Complications
Frequently, a delay in presentation and multiple attempts at self-removal lead to mucosal oedema, laceration, bleeding, and muscular spasms. Perforations may occur but are less common than other complications.
Foreign bodies can obstruct passageways either by their size (e.g., objects that are >6 cm long or >2.5 cm in diameter may not be able to pass the pylorus) or by the subsequent inflammation or scarring that they may cause.
Small retained colonic foreign bodies usually pass spontaneously; however, large colonic foreign bodies may become entrapped due to the local reaction caused by their presence, such as oedema or atony.
For an encased foreign body, extraction may be difficult or impossible. In this case it may be useful to postpone extraction and initiate a short course of an intravenous corticosteroid for 12 to 24 hours. This can reduce inflammation and facilitate foreign body extraction at a later time.[21]
These objects can be removed endoscopically or surgically depending on their location and size.
The ingestion of multiple magnets is a special case: the magnets may cause adjacent intestinal loops to be forcefully attracted to each other and produce obstruction, as well as pressure necrosis of the intestinal wall leading to a perforation, or fistula formation.[3][19] Urgent surgical intervention, such as explorative laparotomy to remove the objects and repair any damage, is vital, especially if the patient is symptomatic or sequential abdominal radiology films suggest no change in the position of the magnets.[3][19][54]
The most common complication involves tearing of the mucosa during insertion or removal of the object or objects. The associated bleeding is often self-limiting, although more pronounced ongoing bleeding may require endoscopy or suture ligation.
If the foreign body is sharp, pointed, >6 cm long or >2.5 cm in diameter, or multiple, it should be removed endoscopically on an urgent basis. Up to 35% of these objects may perforate the bowel wall if not removed.
Special consideration should be given to button or disc batteries localised in the oesophagus.
Oesophageal perforation (by the object or during instrumentation) carries a high mortality secondary to rapidly developing mediastinitis. Patients with mediastinitis may report sudden, sharp chest or epigastric pain radiating to the interscapular region, followed later by dyspnoea, cyanosis, and shock.
Perforation may be suspected and confirmed by the presence of subcutaneous emphysema, pneumomediastinum, pneumothorax, or pleural effusion on posteroanterior and lateral x-rays of the neck and chest, computed tomography scan of neck and chest, or gastrografin swallow.
Early recognition of perforation and management (within the first 24 hours) dramatically improves survival.
In patients who are considered poor surgical candidates, management includes: observation, nil per mouth, and intravenous antibiotics.
Endoscopic interventions can include closing the mucosal defect with endoclips or using a self-expandable metal stent (SEMS) or plastic stent (SEPS) in cases of iatrogenic cervical oesophageal perforation. Polyflex stent placement may avoid the potential morbidity and mortality of emergency operative repair. Intravenous broad-spectrum antibiotics are indicated for the first 3 to 5 days.
Surgery is the treatment of choice for perforations that have occurred more than 24 hours prior to presentation.
Foreign bodies can cause infections or carry infectious agents.
Children with a chronic oesophageal foreign body may be difficult to diagnose. They may present with poor feeding, irritability, failure to thrive, fever, stridor, or pulmonary symptoms such as recurrent pneumonia from aspiration.
If an infection is suspected, appropriate management includes the removal of the object (endoscopically or surgically), collection of cultures, and initiation of antibiotics.
Signs include central nervous system and respiratory depression, miosis, and apnoea. Supportive ventilation is usually sufficient to prevent death but may be avoided by cautious administration of naloxone.
If the patient is asymptomatic, activated charcoal should be given and whole-bowel irrigation should be performed to decontaminate the patient.
Presentation includes tachycardia, hypertension, hyperthermia, diaphoresis, mydriasis, and agitation. If body packers show symptoms or signs of cocaine overdose, they should be referred immediately for surgical decontamination. If they are asymptomatic, activated charcoal should be given and whole-bowel irrigation should be performed to decontaminate the patient.
Cultures should be obtained in patients with signs or symptoms of septicaemia or elevated white blood cell count at presentation, followed by intravenous broad-spectrum antibiotics.
Traumatic disruption of the sphincteric complex (during removal of the object) often results in varying degrees of faecal incontinence, especially with repetitive damage.
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