00:00:01: That's probably the only moment where I really drop everything right away and just get into hospital because it can have devastating consequences.

00:00:12: Welcome

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00:00:36: And join us as we advance GI

00:00:45: Endoscopy Care the Foreign Bodies Playbook, and my guest once again is Dr.

00:01:01: Henrietta Heinrich who is head of endoscopy at the Clarence Abdominal Center in Basel Switzerland.

00:01:08: Welcome to the podcast!

00:01:12: Thank you Ian for having me.

00:01:13: it's a great pleasure.

00:01:15: So today we are going to discuss foreign bodies.

00:01:19: When we spoke a few months ago, part one was on food impaction.

00:01:24: so let's get to it here.

00:01:26: for foreign bodies you're called from the emergency department.

00:01:30: somebody has swallowed something.

00:01:32: And the first issue really in these types of patients is assessment and triage, so what's your criteria or what's really the evidence today?

00:01:40: The criteria for emergent versus urgent vs elective endoscopy.

00:01:49: So it very much depends on what has been swallowed and what type of patient we have.

00:01:56: There are many areas in Europe where we also are in charge at night for pediatric emergencies, I think that's important to see the types of patients.

00:02:06: If you're a pediatric patient or an elderly patient who might want to be on high alert then what kind of foreign body is sharp?

00:02:16: How large is it?

00:02:17: Is a button battery, magnet.

00:02:20: Is there pain other patients in stress?

00:02:23: what are the comorbidities?

00:02:25: What time of day all these things play into how quickly we need to get into interaction or at night Into hospital.

00:02:35: So that's essential part of triage.

00:02:37: What type patient and foreign body And can we localize where it is In the esophagus?

00:02:44: because that's a different ball game.

00:02:46: Is it in the stomach?

00:02:47: Has an X-ray been performed?

00:02:49: and sometimes, It is even very hard to find out whether patient has actually swallowed something Because some times they just feel They have thrown down glass from a cupboard And then somehow got splintered into their mouth Then accidentally swallowed.

00:03:07: So stories can be quite interesting.

00:03:10: You really need make sure you get your foreign body Determined what it is.

00:03:15: So history is important and also whether this was accidental ingestion of a foreign body or volitional ingestion Of the foreign body, What are there?

00:03:25: certain things you want?

00:03:26: The emergency department to do for you while You're coming to the hospital Or before your going To perform upper endoscopy.

00:03:35: So, it very much depends how stable the patient is and what type of foreign body we have.

00:03:43: Let's just have an example for a young child having swallowed a button battery... ...and you're pretty sure that this is in the esophagus!

00:03:50: That's probably the only moment where I really drop everything right away and just get into hospital.

00:03:58: The pediatric anesthesiologists in our place are very good, so you can literally go within half an hour to an hour and intubate that patient out because it could have devastating consequences.

00:04:11: The guidelines here is also clear and specific but sadly there's a few button battery producers who are child safe.

00:04:21: I drop everything.

00:04:22: let the patient be intubated as quickly as possible.

00:04:27: And what I want people in the emergency department to prepare for me is a general assessment how good that patient, it's respiratory tract stable.

00:04:39: can their patients still swallow?

00:04:41: His or her own saliva?

00:04:42: this also determines for me if I need standby by anesthesiology.

00:04:46: If it's really obstructing and sharp in the upper G.I.

00:04:50: tract then, than i need stable conditions And I would ask for anesthesiology stand-by.

00:04:57: Is that for both pediatric patients as well as adults?

00:05:00: In terms of anesthesia support.

00:05:02: So I think for pediatric patient there is no question.

00:05:06: You need anesthesia and you need specialized anesthesia.

00:05:09: We're very lucky.

00:05:10: we have a very good collaboration with our pediatric gastro unit when were on call for them.

00:05:15: the anesthesiology is great week.

00:05:18: go there, we perform the endoscopy in they can take care of their anesthesiology.

00:05:22: And then an adult said it very much depends on A what time of day Be aware and what the foreign body is.

00:05:31: And see how experienced you are, and de-how comorbid that patient is.

00:05:35: So if it's still during working hours I usually make this assessment myself... ...I look at the patients to see whether i can do it.

00:05:43: If its an elderly patient with possible cancer or unclear dysphagia Then in a very high bolus then I might go For a very high foreign body stuck in the esophagus, I might go for anesthesiology.

00:06:00: Also if there is tricky heart disease or lung disease in these patients and that gets even more crucial at night because you might have a nurse on your own And If You Do That Alone In Your Endoscopy Suite Something Goes Wrong then help can take a long time.

00:06:16: So at night, usually if it's an urgent foreign body obstruction in the esophagus or stomach I do recommend to have at least the anesthesiologist help you because its question of manpower and protected airway.

00:06:31: Let me ask you this What are potential foreign bodies for adults?

00:06:35: Forget about children right now In adult way say You know what It is okay i don't need rush-in.

00:06:42: We could actually do that in morning and do what we need to.

00:06:46: What are those cases where it's not nearly as urgent?

00:06:50: So, I think that I have swallowed something sharp but i'm not sure of the case.

00:06:56: then usually quite relaxed about having swallowed a two-frame coin I am relaxed also.

00:07:06: some time had a case with bitten off toothbrush.

00:07:09: head is less than two centimeters.

00:07:12: its not too sharp.

00:07:14: It clearly had went down.

00:07:16: There was no sign of obstruction in the esophagus.

00:07:18: I waited, I just extracted it the next day.

00:07:22: but we also have recently a funny case where there's an in-between Where you...there is now clear guidance.

00:07:29: Someone has swallowed and attack An apple tag But theres button battery inside.

00:07:37: It was a patient that was curious whether it could come out or not and after couple of days he realized, That might be dangerous because online there were some cases where dogs had died off eating an apple tag.

00:07:51: And then we presented to the emergency department in middle-of-the night.

00:07:55: We asked ourselves should we retracted next morning?

00:07:58: Or should do with tonight Because it's button battery decided six o'clock in the mornig Retrieve it and was actually a good decision because the tag had started to open.

00:08:12: So we were right on time, It wasn't stomach but still important that we retrieved.

00:08:19: so you really need make sure what type of foreign body do have.

00:08:25: this is something where I'm not sure whether i should go in right away or not protected the button battery, but if it had opened in stomach.

00:08:34: It wouldn't have been exceptionally good.

00:08:36: so we were right to retrieve.

00:08:38: people are a little bit sometimes too curious to check certain things don't you think?

00:08:42: Yes yes um So what's important?

00:08:45: uh To know.

00:08:46: is it a needle?

00:08:47: Is it a safety pin?

00:08:49: Is it something where you tag together your papers?

00:08:52: That's also very important.

00:08:53: But there You usually Have the possibility to ask Your emergency unit to take an x-ray Because you can see Because the metallic foreign bodies, you can see.

00:09:03: You can see the localization and once that it has moved deeply into this small bowel... ...you don't need to move anymore.

00:09:12: Also there's a question of removing swallowed razors.

00:09:17: There are many patients who do these for psychiatric reasons

00:09:22: Or patients or individuals

00:09:26: in prison Who want to get out?

00:09:27: Yes But then watch out how they swallow these things, because usually it's very rare that whole razor blade can be swallowed.

00:09:39: They're usually tiny little pieces and then also gives you an argumentation or a good argument to wait if its not in the esophagus.

00:09:48: so x-ray on the ER helps you great deal If You Have A Metallic Foreign Body.

00:09:56: So let's talk about endoscopy.

00:09:59: What are some of the tools that you use to remove these various foreign objects?

00:10:04: And I know it also depends on what type of a foreign body is there, but what's your usual go-to Tools.

00:10:10: So what i usually put on my scope Is a distance cap

00:10:17: A clear cap or hood.

00:10:19: It's a clear cap because they're just a simple distance cap Because if you have to maneuver The upper esophageal sphincter and something stuck in it don't have the danger of rapidly moving, moving the foreign body and creating damage.

00:10:34: but you can really see how it unfolds.

00:10:37: And where is stuck?

00:10:38: That helps me a great deal!

00:10:40: If I had something sharp stuck there in the Akraosophageal Swinger... ...I'd add some really sharp fish bones that are like... completely obstructing the upper esophageal sphincter, then a distance cap can help you to wriggle that out with good forceps.

00:11:00: You need really watch not to hurt your mucosa but most of time get it out and nothing serious happens.

00:11:10: A lot times these foreign bodies actually make it into stomach?

00:11:15: Yeah!

00:11:16: So

00:11:17: what are we doing there?

00:11:19: I always find it, you know.

00:11:20: the first thing i want to say is how much enosophagus can take without really

00:11:27: getting injured.

00:11:30: Yes

00:11:31: its an amazing organ and incredibly tough stomach as well.

00:11:35: but once in this stomach for example razor blades something sharp sometimes use an overtube.

00:11:41: if not too broad then anesthesiology helps because the overtube.

00:11:49: The long overtube is something quite massive, you have to gently maneuver it because there also has been cases described where you actually perforate with the overtubes.

00:11:59: that's why I'm always very careful using it.

00:12:01: but if you have a large sharp foreign body then they're something we call the capuchin and basically its little bit like condom on your scope.

00:12:15: It's a big hood, and then you grab it.

00:12:17: And once you traverse the GEOJ in the backwards... ...then the hood goes over the critical

00:12:27: part.".

00:12:28: Yeah!

00:12:28: It flips on itself so that protects the distal or lower softshell sphincter?

00:12:35: But also here you have to be careful if its really to get the foreign body into right axis Correct.

00:12:43: I would always try to really get your axis of removal right, sometimes what can also help you to maneuver that is a bigger distance cap in addition Make it harder for you is if the stomach is full.

00:13:05: Sometimes that happens and you cannot find a foreign body, And then something where

00:13:10: I

00:13:11: wait.

00:13:13: Then You just have to wait because he can't see anything.

00:13:16: It makes no sense really dig through A full stomach To Find The Foreign Body

00:13:22: And your increasing potentially risk of aspiration as well.

00:13:29: So in a patient, that's a good point.

00:13:30: At that point the patient will swallow foreign body but there is actually lot of old food or liquids.

00:13:36: you can't see The recommendation to pull out your scope and wait awhile.

00:13:41: Would you give a promotility agent?

00:13:43: To facilitate something like erythromycin or metaclopramide?

00:13:47: That really depends on the foreign body.

00:13:49: I'm reluctant In these situations to do it.

00:13:52: i'd rather wait for the patient clinically I

00:13:56: agree, because you don't want it going into the small bowel and then you've lost it.

00:13:59: Exactly!

00:14:01: I tend to monitor the patient.

00:14:03: then The motility can also do more harm than good there?

00:14:07: I would agree with you...I'd just wait and not give anything to promote gastric emptying Because You Don't Want Your Foreign Body Slipping Away And Then It Could Become A Surgical Issue.

00:14:18: Yeah, but you know the magic is and this is something that I learned from The Pediatricians so many foreign bodies just passed without us knowing they are there.

00:14:26: The pediatricians are incredibly relaxed about Many large objects.

00:14:33: it's really interesting.

00:14:35: So the only thing They're really say yeah That you need to get out magnets And button batteries.

00:14:39: You need To be There.

00:14:41: But the rest Are like Yeah,

00:14:43: the kids have a proclivity to swallowing button batteries and also these magnets which can adhere to each other.

00:14:50: And cause fissualization in holes... We're lucky at my place because pediatric gastroenterologists they are on call!

00:14:59: They get called more for foreign body ingestions than we do.

00:15:02: but ...we've got our fair share.

00:15:06: What's the threshold for referring somebody for surgery?

00:15:11: Endoscopy is just not successful or is not feasible.

00:15:15: It's uncommon, but when would you do it?

00:15:18: If you cannot retract safely the sharp foreign body and you need to take it out?

00:15:24: so I remember a patient having swallowed that glass cover of an iPhone rolled then swallowed.

00:15:32: there was no way in extracting that safely without breaking into thousand little pieces to come out because it was rough on the surface, there were already splinters coming out.

00:15:46: There is no other way and we couldn't get it out.

00:15:49: so these are cases for

00:15:50: surgery.".

00:15:52: Most of time if you have a sign of perforation then you shouldn't go in with endoscopy but most peritonitis or peritoneal signs, or air under the skin.

00:16:11: Then you really need to work together in a multidisciplinary team and decide what is best.

00:16:17: but that luckily happens very rarely.

00:16:21: So this isn't an ingested foreign body But it's sort of a form-body.

00:16:26: What do you about Bezos?

00:16:28: Oh Bezos

00:16:30: Yeah Bezos

00:16:32: They can be quite challenging.

00:16:34: No kidding

00:16:36: They can be very challenging, but I do enjoy it.

00:16:39: It's you can spend the whole day Extracting it.

00:16:42: i put them into little pieces and then take it out bit by bit.

00:16:47: Use this use a snare to try and break

00:16:51: up.

00:16:51: There are some people have used apc But that actually caused problems with uh with the current.

00:16:58: so I usually cold snare.

00:17:03: Some are so big you can't get them out, they actually have to go for surgery.

00:17:07: Because literally fill the whole stomach?

00:17:10: Exactly!

00:17:10: Don't any movement make it smaller.

00:17:15: and when then open the form of the stomach is replicated with Vesor.

00:17:21: Luckily I've rarely ever had that... Big Bezoage, but I was able to take them out in little pieces and over two or three sessions.

00:17:33: But usually it's luckily not that extreme yet... ...but is very tedious work!

00:17:40: Have you ever used... there have been reports.

00:17:42: people use Coca-Cola?

00:17:43: They have the patient drink Coca-Cola to try and dissolve the Bezor.

00:17:47: Have you ever tried that?

00:17:48: And has it worked for ya'?

00:17:50: You know, I think it dissolves... ...the stuff between the hairs a little bit better.. ..and makes it more gooey.

00:17:58: That's my belief!

00:17:59: That is also what we use for peck tubes which are obstructed There some acidity or some... formula that makes stuff dissolve.

00:18:09: So, yes...

00:18:10: This is not a commercial for a plug-for-coca-cola or Pepsi.

00:18:14: it's yeah

00:18:15: okay

00:18:15: well listen this has been a great part two.

00:18:18: we've now covered everything from foreign body ingestions to food impactions and given some great tips.

00:18:26: I want to know more.

00:18:27: i know this is this is airing in September but uh we're actually recording.

00:18:35: So tell me you're watching the World Cup matches right now, Switzerland.

00:18:39: Are they still in?

00:18:40: Switzerland

00:18:42: is still in, yes.

00:18:44: Who I'm rooting for at the moment?

00:18:47: Is the Austrians and the Swiss because they're really happy that they get one round further.

00:18:52: there There's not the expectation to become world champion but be part of it And with that joy i find very infectious.

00:19:02: Well last night USA beat Bosnia.

00:19:05: They got through.

00:19:08: The women have done this multiple times.

00:19:11: Magic of football because the unexpected can happen and the usual contenders are out.

00:19:18: The Dutch are out, the Germans are already... I mean this is old news.

00:19:22: by the time everybody's gonna hear this podcast but well i'm glad to hear that you're a fan!

00:19:26: I've been following it too.

00:19:27: It's great to watch it.

00:19:29: Listen Henry thank you again for being here for part two has been great having ya And appreciate all your tips & pearls of wisdom regarding foreign bodies today.

00:19:38: Thanks.

00:19:39: Thanks, Ian for having me.

00:19:41: It was a pleasure.

00:19:42: Bye-bye!

00:19:45: And of course, we'd love to hear your feedback.

00:20:08: What would you like to hear more?

00:20:10: Send your thoughts at ESG.com.

00:20:13: Thanks for listening and join us next time!