Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

unstable patients

1st line – resuscitation

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INITIAL
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unstable patients
1st line – 

resuscitation

Patients should be considered unstable if they present with airway compromise, drooling, inability to tolerate fluids, evidence of sepsis, perforation, or active bleeding.

Elective endotracheal intubation should be considered in patients with respiratory compromise or distress, mental status alteration, or active bleeding. Elective endotracheal intubation will protect the airway and facilitate endoscopy.

Bilateral peripheral or central intravenous access should be obtained for adequate fluid resuscitation.

Resuscitative measures as appropriate, including volume resuscitation (crystalloid infusion), oxygen (if O₂ saturation is <90%), blood product replacement with packed red blood cell transfusion if indicated for ongoing bleeding (Hb <70 g/L [<7 g/dL] or <80 g/L [<8 g/dL] with cardiac issues) and correction of coagulopathy if present.

As soon as the patient is stable, a complete history and physical examination (from mouth to anus) can be performed with relevant interventions applied as required according to the stable patient group.

Plus – surgery

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INITIAL
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unstable patients
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with perforation
Plus – 

surgery

Treatment recommended for ALL patients in selected patient group

Emergency surgery is mandatory in patients with perforation due to obstruction, with the goal of cleaning out intra-abdominal contamination via irrigation, resecting the area of perforation, and addressing the underlying problem.

Plus – intravenous broad-spectrum antibiotics

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INITIAL
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unstable patients
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with signs of sepsis
Plus – 

intravenous broad-spectrum antibiotics

Treatment recommended for ALL patients in selected patient group

In patients with signs or symptoms of septicaemia or elevated white blood cell count at presentation, intravenous broad-spectrum antibiotics covering anaerobes and both gram-positive and gram-negative aerobes should be started.

Antibiotic selection will depend on institutional protocols and culture results.

ACUTE

stable patients: oropharyngeal foreign body

1st line – fibre-optic nasopharyngoscopy

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ACUTE
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stable patients: oropharyngeal foreign body
1st line – 

fibre-optic nasopharyngoscopy

Ear, nose, and throat evaluation should be considered for patients with an object in the oropharynx that cannot be seen during the physical examination.

Foreign bodies can be removed using a tongue depressor and laryngoscopy.[13][59]

Consider – antiemetics

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ACUTE
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stable patients: oropharyngeal foreign body
Consider – 

antiemetics

Additional treatment recommended for SOME patients in selected patient group

Antiemetics are useful for controlling nausea and vomiting. Commonly prescribed agents include promethazine, ondansetron, or prochlorperazine.

Primary options

promethazine: children: 0.25 to 1 mg/kg orally/intravenously every 4-6 hours when required, maximum 25 mg/dose; adults: 12.5 to 25 mg orally/intravenously every 4-6 hours when required

OR

prochlorperazine: children ≥2 years of age: 0.4 mg/kg/day orally given in 3-4 divided doses when required; adults: 5-10 mg orally three to four times daily when required, or 2.5 to 10 mg intravenously/intramuscularly every 3-4 hours when required, maximum 40 mg/day

OR

ondansetron: children: 0.15 mg/kg intravenously every 8 hours when required; adults: 4 mg intravenously/intramuscularly every 8 hours when required

Consider – corticosteroids

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ACUTE
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stable patients: oropharyngeal foreign body
Consider – 

corticosteroids

Additional treatment recommended for SOME patients in selected patient group

In cases of complete obstruction, a short course (12-24 hours) of an intravenous corticosteroid may reduce inflammation and facilitate extraction of the object at a later time.[21]​​

Primary options

methylprednisolone: children and adults: consult specialist for guidance on dose

stable patients: oesophageal or rectal foreign body (excluding multiple magnets and batteries)

1st line – fibre-optic endoscopy

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ACUTE
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stable patients: oesophageal or rectal foreign body (excluding multiple magnets and batteries)
1st line – 

fibre-optic endoscopy

The forward-viewing flexible endoscope, which is used in oesophagogastroduodenoscopy, flexible sigmoidoscopy, and colonoscopy, is the instrument of choice in managing most impacted foreign bodies.

Emergency endoscopy is indicated for patients whose airway is compromised, those who show signs of complications, or if a battery is impacted in the oesophagus.

Endoscopy is required for foreign bodies that are non-progressive, sharp, or non-radiopaque; batteries; multiple foreign bodies; foreign bodies in the stomach >6 cm long or >2.5 cm in diameter; or oddly shaped foreign bodies such as open safety pins. 'Side-viewing' flexible endoscopy has been used to diagnose and manage foreign bodies in the common bile duct.[60] Enteroscopy (single or double balloon) may allow the removal of foreign bodies in the small intestine, when indicated.[45]

The following tools can be used to assist in the endoscopic removal of foreign bodies: forceps, snares, Roth retrieval net, Dormia baskets, balloons, overtubes, and latex protector hood. Despite potential technical challenges, endoscopy has made the removal of foreign bodies possible without surgical intervention (which is only needed in approximately 1% of cases); furthermore, it has emerged as one of the safest methods of managing foreign bodies in the gastrointestinal tract.[59][61][62]

Consider – antiemetics

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ACUTE
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stable patients: oesophageal or rectal foreign body (excluding multiple magnets and batteries)
Consider – 

antiemetics

Additional treatment recommended for SOME patients in selected patient group

Antiemetics are useful for controlling nausea and vomiting. Commonly prescribed agents include promethazine, ondansetron, or prochlorperazine.

Primary options

promethazine: children: 0.25 to 1 mg/kg orally/intravenously every 4-6 hours when required, maximum 25 mg/dose; adults: 12.5 to 25 mg orally/intravenously every 4-6 hours when required

OR

prochlorperazine: children ≥2 years of age: 0.4 mg/kg/day orally given in 3-4 divided doses when required; adults: 5-10 mg orally three to four times daily when required, or 2.5 to 10 mg intravenously/intramuscularly every 3-4 hours when required, maximum 40 mg/day

OR

ondansetron: children: 0.15 mg/kg intravenously every 8 hours when required; adults: 4 mg intravenously/intramuscularly every 8 hours when required

Consider – corticosteroids

Back
ACUTE
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stable patients: oesophageal or rectal foreign body (excluding multiple magnets and batteries)
Consider – 

corticosteroids

Additional treatment recommended for SOME patients in selected patient group

In cases of complete obstruction, a short course (12-24 hours) of an intravenous corticosteroid may reduce inflammation and facilitate extraction of the object at a later time.[21]​​

Primary options

methylprednisolone: children and adults: consult specialist for guidance on dose

Consider – glucagon

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ACUTE
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stable patients: oesophageal or rectal foreign body (excluding multiple magnets and batteries)
Consider – 

glucagon

Additional treatment recommended for SOME patients in selected patient group

Glucagon can be given intravenously to attempt spontaneous passage of an impacted foreign body. It should be infused slowly to prevent nausea and vomiting.

If there is no response, it can be repeated after 20 to 30 minutes.[69]

Primary options

glucagon: children: 0.02 to 0.03 mg/kg intravenously, maximum 0.5 mg; adults: 1-2 mg intravenously as a single dose, repeat after 20-30 minutes if necessary

2nd line – surgery

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ACUTE
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stable patients: oesophageal or rectal foreign body (excluding multiple magnets and batteries)
2nd line – 

surgery

For failed extraction or objects of >10 cm in the rectum, surgical intervention may be needed. Laparoscopy can be a valuable tool in the management of gastrointestinal foreign bodies, particularly when an object is not progressing or endoscopy is unsuccessful or dangerous. Other indications for surgical intervention include perforation and complications that cannot be resolved endoscopically, such as excessive bleeding.

Most rectal foreign bodies can be removed transanally. After radiological confirmation of the presence, size, and location of the object, the patient is sedated (often with an intravenous sedative and/or perianal nerve block) and then placed in the left lateral or lithotomy position. Various retractors and clamps commonly used in routine anorectal surgery have been used successfully to grasp and remove objects from this area.[67]

stable patients: oesophageal or rectal foreign body - multiple magnets

1st line – emergency endoscopic or surgical removal

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ACUTE
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stable patients: oesophageal or rectal foreign body - multiple magnets
1st line – 

emergency endoscopic or surgical removal

Ingestion of multiple magnets is serious and requires special attention and follow-up.[43] The ingestion of multiple magnets (or a single magnet with other ferrous objects) can cause adjacent intestinal loops to be forcefully attracted to each other and produce obstruction, pressure necrosis of the intestinal wall leading to a perforation, or fistula formation.[3][19]​ Early endoscopic removal should be the treatment of choice when there is no clinical or radiographic evidence of intestinal damage or complications.

If the patient is symptomatic, there is evidence of complications, or sequential abdominal radiology films suggest the objects are in close proximity to one another and static, urgent surgical intervention by explorative laparotomy to remove the objects and repair any damage may be more appropriate.[3][19][54]

stable patients: oesophageal or rectal foreign body - batteries

1st line – emergency endoscopic or surgical removal if impacted

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ACUTE
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stable patients: oesophageal or rectal foreign body - batteries
1st line – 

emergency endoscopic or surgical removal if impacted

Although most button batteries pass through the gut uneventfully and are eliminated in the stool, batteries that lodge and become impacted in the oesophagus can cause life-threatening complications within 2 hours.[56] Immediate x-rays should be obtained, and if a battery is impacted within the oesophagus it requires emergency endoscopic or surgical removal.[43]

Complications (which may be delayed up to 18 days after battery removal) include oesophageal perforation, tracheo-oesophageal fistula, oesophageal strictures, mediastinitis, vocal cord paralysis, tracheal stenosis, and exsanguination from arterial fistulisation. These complications should be monitored vigorously after the battery is removed, and patients advised to report symptoms urgently.

Injury is thought to be secondary to electrochemical burns from electrical discharge. Chemical burns from electrolyte alkali leakage and pressure necrosis may also contribute. Special considerations apply to small disc or button battery ingestion. The 3-volt, 20 mm-diameter (CR/BR type) lithium button battery is particularly prone to lodging in the oesophagus, especially in children. Oesophageal impaction of a battery requires emergency endoscopic or surgical removal.[43]

For patients without impaction, conservative intervention is recommended in the absence of symptoms and signs of injury.[57][58]​ Retrieval is indicated only if two or more magnets are ingested at the same time, symptoms develop, or a large diameter battery (>15 mm) fails to pass the pylorus in 4 days. All other batteries beyond the oesophagus may be managed at home with regular diet and activity. If passage is not documented within 10 to 14 days, repeat radiographs can be performed to confirm passage of the battery.[56]

stable patients: foreign body in the stomach, proximal small bowel, or beyond reach of endoscope (excluding multiple magnets and batteries)

1st line – watchful waiting + radiology

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ACUTE
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stable patients: foreign body in the stomach, proximal small bowel, or beyond reach of endoscope (excluding multiple magnets and batteries)
1st line – 

watchful waiting + radiology

Spontaneous passage with no intervention (watchful waiting) and serial radiographic follow-up is often appropriate, as 80% of ingested or inserted foreign bodies pass through the gastrointestinal tract without symptoms and cause only minor mucosal injury.

The decision to 'wait and see' will depend on several factors, such as age of the patient, physical characteristics of the object, location, and symptoms of obstruction. This option can be considered in children with single coin ingestion and in adults with foreign objects that are distal to the oesophagus. These patients can be observed (stools should be searched for the object or serial x-rays performed) to determine whether the object will advance to the rectum.

Watchful waiting is not appropriate in all instances. Exclusions include unstable patients; those with impacted objects complicated with rupture of viscera; objects in the oesophagus; magnets; objects >6 cm long or with a diameter >2.5 cm, which may become trapped at the pylorus; or objects larger than 10 cm in the rectum.

stable patients: foreign body in the stomach, proximal small bowel, or beyond reach of endoscope - multiple magnets

1st line – urgent surgical consultation

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ACUTE
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stable patients: foreign body in the stomach, proximal small bowel, or beyond reach of endoscope - multiple magnets
1st line – 

urgent surgical consultation

The ingestion of multiple magnets (or a single magnet with other ferrous objects) can cause adjacent intestinal loops to be forcefully attracted to each other and produce obstruction, pressure necrosis of the intestinal wall leading to a perforation, or fistula formation.[3][19]​ Retrieval is indicated only if two or more magnets are ingested at the same time.

Urgent surgical consultation for explorative laparotomy to remove the objects and repair any damage is vital, especially if the patient is symptomatic or sequential abdominal radiology films suggest the objects are in close proximity to one another and static.[3][19][54]

stable patients: foreign body in the stomach, proximal small bowel, or beyond reach of endoscope - batteries

1st line – watchful waiting + radiology

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ACUTE
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stable patients: foreign body in the stomach, proximal small bowel, or beyond reach of endoscope - batteries
1st line – 

watchful waiting + radiology

For patients where the battery is distal to the oesophagus, conservative intervention is recommended in the absence of symptoms and signs of injury.[57][58]​ Retrieval is indicated only if symptoms develop or a large diameter battery (>15 mm) fails to pass the pylorus in 4 days. All other batteries beyond the oesophagus may be managed at home with regular diet and activity. If passage is not documented within 10 to 14 days, repeat radiographs can be performed to confirm passage of the battery.[56]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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