrated gastric body: linitis plastica.
  53. 55. Melena: ch active DU& Gastric polyp:
  54. 56. Antral gastropathy& Ch active DU:
  55. 57. Antral sessile polyp/mass
  56. 58. Middle aged woman with BPR/pile surgery:anal canal malignant looking polyp
  57. 60. CAH or PBC or overlap:
  58. 61. Laurence moon bedl syndrome:
  59. 62. Necrotizing fascitis:
  60. 63. SLE:
  61. 64. RA deformed hands:
  62. 65. Psoriatic arthritis:
  63. 66. Young man with clubing from childhood & severe esophagitis:
  64. 67. Middle aged man with bleeding varices: EBL done.
  65. 68. Young man with bleeding varices: white ball( bleeding varix) vs red ball (non- bleeding varix) appearance, after EBL.
  66. 69. Cardial varix after eso varices obliteration by EBL in a middle aged woman: