In adults, foreign body ingestion typically correlates with underlying gastrointestinal (GI) pathologies, psychiatric conditions, or altered mental status. While most foreign bodies pass spontaneously through the GI tract, approximately 10% to 20% require endoscopic removal and less than 1% necessitate surgery, typically for complications like obstruction or perforation, noted Biras Mejbel Abed, of the Department of General Surgery at the Royal Hospital in Muscat, Oman.

Symptoms vary depending on the site and nature of impaction, ranging from globus sensation and dysphagia when lodged in the esophagus to classic signs of bowel obstruction when trapped in the small or large intestine. Notably, a significant proportion of patients may remain asymptomatic, underscoring the importance of detailed history-taking and appropriate imaging.

Case 1: Small Bowel Obstruction 

A 76-year-old woman with hypertension presented with 3 days of abdominal pain, bilious vomiting, and constipation—classic features of small bowel obstruction. Initial CT imaging showed dilated proximal small bowel loops up to the proximal ileum, suggesting a mechanical obstruction with a transition point. Importantly, there was no evidence of free air or overt perforation.

Management Challenges: Given the patient’s advanced age, the surgical team faced concerns about perioperative risks, compounded by her deranged renal function and small umbilical hernia, which could complicate laparoscopy.

Intraoperative Findings: Due to severe distension, the case was converted from laparoscopy to laparotomy. A firm intraluminal mass was located and extracted via enterotomy without signs of bowel ischemia or perforation.

Outcome: Postoperatively, her course was smooth. However, subsequent imaging revealed incidental gastric wall thickening and enlarged celiac lymph nodes. This led to the diagnosis of moderately differentiated gastric adenocarcinoma. Subtotal gastrectomy and D2 lymphadenectomy were performed without neoadjuvant therapy due to her initial operative history. 

Discussion Points: This case highlights how FB ingestion can unmask an occult malignancy and underscores the need for a comprehensive evaluation even after an initially successful surgery.

Case 2: Recurrent Foreign Body Ingestion 

A 28-year-old woman with a longstanding psychiatric history presented repeatedly over a decade with foreign body ingestion.

First Event (2011, age 16): Multiple metallic objects (screws) were identified in the stomach via X-ray. Initial endoscopic attempts failed due to pyloric obstruction. Laparoscopic gastrostomy removed 31 metallic objects weighing 1.25 kg.

Second Event (2020, age 25): CT revealed a needle penetrating from the cecum to the abdominal wall with an associated abscess. The object likely caused slow transmural migration and chronic localized infection. Surgery drained the abscess and removed the needle without needing bowel resection.

Third Event (2021): Plain films showed a metallic fork impacted in the cervical esophagus. A trans-cervical esophagostomy was performed successfully. A small esophageal tear was repaired primarily with no complications.

Fourth Event (2023): Multiple objects (spoon, coins, wires, screws, and a food packet) were found throughout the stomach and colon. Exploratory laparotomy with gastrostomy and manual extraction was required after failure of endoscopic retrieval. Foreign bodies were milked through the large bowel into the rectum.

Fifth Event (1 Month Later, 2023): A 12-cm metallic rod was found in the descending colon. With close monitoring and supportive care, she passed the object spontaneously after 6 days.

Management Challenges:

• Risk of perforation versus spontaneous passage

• Deciding on conservative versus surgical approach

• Protecting airway in setting of altered mental status

• Preventing recurrence with psychiatric care integration

Discussion Points: Recurrent foreign body ingestion highlights the need for psychiatric stabilization alongside surgical management. This case also demonstrates that conservative management is feasible when objects are blunt, static, and non-obstructive.

Case 3: Small Bowel Obstruction Due to Food Bezoar

A 62-year-old woman with metabolic comorbidities (diabetes, hypertension) and prior cholecystectomy was initially treated conservatively for presumed partial small bowel obstruction. On her return with worsening symptoms, imaging indicated a fixed transition point.

Intraoperative Findings: A large, firm, non-metallic mass (food bezoar) was found lodged in the mid-ileum. There were no underlying strictures or malignancies, confirmed by running the bowel.

Management: A distal longitudinal enterotomy was performed to extract the bezoar. The enterotomy was closed transversely to prevent future narrowing.

Outcome: The patient had an uneventful recovery with resolution of obstructive symptoms and remained asymptomatic at 6-month follow-up.

Discussion Points: Bezoars must be considered, particularly in elderly patients with dentition issues, rapid eating habits, or prior gastric surgeries altering motility. CT imaging can differentiate bezoars from tumors or strictures if characteristic mottled intraluminal masses are identified.

Case 4: Small Bowel Obstruction Due to Internal Hernia and Food Bezoar 

A 79-year-old woman with a prior Roux-en-Y duodenojejunostomy for duodenal cancer presented with acute-onset abdominal pain, vomiting, and constipation.

Imaging Findings: CT scan demonstrated features of internal herniation with a transition point and proximal small bowel distension.

Intraoperative Findings: The obstruction was due to a large food bezoar at the mid-ileum, in the absence of a clear internal hernia sac. Adhesions were lysed and the bezoar was removed via enterotomy.

Postoperative Course: Complicated by a superficial surgical site infection managed with local care and antibiotics.

Contributing Factors: Upon further questioning, the patient admitted to difficulty chewing food because of poor dentition, leading to inadequate mechanical digestion and bezoar formation.

Discussion Points: Roux-en-Y surgery can predispose patients to internal hernias and motility issues, emphasizing the need for long-term dietary counseling and dental assessments.

Diagnostic and Management Considerations

Diagnosis relies heavily on a careful history, including the nature of the ingested material, and complementary imaging studies. Plain radiographs are effective for radiopaque objects, while CT scans are invaluable when complications such as obstruction or perforation are suspected.

In general:

• Objects greater than 2 cm in diameter struggle to pass the pylorus.

• Objects longer than 6 cm may not navigate the duodenum.

• Esophageal impactions require aggressive endoscopic intervention to prevent serious complications like perforation or mediastinitis.

• Gastric objects are more likely to pass naturally but require monitoring.

Management strategies include:

• Conservative observation with serial imaging for small, blunt, non-obstructing objects.

• Endoscopic removal for esophageal impactions, sharp objects, or non-progressing items.

• Surgical intervention in cases of bowel obstruction, perforation, or failure of non-operative measures.

Interestingly, while recent studies have shown a predominance of impaction in the esophagus, half of the obstructions in this small series occurred in the small bowel, highlighting the diversity of adult presentations, noted Mejbel and colleagues.

Potential complications from foreign body ingestion include:

• Mucosal injury and perforation in the oropharynx or esophagus

• Mediastinitis following esophageal perforation

• Bowel perforation and peritonitis

• Septicemia secondary to perforation

• Mechanical bowel obstruction

Rapid identification, careful monitoring, and appropriate intervention are critical to minimize morbidity and mortality.

The case series reinforces that foreign body ingestion in adults, while uncommon, demands a high index of suspicion and a multidisciplinary approach. Surgical management remains a crucial tool, particularly when complications arise or non-operative measures fail. Clinicians must also be vigilant for psychiatric comorbidities and potential underlying GI diseases that may predispose to foreign body impaction. Comprehensive management, including mental health support and dental care when necessary, can help prevent recurrent episodes and improve long-term outcomes.

Disclosures can be found in the published article.

Source: Scientific Research