Abdominal Pain Secondary to… Lots of Foreign Bodies 11/6/2018

Our doctor-in-training, Jacqueline, presented a case of a 46yo man with a complicated abdominal surgical history, as well as schizophrenia, who presents with acute onset vague abdominal pain. He could not provide any remarkable history (other than abd pain and losing a bag of coins), and his exam was otherwise benign except for mild diffused abdominal pain…

The mystery was resolved on a radiography.

Foreign Body Ingestion

Epidemiology

Mostly in kids, peaks 1-2 years of age
Adults: Typically, accidental (95% of cases) usually related to fish, chicken bones, or toothpicks. More common in older adults, pts with mental illnesses, intoxicated, or inmates (drug trafficking, packers vs stuffers).
Most frequent cause of esophageal obstruction = food bolus on existing stricture

Presentation

Asymptomatic
Stridor/airway compromise/aspiration
Chest pain/abdominal pain
Fever, shock (perforation)
Hemoptysis, hematemesis

Diagnosis

Imaging, clinical history

Management:

Will depend on stability, the location, nature of the objects ingested, and progression.
Expectant management for most blunt objects, ~ 70-80% of objects will pass by day 4. Consider surgical/endoscopic intervention if failure to progress

Battery

Presentation
- Local necrosis secondary to pressure, electrical current, or caustic chemicals.
- Ulceration can occur within 2-4 hours
- Perforation can be seen as early as 4-8 hours
- VERY IMPORTANT to distinguish between coin batteries (thicker, concentric circles) vs coins (thinner, confluent)!
Complications
- Vocal cord paralysis, esophageal perf, stricture, tracheal/esophageal fistula, aspiration pneumonia, mediastinitis, erosions into arteries, gastric hemorrhage, intestinal perf
Management
- Esophagus: Emergent removal
- Beyond esophagus: Depends, most (89%) will pass within 7 days
  - Surgical/Endoscopic option: consider if co-ingestion of magnets, or if remained in stomach for more than 48 hours.
  - GI symptoms
- Cylindrical batteries: Relatively harmless and usually pass through GI tract without issues, but if stuck in stomach or esophagus, endoscopic removal is recommended

Magnets

Presentation
- Fistula, perforation, volvulus, obstruction, localized necrosis (pressure)
- Higher chance of complications if multiple magnets and/or metallic objects were ingested.
- Can react with metal external of the body and cause injury
Complications
- Localized bowel necrosis, obstruction
Management
- Prompt removal endoscopically if in esophagus or stomach.
- Beyond stomach: Surgery if symptomatic or failure to progress
- Single magnet: Expectant management, serial XR, monitor progress, don’t be around anything ferromagnetic

Sharp

Presentation
- High risk of perforation/injury if in esophagus, medical emergency
Complications
- Esophageal perforation
- Intestinal perforation
Management
- Immediately endoscopic removal if in esophagus
- Beyond:
  - Stomach/proximal duodenum: still consider urgent endoscopic removal, complication risk varies from as low as 10% to 40%
  - Beyond and failure to progress: Surgical intervention recommended.

Packers vs Stuffers

Packers: Carefully PACKING illicit substances into packages, lower chance of leakage (image adapted from Vectortoons.com)
Stuffers: Hastily STUFFING illicit substances to hide evidence from law enforcement (image adapted from Family Guy), higher chance of content leakage.
Management:
- Decontamination:
  - Packers: Whole-bowel irrigation safe and feasible
  - Stuffers: Controversial
- Symptomatic:
  - Opioid (CNS depression, hypoventilation, pinpoint pupils): IV Naloxone 0.05 in nonapneic patients, 0.2 – 1mg in apneic patients. Larger doses may be required if pt ingested a large amount of heroin.
  - Sympathomimetic (agitation, hypertension, hyperthermia): Symptomatic management, airway monitoring, temperature control. AVOID pure beta blockers. Can consider GI decontamination but consult Poison Control.