You Swallowed What? How to Treat Inappropriate Ingestion

People swallow a lot of things they should not--usually by accident, but also in suicide attempts, drug smuggling through 'body packing', and in some cases because they are mentally ill. In the case of accidental swallowing of objects, most items pass through the digestive tract.

But when they do not, said Seth Gross, MD, director of endoscopy at Tisch Hospital, NYU Langone Medical Center, it's time to involve endoscopy.

Speaking at a symposium on gastro-intestinal emergencies held at the American College of Gastroenterology Annual Scientific Meeting in Honolulu Oct 18, Gross advised his listeners to pack an extensive tool kit. About 1,500 people die from ingesting objects or substances annually, he said. In 95% of the cases the swallowing is accidental.

The things swallowed include coins (most common in children along with small batteries) a food bolus that gets stuck in the esophagus, and sharp objects including chicken bones or fish bones, open safety pins, toothpicks and other miscellaneous items.

How to get them out? Useful endoscopy tools includes ones with graspers, forceps, hooded tubes, banding caps, baskets and snares, he said.

It is up to the individual physician to decide how to deploy them.

Radiographic images can be useful, "but they should delay endoscopy," Gross said, particularly the case of sharp objects which do more damage every minute they stay inside the GI tract. Batteries also confer urgency, since they can degrade and cause tissue damage. Coins can stay in the tract for a longer time without causing harm, he said.

Even with an arsenal of retrieval tools, it can be difficult to get a long, slender object out of the gut -- a pen for instance. "Slow and steady is the way," Gross said. Don't panic, don't push, and eventually the way to retrieve it will become clear, he said.

In cases of drug body-packing, such as cocaine or methamphetamine wrapped in latex, endoscopy is not recommended. The drug packets should be monitored with radiography and retrieved surgically if they do not pass.

Gross said he has also seen the devices used for capsule endoscopy get stuck, though in fewer than 1% of cases where they are used.

Less mechanical and potentially more damaging is the ingestion of caustic substances, usually a failed suicide attempt. There is a global geographic difference in the substances people swallow to try to take their lives, he said. In the East, it is generally acids; in the West, it is alkaline substances, including substances used to clean dishwashers, he said. In the most serious cases the caustic substances will cause perforations and require surgery.

Another danger is that these substances will eventually cause cancer, or lesser but serious problems like delayed gastric emptying. The least serious cases will mean patients will get prescriptions for antacids and be put on a special diet. "They leave the hospital in a day or two," Gross said.

The most severely damaged patients will see long stays in the ICU and "usually damaged organs will have to be taken out," with surgery, he said.