Therapeutic endoscopy for foreign bodies

Foreign bodies of the upper gastrointestinal tract

Foreign bodies are all bodies that enter from outside in a special way or are formed in the body, digestible or not, of living or non-living nature, serving as food products or not, with or without clinical manifestations.

Without forcible pushing, a foreign body can enter the upper digestive tract if its length does not exceed 15 cm and its width does not exceed 1.5 cm. The maximum stretch of the esophagus in width is 3.5 cm.

In the esophagus, sharp foreign bodies (mainly bones) most often get stuck in the cervical part and much less often in the thoracic part, respectively, in places of physiological constrictions. The latter include the area of the cricopharyngeal muscle (m. cricopharyngeus) in the proximal part, external compression of the esophagus in its middle third by the aortic arch and the left main bronchus, as well as the area of the lower esophageal sphincter above the esophagogastric junction. Large blunt foreign bodies, such as coins, get stuck mainly in the thoracic part, where obstruction of the esophagus by poorly chewed dense food also occurs. If the foreign body is long, one end of it may be located in the esophagus, and the other may rest against the wall of the stomach in the area of the greater curvature. Occasionally, a foreign body may remain in the esophagus for a long time and cause cicatricial changes in its walls.

Foreign bodies that are large enough or have sharp edges and thorns are retained in the stomach. Most often, the pyloric sphincter in the gastroduodenal junction becomes an obstacle to the passage of a foreign body. Relatively small foreign bodies, even those with sharp edges, are usually freely evacuated into the intestine, but heavy metal objects (e.g., pellets) are sometimes encapsulated in the stomach wall. Sharp objects occasionally penetrate the mucous membrane; in this case, a through puncture of the wall (with a long needle, pin) is possible with the development of peritonitis . Large foreign bodies that remain in the stomach for a long time can cause bedsores of the wall with bleeding or perforation. Foreign bodies of animal or plant origin can form so-called bezoars in the stomach. Trichobezoars are formed from balls of swallowed hair, phytobezoars - from plant fibers and fruit stones. Bezoars gradually increase in size and can fill almost the entire lumen of the stomach.

Needles and other long objects that can perforate the intestinal wall often get stuck in the duodenum in the area of fixed bends and the Treitz ligament. Foreign body sticking is also facilitated by pathological changes in the upper gastrointestinal tract (scar or tumor stenosis, segmental spasm, inflammatory infiltrate, etc.).

Most patients with foreign bodies in the gastrointestinal tract are children. Other high-risk groups include people with mental disorders and people who abuse alcohol and sedatives and hypnotics. An increased risk of foreign bodies entering the gastrointestinal tract exists in the elderly who have poor-quality dentures and in the elderly with weakened self-criticism due to drug therapy, senile dementia, and in the presence of dysphagia due to stroke. Intentional introduction of foreign bodies into the gastrointestinal tract has been described in people smuggling illegal drugs, narcotics, jewelry, or other valuables.

The number of patients with foreign bodies increases due to:

1. Aging of the population. Lack of teeth, impaired swallowing and sensitivity.
2. Acceleration of the pace of life. Lack of reflex to eat.
3. Increase in the number of mentally ill patients and alcoholics.

Methods of managing patients with foreign bodies.

Expectant management: sharp objects (pins, needles, nails, and toothpicks) pass through the gastrointestinal tract without complications in 70-90% of cases within a few days. There are two factors that allow foreign bodies to pass safely through the gastrointestinal tract:

1. foreign bodies usually pass along the central axis of the intestinal lumen;
2. reflex relaxation of the intestinal wall muscles and slowing of intestinal peristalsis leads to sharp objects in the intestinal lumen turning in such a way that they move forward with the blunt end. It is necessary to monitor the patient in a hospital setting with X-ray control of the movement of the foreign body.

Indications for therapeutic endoscopy in case of foreign bodies

Methodology for conducting fibroendoscopy with foreign bodies. In all cases, it is better to take an esophagogastroduodenoscope with end optics for the examination. You should not take a new device, since when removing foreign bodies, devices are often damaged. If a foreign body is detected in the duodenum after a preliminary examination with a device with end optics, a duodenoscope is used.

In case of foreign bodies located in the esophagus, the device is inserted only under visual control, starting the examination from the area of the oropharynx, the root of the tongue, the pyriform sinuses - foreign bodies often get stuck there, and X-ray diagnostics is not effective. Most foreign bodies of the esophagus get stuck between the I and II physiological constrictions, which corresponds to the Lammer triangle, where a physiological diverticulum is formed. The wall of the esophagus does not participate in peristalsis here and foreign bodies are retained here. When the esophagus is stretched with air, they fall lower. It is often possible to pass the device below the foreign body. Often, foreign bodies have an unusual appearance: there are remains of meat on the bone, the metal quickly darkens, acquiring a dark or black color. Foreign bodies are often covered with mucus, food residues, which complicates diagnostics. If the foreign body is known in advance, it is good, but sometimes its nature is extremely difficult to determine. Foreign bodies in the esophagus are usually easy to diagnose: narrow lumen, foreign bodies are often single. Foreign bodies in the stomach are often multiple. It is necessary to try to wash out foreign bodies with a stream of water.

Methodology for performing fibroendoscopy with foreign bodies

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