This study is based on CT scans, collected in the department of Radiology (Polyvalent and Emergency divisions) for the last 3 years.
Types of ingestions:
- Accidental
- Intentional
Risk factors:
- Pre-existing digestive tract pathology such as: strictures, malignancy, esophageal rings, achalasia, eosinophilic esophagitis (5, 6).
- Physiologically narrow parts of the gastrointestinal tract that make the passage of ingested body difficult are sites for foreign body impaction (7, 8).
- Age, infants aged six months to three years and elderly people (9).
- Dentures
- Mental retardation, psychiatric disorders, alcohol abuse (8, 9).
- Bolus impaction is an independent sub entity with an annual prevalence of 13/100 000 (10).
- The majority of our cases are discovered during holidays where the consumption of meat and fish increases such as Christmas or New Year.
- Also, a high suspicion should be in the population that live near the sea or lake, where the consumption of fish is high.
- However, in some cases no pathological predisposition is present.
Clinical presentation:
- Patients usually seek medical attention immediately after ingesting a foreign body and provide information about it. Most patients present with the sensation of a foreign body, difficulty in swallowing, chest or abdominal pain, vomiting (11).
- Often, the diagnosis of an ingested foreign body is made days or months after the body was ingested (12). Patient may not present with specific symptoms and this depends on the localization of damage.
We made a selection based on the various complications of ingested foreign bodies.
Once it is swallowed, what comes next:
Nothing: Uncomplicated passage of foreign bodies through the gastrointestinal tract largely depends on their shape and size.
Sharp objects can even pass uneventfully once they cross the esophagus (13). Sometimes, we just discover accidentally alimentary sharp foreign bodies in intestinal loops in CT scans performed for another indication.
Perforation:
Patients who have ingested a foreign body with sharp ends are at increased risk of perforation. Foreign bodies longer than 6 cm and with a diameter of more than 2.5 cm make the duodenal passage difficult (14, 15).
Without migration of foreign body: can be associated with peritonitis or mediastinitis.
Peritonitis - Gastric perforations secondary to foreign body ingestion mostly present with peritonitis, but some may spontaneously seal off and remain asymptomatic or even lead to an intraabdominal abscess (16-18).
Mediastinitis - Sharp esophageal foreign bodies can perforate the esophagus leading to mediastinitis and severe hemorrhagic complications (19).
With migration of foreign body: Responsible for hepatic abscess, ureteral obstruction, urinoma.
In one of our cases, a toothpick of 6 cm, pierced stomach in pyloric region and migrated to hepatic left lobe, causing abscess. In another case, a fishbone has pierced gastrointestinal tract in an unknown region and has caused ureteral obstruction, which lead then in urinoma formation. In both cases, there were no symptoms related with gastrointestinal tract.
Occlusion
Occlusion is related not only with the foreign body which occludes the lumen but also with the associated edema of the wall.
Diverticulum inflammation
Foreign bodies within Meckel’s diverticulum or colonic diverticulum may be associated with inflammation, perforation, abscess and fistula (20, 21).
Prescribed in literature: Mucosal ulceration, fistula formation, appendicitis, intussusception (22, 23).
Treatment
- 80-90% of ingested foreign bodies are able to pass spontaneously without intervention (24).
- Surgery the absolute indication for surgery exists only in case of perforation. Relative indications for surgery after ingestion of foreign bodies exist in the case of complications that cannot be resolved endoscopically or after unsuccessful attempts at endoscopic recovery (25).
- Endoscopy: the urgent need for endoscopy depends on the risk of aspiration, if the esophagus is completely occluded and on the risk of perforation caused by the foreign body, as well as the risk of the foreign body becoming stuck.
The role of CT in detection of sharp foreign bodies
- With a sensitivity of 100% and a specificity of 91%, CT with 3D reformations has an important role in the diagnostic evaluation of ingested foreign bodies (26).
- CT scan offers information about characteristics of foreign bodies (such as size, shape, density) position and complications caused by their ingestion.
- The use of intravenous contrast agent may be recommended in the suspicion of some complications.
- Oral contrast agent administration can hide an unsuspected foreign body and would make it difficult to perform a subsequent endoscopy (27).
- Limitations of CT in the detection may be the lack of observer awareness and scanning thickness.