Gastrointestinal Foreign Body

Etiology

Foreign body ingestion, although commonly seen in both pediatric and adult populations, may have different underlying causes and motives due to the groups involved.[3] Foreign bodies can be blunt, including coins or buttons, food boluses, or sharp objects (eg, needles, razor blades, and chicken or fish bones). 

Foreign Body Ingestion in Children

In children, most foreign body ingestions are accidental and often occur without being witnessed. Young children, in particular, naturally explore the environment using their mouths, which leads to a higher incidence of accidental swallowing.[4] Recently, concerns have arisen about the ingestion of hazardous items, eg, rare-earth magnets and lithium batteries, which are often found in newer toys and household electronics.

Children with underlying developmental impairment are also at a higher risk of ingesting foreign bodies. The most commonly ingested objects include coins, buttons, batteries, toys, and magnets. The cricopharyngeal area, the middle third of the esophagus, the lower esophageal sphincter, the pylorus, and the ileocecal valve are the most frequent locations for these impactions. Children are especially at risk of having foreign objects lodged in the esophagus because of its smaller diameter.[5]

Foreign Body Ingestion in Adults

In adults, foreign body ingestion may be further influenced by anatomical, pathological, or intentional circumstances. Risk factors in adults include self-harm, alcohol or substance abuse, lack of teeth, or dentures.[1] Older adult populations with low vision can sometimes mistake small objects for pills. 

Anatomical conditions

Accidental ingestion most often results from anatomical factors. Foreign bodies frequently enter the digestive tract along with food, and a food bolus may become lodged during swallowing, producing symptoms consistent with an esophageal obstruction. Once a foreign body reaches the stomach, most cases suggest continued passage through the gastrointestinal tract without the need for intervention.[2] The 3 following naturally constricted sections of the esophagus (common sites for impaction) present a higher risk for foreign body entrapment:

• Thoracic inlet (the first and the most common site where the cricopharyngeus muscle is located)
• Aortic arch (exerts mild extrinsic compression on the esophagus at a distance of around 25 cm from the incisors)
• Gastroesophageal junction [6]

Pathological or intentional causes

In adults, recognizing that foreign body impactions predominantly occur in conjunction with preexisting medical conditions remains essential. Sung and colleagues identified several contributing factors associated with impactions:

• Strictures (37%)
• Eosinophilic esophagitis (33%)
• Malignancy (10%)
• Esophageal rings (6%)
• Achalasia (2%) [7]

Other conditions that contribute to these ingestions include developmental delay, cognitive impairment, psychiatric disorders (pica, borderline personality disorder), and substance abuse or alcohol intoxication.[6] 

Epidemiology

Ingestion of non-food foreign bodies is more common in children than in adults, particularly between the ages of 6 months and 6 years.[3] In adults, esophageal food bolus impaction is more common, with an estimated annual incidence of 13 cases per 100,000 people.[8] Globally, it accounts for a considerable number of emergency department visits annually, with an estimated incidence of 120 to 300 cases per 100,000 people.[9] In 2019, the American Association of Poison Control Centers reported a total of 94,051 cases of foreign body ingestion across all age groups. This included 67,186 cases in children younger than 5 years and 12,223 cases in adults aged 20 or older.[10]

Swallowing several foreign objects and experiencing multiple episodes of ingestion are common occurrences. Studies in pediatrics have shown a higher prevalence of conditions among males compared to females.[11] Ingestion in older age groups or of unusual objects requires consideration of other factors, including psychiatric concerns, self-harm, eating disorders (eg, bulimia or drug packing).[6] 

Pathophysiology

The majority of swallowed foreign objects pass through the gastrointestinal tract without incident; however, certain objects can result in serious complications, depending on the type of object, the duration of impaction, and the specific anatomical areas they affect.[7] Most foreign bodies that enter the esophagus may become lodged at physiological narrowing points, eg, the upper esophageal sphincter, the aortic arch level, and the lower esophageal sphincter.[6] Esophageal foreign bodies are more commonly observed in patients with a history of gastrointestinal diseases, eg, eosinophilic esophagitis, gastroesophageal reflux disease (GERD), congenital gastrointestinal anomalies, and neuromuscular disorders. The most common site for obstruction is at the thoracic inlet (at the level of the clavicles and cricopharyngeus muscle). Approximately 10% to 15 % lodge at the level of the carina and aortic arch, and the rest at the esophagogastric junction. Sharp, bulky, or irregularly shaped objects can cause mucosal injury, perforation, or obstruction, especially at these locations.[3]

Tissue injury can result from mechanical trauma, chemical corrosion, or pressure necrosis. Objects like button batteries result in caustic rather than thermal injury.[12] When a battery becomes lodged in the gastrointestinal tract, the mucosa creates a conductive path between the positive and negative terminals of the battery, allowing current to flow. This, in turn, generates hydroxide radicals in the esophageal tissue, leading to caustic damage and coagulative necrosis by rapidly increasing tissue pH, which results in weakening and, hence, necrosis of the esophageal wall within 15 minutes of contact.[13]

Magnets, if multiple, attract across the walls of the gastrointestinal tract, leading to ischemia, tissue necrosis, perforation, fistula formation, obstruction, peritonitis, or even death.[14][15][16] Similarly, sharp objects, eg, needles, bones, or glass shards, directly perforate the mucosa, especially at angulated segments, including the pylorus, ileocecal valve, or rectosigmoid junction.[17] Long or rigid objects may be unable to pass through the curvatures and angulations of the gastrointestinal tract, increasing the risk of impaction and perforation.

History and Physical

The complications and severity of clinical presentation depend on the type of ingestion, the quantity ingested, the location of impaction, and the time since ingestion.[18] Hence, a thorough history and evaluation detailing these aspects is essential and guides management.

Clinical History

Children who ingest foreign bodies may exhibit a wide range of symptoms. Many individuals remain asymptomatic or report only mild symptoms, eg, a sore throat, chest discomfort, or a globus sensation.[2] Additional symptoms, eg, nausea, vomiting, abdominal pain, and fever, may indicate complications of peritonitis or mediastinitis, depending on the site of intestinal perforation. Symptoms suggestive of impaction include dysphagia, odynophagia, refusal to eat, and inability to tolerate secretions.[4] 

In adults, food impaction is more frequently encountered than foreign body ingestion, though clinical history and presentation often overlap. Adults typically present with symptoms, eg, globus sensation, dysphagia, and chest pain.[19] Clinicians should inquire about what the patient was eating or ingesting, when the event occurred, and the patient's tolerance of oral intake after ingestion. A detailed medical history is crucial, especially if esophageal pathology or a history of prior food impaction exists.[18] Although adults may point to specific areas of chest discomfort, these locations rarely match the actual site of impaction.

Circumstances surrounding the ingestion and a past ingestion history are helpful in management and preventing future recurrence. Repeated ingestions may indicate neglect, abuse, or underlying cognitive or mental health disorders. 

Physical Examination

High-risk objects include batteries, magnets, and sharp or pointed items. Sharp objects may lead to perforation and leakage of gastric contents, potentially causing peritonitis or mediastinitis.[2] Button batteries can produce significant tissue damage and burns. Ingestion of magnets, or coingestion of a magnet with metallic items, may result in bowel obstruction, volvulus, or peritonitis.[4]

Physical assessment should begin with the airway and breathing.[20] While foreign bodies in the posterior pharynx are rarely visible, the area should still be examined. Accumulation of saliva in the mouth may occur, and the inability to swallow liquids or drooling strongly suggests an esophageal obstruction requiring urgent endoscopy. Pediatric patients should also undergo ear and nose examinations to rule out additional foreign bodies.[2] In patients with clinical concern for esophageal perforation, a crackling or popping sensation may be felt along the neck, called crepitus. This finding signals air in the subcutaneous tissue. Guarding and rebound tenderness on abdominal palpation are physical exam findings concerning for peritonitis. Signs, eg, shock, dyspnea, and respiratory distress, may further indicate intestinal perforation secondary to a foreign body.[18] 

Evaluation

Radiography serves as the first-line imaging modality for evaluating patients with suspected foreign body ingestion. Radiographs help confirm the size, location, quantity, and shape of ingested materials. Approximately 83% of ingested foreign bodies are radiopaque; however, smaller objects may remain undetectable in thicker anatomical regions. Frontal and lateral neck and chest x-rays, along with an abdominal x-ray, should be obtained for a comprehensive evaluation.[21] Radiolucent objects may appear as subtle edges or irregularities on the radiograph.[20] Overall, x-rays detect about one-third of ingested foreign bodies, and some items, eg, fish or chicken bones, wood, plastic, thin metals, and glass, may be missed.[18] 

In cases involving ingested button batteries, x-rays should be obtained in all patients younger than 12 years. For those 12 and older, imaging is recommended if the battery exceeds 12 mm in diameter. On plain films, button batteries can be differentiated from coins by the characteristic double-density circular opacity.[4] Although not commonly used, handheld metal detectors can assist in identifying the foreign body’s location. Initial radiographs help identify high-risk objects, but when conservative management is appropriate, metal detectors can monitor the object’s progression through the gastrointestinal tract.[22]

Computed tomography (CT) imaging may not detect radiolucent objects; however, this modality should be performed in cases where complications (eg, perforation) are suspected or when anatomic information is needed for preprocedural or surgical planning. The use of intravenous (IV) contrast can enhance the detection of foreign body-associated fistula formation, abscesses, and peritonitis. However, in suspected acute esophageal obstruction, imaging should not delay urgent endoscopy, as localization is not necessary before intervention is performed.

Treatment / Management

Gastrointestinal Foreign Body Management 

Management of a foreign body in the gastrointestinal tract is influenced by multiple factors, including the type, size, and location of the ingested object, the time since ingestion, the patient's clinical condition, and NPO status.[23] The European Society of Gastrointestinal Endoscopy (ESGE) and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) categorize intervention timing as follows:(A1)

• Emergent: Within 2 hours of presentation, irrespective of NPO status
• Urgent: Within 24 hours [24]

The American Society for Gastrointestinal Endoscopy Committee recommends an otorhinolaryngology (ENT) consultation for foreign bodies located at or above the cricopharyngeus, with rigid endoscopy being the standard in some institutions. The plan of care is tailored to the type of objects ingested.[9]

Button Battery Ingestion Management

Button battery ingestion is usually considered a medical emergency requiring immediate evaluation and management, especially if the battery gets stuck in the esophagus, due to a high risk of rapid tissue damage such as mucosal burns, perforation, fistula formation, and even death. Management differs depending on the battery's position, the patient's age, the battery's size and kind, and the presence or absence of symptoms.[25] Batteries located in the esophagus at the time of presentation must be removed immediately, ideally within 2 hours of ingestion, even if the patient is asymptomatic, to reduce the possibility of serious complications.[26] 

In asymptomatic children younger than 12 years who have ingested a 20 mm or larger button battery, endoscopic removal is recommended if the battery remains in the stomach for more than 48 hours.[Poison Control. Updated 2025] However, if the button battery has already passed into the intestine, and the patient is asymptomatic, an outpatient management approach may be utilized. Parents should be instructed to watch for symptoms of obstruction or gastrointestinal injury. The patient should maintain a regular diet and participate in physical activity, and their stool should be inspected for the presence of the battery. If the battery doesn't pass within 10 to 14 days, repeat imaging may be required.

Magnet Ingestion Management

Ingestion of a single magnet is a low-risk event; outpatient management is reasonable with serial radiographs and observation. However, if several magnets or coingestion of a magnet and other metals occurs, prompt intervention is required. Neodymium and other high-powered earth magnets are most concerning and have the power to attract each other through several layers of the bowel wall. Immediate endoscopy should be performed in these instances. If they are in the esophagus or stomach, endoscopic removal should occur within 12 hours.[16] 

If endoscopy is not feasible, immediate surgical consultation is warranted. Once magnets have passed beyond the stomach, asymptomatic patients may be observed with close monitoring. However, any signs of clinical deterioration, eg, abdominal pain, vomiting, fever, or localized tenderness, should prompt urgent surgical evaluation.[16] Surgical interventions are reserved for patients presenting with signs of obstruction, peritonitis, perforation, or ingesting more than 1 magnet.[5]

Sharp Object Ingestion Management

The ingestion of various sharp or pointed objects, including pins, sewing needles, safety pins, nails, screws, toothpicks, and bones, has been well-documented in both pediatric and adult populations.[27][28] Early recognition and prompt intervention are critical to reduce serious complications, including gastrointestinal perforation, abscess formation, peritonitis, and even life-threatening vascular injuries.[27] When a sharp object is lodged in the esophagus, emergent endoscopic removal within 6 hours is strongly recommended due to the high risk of perforation and mediastinitis.[29](B3)

If the object is located in the stomach or duodenum, urgent endoscopy within 24 hours is still advised. This urgency is due to the challenge of retrieval in the duodenum, where a narrower lumen and fixed anatomical position increase the risk of injury during extraction.[30] Once the object passes into the small intestine, asymptomatic patients may be managed conservatively. However, if the object fails to progress within 72 hours or if the patient develops symptoms, eg, pain, vomiting, or shows signs of obstruction, immediate surgical intervention is warranted.[29]

Coins and Blunt Object Ingestion Management

Coins are the most commonly ingested foreign objects in children aged between 7 months and 10 years.[31] Coins located in the esophagus should be removed within 24 hours in asymptomatic children and emergently if symptoms, eg, drooling, dysphagia, or respiratory distress are present.[24] Once a blunt object larger than 2.5 cm in diameter enters the stomach or small intestine and the patient remains asymptomatic, especially in younger children, removal within 24 hours is recommended, as the chance of passage across the pylorus is unlikely.[32] If endoscopic removal is not feasible, repositioning the coin vertically with a nasogastric tube is suggested in some instances, as this repositioning allows the coin to pass into the stomach. Coins in the upper esophagus may also be retrieved using a Foley catheter under fluoroscopic guidance, provided that battery ingestion has been excluded.[31](A1)

Food or Bolus Impaction Management

For adults presenting with suspected food impaction, medical management may be attempted, though endoscopy is often necessary. Complications tend to depend on the location of the object and the duration since the foreign body was ingested.[18] Esophageal foreign bodies can lead to mucosal wall edema and weakening, increasing the risk of bleeding and perforation. Prompt removal of esophageal foreign bodies is essential to minimize these risks.[1](B2)

Success with glucagon in relieving food impaction remains variable. In some cases, diazepam has been administered in conjunction with glucagon. This approach offers a favorable safety profile with relatively few adverse effects.[33] Glucagon works by reducing the tone of the lower esophageal sphincter.[34] This mechanism facilitates relief of the obstruction but may also induce vomiting, raising the risk of perforation and distal obstruction.[33]

One study demonstrated that glucagon successfully resolved food impaction in approximately one-third of cases and found that initial treatment with glucagon was significantly more cost-effective than proceeding directly to endoscopy.[34] Older age and early presentation to the emergency department serve as independent predictors of foreign body presence on endoscopy. Reduced esophageal motility in older patients likely contributes to a decreased likelihood of spontaneous dislodgement. Dysphagia and chest pain frequently accompany foreign body impaction and often localize to the upper third of the esophagus.

Patients with endoscopically confirmed food impaction were generally older and more likely to have underlying psychological disorders. These impactions most commonly involve the lower third of the esophagus. For such patients, prompt endoscopy is strongly recommended. In contrast, younger asymptomatic patients may benefit more from initial observation or a trial of medical management.[19]

Differential Diagnosis

A patient presenting with a witnessed foreign body ingestion or globus sensation may appear straightforward; however, underlying pathologies should be considered including:

• Esophagitis
• Pharyngitis
• Laryngitis
• Peritonsillar or retropharyngeal abscess
• GERD
• Acute coronary syndrome in adults
• Gastritis
• Gastroparesis
• Pyloric stenosis [20]

Treatment Planning

Foreign bodies considered dangerous due to their shape or size require prompt and effective removal. Available interventions include endoscopy, laparoscopy, and laparo-endoscopic techniques.[35] Endoscopic removal serves as the preferred method and proves successful in the majority of cases. Outcomes are particularly favorable in children and in patients who present shortly after ingestion.[36]

Prognosis

Most foreign bodies pass spontaneously without any intervention, with only 1% causing perforation. A high risk of perforation exists when the foreign body has sharp edges. The common sites of perforation are at points of narrowing in the gastrointestinal tract.[37] Early diagnosis and immediate treatment are crucial for improving the prognosis of foreign bodies lodged in unusual locations. Up to a 10% mortality rate has been reported because of missed or delayed diagnosis.[38]

Complications

Complications and their severity are typically related to the object ingested, its location, and the duration of time that has passed since ingestion.[18] A primary concern with a foreign body or food impaction in the esophagus is the pressure placed on the mucosal walls and the resulting edema. This causes weakening of the esophageal walls, increasing the risk of bleeding and perforation.[1]

Button batteries, which are not chemically inert, can impact the esophagus and cause severe tissue damage and burns due to the build-up of sodium hydroxide. In these cases, fistulization into major blood vessels can occur, resulting in severe, even fatal hemorrhage. Moreover, damage can begin to develop as early as 2 hours after ingestion.

Complications from the ingestion of magnets usually occur if numerous magnets or a magnet with additional metallic objects are ingested. The magnets can attract through several layers of the bowel wall, leading to obstruction, volvulus, and fistula formation. Tissue necrosis and perforation can occur, leading to peritonitis. Deep pressure ulcerations can occur within the first 8 to 24 hours following ingestion.[4][39]