sharp ingested FBs

[DrMom]

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Curious how this is handled in other places...

Had a pt today who ingested the blades from a disposable razor. Stable vitals. No apparent bleeding. XR shows radioopaque linear object in stomach.

Spoke to GI for scope, was told that it was a surgical issue. Spoke with surgery & was told that they take a wait and see approach with an outpatient repeat xray tomorrow to see if it has moved. They say they'll only intervene if it stays in the stomach > 2 days.

Tintinalli says that sharp FBs should be removed before passing from the stomach. How have these cases been dealt with at your hospitals?

 

[Lumberg]

Follow up in perfed bowel clinic.

 

[beanbean]

MY brother-in-law is a GI guy and I know he has fished a razor out of the esophagus before. Not an easy thing to do without causing more harm, but surgical exploration of the esophagus is risky as well. It is certainly better when patients eat things that are not sharp or corrosive! Too bad they seldom read the handbook. I had a gentleman with some loose change and a stereo part a short time ago and a girl who swallowed a fork and her eyeglasses (separate incidents). It is an odd afflication with some pretty serious consequences.

 

[AmoryBlaine]

UpToDate says sharp FBs should be removed. I know this isn't the practice everywhere but I personally would have a hard time telling a patient who had swallowed a razor blade that we were going to take a "wait and see" approach.

As someone mentioned, this is in effect a "wait and see if this thing perfs your gut." Then a somewhat risky scope has become a true surgical emergency...

 

[DrMom]

I agree, but we didn't get anywhere with either GI or surgery...that's why I'd like to see what the GI/surgery folks do in other places.

 

[Aloha Kid]

GI rigid endoscopy w/ a few other tricks usually is first line in retrieving sharp objects such as a razor blade. I'm not sure what GI was thinking. Either they have little experience with the issue or were too chicken. Either way, surgery can perform the EGD and also fix their perforation if they screw up.

 

[DrMom]

surgery was not on GI call today, so they wouldn't scope (although they could have done it tomorrow). semantics. The GI guy said he needed some special equipment/attachment (which he said he did not have) in order to remove a blade by endoscopy.

 

[GeneralVeers]

surgery was not on GI call today, so they wouldn't scope (although they could have done it tomorrow). semantics. The GI guy said he needed some special equipment/attachment (which he said he did not have) in order to remove a blade by endoscopy.

You could just admit the patient and let GI and surgery fight it out the next day.

 

[jazz]

so what happened in the end?
that's ridiculous-- sharp FB should be removed, especially a razor blade....

was GI call over soon? if so, i would have waited then called surgery for endoscopy...

or call the chair of GI, see if he can find some other guy who can scope and take out the blade.... if no one is willing, can you transfer to tertiary center...

that sucks...

 

[dchristismi]

The was a legendary single psych patient who trained a generation of GI fellows at my med school. When she'd show up in the ED, the attendings would just call with her name, and GI would come fish whatever sharp she'd swallowed that time out.

 

[AmoryBlaine]

The was a legendary single psych patient who trained a generation of GI fellows at my med school. When she'd show up in the ED, the attendings would just call with her name, and GI would come fish whatever sharp she'd swallowed that time out.

I wonder if they listed her as a resource when the fellows interviewed?

 

[macdaddy23]

The last sharp foreign body I had was a kid who swallowed a tack one night(in stomach). I called the local children's hospital and talked to GI and they said just to have him f/u and it should pass without problems. I talked to the ER guy there and they said usually if it's during the day GI will scope and get it out but at night they usually just follow it up and it passes.
I was always taught sharp objects must come out of the stomach.

I guess the objects pass easier at night due to the lower temperature, humidity, etc. Would hate for them to get out of bed for the kid.

 

[docB]

I talked to the ER guy there and they said usually if it's during the day GI will scope and get it out but at night they usually just follow it up and it passes.

Great summation of one of the failures of modern American medicine.

 

[southerndoc]

The surgeon can remove it now or remove it then (after he perfs and has free air on the x-ray).

 

[EM2BE]

Is swallowing sharp objects a specific type of pica / fetish that some possess?

 

[DrMom]

You could just admit the patient and let GI and surgery fight it out the next day.

They refused admission. I guess we could have dumped it on IM...not exactly fair to them, though.

so what happened in the end?
that's ridiculous-- sharp FB should be removed, especially a razor blade....

was GI call over soon? if so, i would have waited then called surgery for endoscopy...

or call the chair of GI, see if he can find some other guy who can scope and take out the blade.... if no one is willing, can you transfer to tertiary center...

that sucks...

Neither surgery or GI would scope. We attempted a transfer without success. Ended up discharging back to the jail (yes, he got a razor while in jail) with explicit instructions to return if xyz, etc. Got a phone call from another ED during the same shift saying he'd been taken there b/c he was vomiting blood. *sigh*


I'm really wanting to gather more info on what happens with these cases elsewhere. Could be useful the next time this happens.

 

[AmoryBlaine]

They refused admission. I guess we could have dumped it on IM...not exactly fair to them, though.



Neither surgery or GI would scope. We attempted a transfer without success. Ended up discharging back to the jail (yes, he got a razor while in jail) with explicit instructions to return if xyz, etc. Got a phone call from another ED during the same shift saying he'd been taken there b/c he was vomiting blood. *sigh*


I'm really wanting to gather more info on what happens with these cases elsewhere. Could be useful the next time this happens.

I'm not intimately familiar with malpractice standards in this area but this seems like a minefield that would get any GI/surg attending out of their bed at night.

EM doc documents in chart: "GI consulted, no scope tonight, will follow patient in morning." Then the guy perfs, spills a bunch of **** into his peritoneum, and dies of intraabdominal sepsis. Surely this would make a trial lawyer salivate?

 

[DrMom]

Surely this would make a trial lawyer salivate?

One would think.

 

[Angelo84]

I was bored and lurking but this caught my attention. I don't know if it would be an option in people but if a dog ate a razor blade and can't go to surgery/endoscopy due to finances feeding cotton balls (or wheat bread) has worked--they get caught on the sharp edges and the blade comes out swathed in cotton. It might be harder to convince a person to eat some chicken broth flavored cotton balls than a labrador though!

 

[southerndoc]

They refused admission. I guess we could have dumped it on IM...not exactly fair to them, though.



Neither surgery or GI would scope. We attempted a transfer without success. Ended up discharging back to the jail (yes, he got a razor while in jail) with explicit instructions to return if xyz, etc. Got a phone call from another ED during the same shift saying he'd been taken there b/c he was vomiting blood. *sigh*


I'm really wanting to gather more info on what happens with these cases elsewhere. Could be useful the next time this happens.

If you have a situation where someone is not safe for discharge and needs to be either scoped or surgically explored (as in this situation), then you should not discharge the patient. If specialists are refusing to see the patient, then I would recommend calling your hospital administrator or the chief of staff. Trust me, a 3 am call to one of those two people will get you the consult you need. Most hospitals, and if I'm not mistaken even EMTALA, require on-call physicians to see and examine a patient in the emergency department if an emergency consult is requested.

I am aware of one physician who refused to see a patient and who ultimately lost his hospital privileges. Funny thing how a cardiologist is now staffing an urgent care clinic because he can no longer get credentialed at a hospital because of a "little incident."

 

[DrMom]

The final call was not mine.

Again, I really am needing some insight into what is standardly done in your facilities. Do the surgeons/GI scope to remove the item? Do they go directly to the OR? Does anyone else actually do this watch-and-wait approach?

 

[AmoryBlaine]

I was bored and lurking but this caught my attention. I don't know if it would be an option in people but if a dog ate a razor blade and can't go to surgery/endoscopy due to finances feeding cotton balls (or wheat bread) has worked--they get caught on the sharp edges and the blade comes out swathed in cotton. It might be harder to convince a person to eat some chicken broth flavored cotton balls than a labrador though!

Can't be much worse than barium...

 

[littlefield]

I've just finished my first year as an EM attending, so my experience is limited. But, I had a prisoner who swallowed several razors and x-rays showed them in the small bowel. I consulted general surgery at 0300, and they took the patient to the OR around 0800.

L

 

[southerndoc]

I've just finished my first year as an EM attending, so my experience is limited. But, I had a prisoner who swallowed several razors and x-rays showed them in the small bowel. I consulted general surgery at 0300, and they took the patient to the OR around 0800.

L

I think community attendings seem to be less resistant to admissions, procedures, etc. when compared to resident-run services.

 

[macdaddy23]

I think community attendings seem to be less resistant to admissions, procedures, etc. when compared to resident-run services.

I think overall that is correct but even the community attendings resist doing things at night. At least at the few places I've worked at since residency.

 

[GeneralVeers]

I think community attendings seem to be less resistant to admissions, procedures, etc. when compared to resident-run services.

I'm still getting used to not having to argue with the admitting docs. When it was resident run services, even old people with chest pain turned into an argument.

 

[DrMom]

interesting. usually for me it is easier to admit at my residency hospital than at the community hospital where I moonlight. I've had to argue chest painers with a big history, ALTE, elderly AMS, even a STEMI for cath lab.

 

[deleted65604]

interesting. usually for me it is easier to admit at my residency hospital than at the community hospital where I moonlight. I've had to argue chest painers with a big history, ALTE, elderly AMS, even a STEMI for cath lab.

I agree. Where I did residency, there was university docs with residents and there were private docs. We could ramrod any admission down a resident's throat. Private attendings were a different matter. Some of them could be real extreme buttholes. About a third of the private doctors were hard to admit to. ABout a third of residents will grow up and be complete jerks too, but they just don't have the clout yet to back up their laziness and negative attitudes. I also worked in a rural hospital and it was the same problem. University settings are much easier to admit to and get consultation than in the private world in my opinion.

 

[Egon]

I think from the description this guy swallowed the metal blade only, not atttached to plastic (like a blade refill)....if it had plastic on it it would be less likely to perf the bowel and could be watched and is reasonable

If it was a sharp blade only, I think GI should have done an EGD.

I would definitely call hospital admin on this case. If you have observation status it would be smart to put him on observation until a consensus could be reached.

If you think a pt needs to be admitted or needs a procedure and you document that in the note, you are the one held liable. In these situtations it will look like the ED is the one who let the patient run off the cliff if they go home and morbidity occurs. They can refuse to admit, but it doesn't mean you send him home. Keep him in the ER and get admin involved.

(At least he was closely monitored in jail and if anything happened he'd be right back.)

 

[jazz]

They refused admission. I guess we could have dumped it on IM...not exactly fair to them, though.


Neither surgery or GI would scope. We attempted a transfer without success. Ended up discharging back to the jail (yes, he got a razor while in jail) with explicit instructions to return if xyz, etc. Got a phone call from another ED during the same shift saying he'd been taken there b/c he was vomiting blood. *sigh*


I'm really wanting to gather more info on what happens with these cases elsewhere. Could be useful the next time this happens.

Hope the chart is documented well.

In my community hospital, GI or ENT is supposed to come in for any potential sharp FB, which means the "i think a fish bone is stuck" is supposed to warrant an emergent consult regardless of time. As you can imagine, both GI and ENT have refused to come in at 2am for something like that. I'm ok with d/c for a pt with chicken or fish bone FB that can tolerate POs with close follow up. However, I would never have discharged someone with a razor blade!
I would have called the chair of ER, he would likely have then called the Chief Medical Officer of the hospital and then someone would have been made to come in. If the CMO can't get a medical staff physician to come in, then I would have considered discharging but documenting, "called CMO of hospital who called GI and Surgery who both refused to come in -- states not emergent can wait until AM" Still no good for the pt but will hopefully get me out of the lawsuit....

On a much more cynical side, why are we spending so much tax payer's money (our hard earned money) taking care of a someone who is already incarcerated (being fed, clothed, and sheltered with our money) who wants to swallow sharp objects such as razor blades....

oh and i would have probably dumped on medicine. agree, not fair for them. however, once you have a guy in orange jumpsuit and shackles in an inpt unit, there is much more incentive for the hospital to find someone to scope the guy, remove razor, and get him discharged back to jail.. much better deal for the hospital to have a 1 day admit vs. perforated bowel, OR, sepsis, prolonged stay.... yes, i know very cynical but money talks

 

[ditch doctor]

The final call was not mine.

Again, I really am needing some insight into what is standardly done in your facilities. Do the surgeons/GI scope to remove the item? Do they go directly to the OR? Does anyone else actually do this watch-and-wait approach?

Dude... It's July... our surgery department just discharged a stab to the abdomen *with* CT evidence of entering the peritoneum after a 6 hour f/u CT and serial belly exams because the guy "looked so great". F/U in "perfe'd bowel" clinic in 2 weeks, to be sure...

 

[Winged Scapula]

Surgical teaching on swallowed FB differs from apparently what Tintanelli states.

In general, objects lodged in the esophagus (either at the upper or lower sphincters or at the arch), are removed because of the increased risk of esophageal perforation and possible mediastinitis. Button type batteries are always removed because of the possibility of esophageal necrosis and non-radioopaque objects, like tooth picks and chicken bones, are also generally removed because you cannot easily follow (any) movement.

However, the vast majority of items will pass through the esophagus in most patients - something like 75%. The remainder of the GIT is fairly resistant to perforation, even by razor blades. The pylorus is quite forgiving; objects smaller than 2 cm will usually pass. Thus, surgeons are taught that for objects which have made it to the stomach, greater than 90% will pass through the pylorus and out the back end. I suspect this is why your surgeons took a "wait and see" stance - if the blade is still there 2 days later, then its not likely to move and will have to be fished out. There is actually a greater risk of perfing the esophagus during EGD from the inflammatory process generated by the FB. So, it is preferable to see if the object passes rather than risk perforating the patient yourself.

The caliber of the small and large bowel is enough to readily accept a razor blade with a very low chance of perforation. It is unusual to lodge at the TI or anywhere distal to the pylorus. For most patients (ie, not someone who is chronically immunesuppressed on steroids), there is very little risk in allowing such a sharp object to pass. Razor blades are a little more worrisome than straight pins, but they too have been known to pass quite readily without untoward effects. Straight pins cruise right through with peristalsis.

Finally, on the very small chance that such an item will perforate the bowel in a normal person, the morbidity and/or mortality to such an event is exceedingly low. The patient would be unlikely to have gross peritonism/contamination which would be life-threatening.

So, items that do need to come out:

anything in an unstable patient
button batteries
non-radiopaque sharp items (chicken bones, toothpicks)
probably everything in kids (if only because of the parent's anxiety over leaving it in, although it is not unreasonable to leave a single coin in if it has made it to the stomach)
patients too unreliable to return for follow-up imaging
patients too unreliable to return for possible perf

IMHO, it is not unreasonable, if the sharp object has passed through the area of greatest risk of perforation (esophagus) without untoward events, to simply follow with serial x-rays to make sure its moving because otherwise you are subjecting the patient to a procedure (endoscopy) which is not without risk (greater risk than potential perf).

Hope that explains at least how this surgeon was trained.

 

[macdaddy23]

What do you all do for chicken/fish bones? Most of the time the person still has the sensation of the FB when it has long since passed. So it is unclear if it is the sensation of the FB or it is truly stuck.
When I cannot see one on exam or on lateral neck xray I have been scanning neck(CT) without contrast in those I feel higher risk and who cannot followup. I understand the radiation risks but don't have a lot better option.
What are you all doing for these??

 

[DrMom]

WS which surgery text would have info on sharp FBs? Either that or some articles. I'd love to see what you guys read on this.

 

[Winged Scapula]

WS which surgery text would have info on sharp FBs? Either that or some articles. I'd love to see what you guys read on this.

Unlike Tintanelli, there really isn't one standard text for surgery. Probably the most comprehensive would be Greenfield (Amazon: http://www.amazon.com/Greenfields-S...bs_sr_1?ie=UTF8&s=books&qid=1217614146&sr=8-1) which I'm sure your library would have.

I have checked all my texts (I have Cameron, Greenfield, Mastery of Surgery, Schwartz and many smaller books) and only Greenfield has much in it...and even then, its a few paragraphs in the Peds Surg Chapter.

They (Greenfield) state that 95% of items swallowed pass through the GIT and are eliminated without problem, if they pass the LES, so its even higher than the 90% I stated above. They also state that in the first 24 hrs, the risk of iatrogenic esoph perforation with EGD is relatively minimal; of course, the risk of perforation with EGD is relatively low anyway, but increases with inflammation and disease and in children (unless you have someone who does a lot in children and understands the differences in their anatomy). I suspect that the risk of EGD perf in such a situation is actually greater than the risk of perf from the FB, hence the hesitation to go after things.

Dug through my Board study notes and found some more practice tips for swallowed FB:

Coins:
- remove in children, even dimes may get lodged
- in stomach can be observed for up to a month, will usually pass spontaneously before then. If not, remove via EGD.
-operate for any symptoms, toxic appearing patient

Magnets:
need to be removed if swallowed in pairs because they can move through at different rates and have been known to perforate/fistulize as they are attracted to each other from different parts of GIT

Sharp/Pointed Objects (pins, razors, bones, safety pins, toothpicks, nails):
- my notes say 25% may perforate at IC valve (this is more than other sources, say; so not sure my source on that
- radioopaque items can be followed for movement through GIT as long as patient is non toxic

Meat:
- do not use enzymes; may digest esophagus!
- if truly impacted, remove with EGD

Button Batteries:
- urgent
- risk of esophtrach or esophaortic fistula
- f/u with UGI after EGD to r/o perf

Cocaine packets:
- NO EGD. If you rupture packet, can be fatal
- OR removal if it appears that they will not pass

Chicken/Fish Bones:
- usually stuck at UES, remove with EGD, laryngoscopy (if in pharynx); otherwise let pass


In regards to articles, there are droves and droves of them. Some case reports of interesting things like the young girl who swallowed 50 straight pin in a suicide attempt (but survived and they all passed out distally without perforating her), to crack pipes, dentures, etc. I haven't seen a review of the literature on this lately, so expect that most of the teaching comes from the texts and experience although I certainly did not do a thorough lit search.

In general, there are going to be the weird cases of things perforating into odd places, but for the most part, it appears outside of the situations as I've listed above, that most surgeons would not remove FB, even sharp ones, unless there was evidence of non-movement (ie, no movement for a few weeks).

Patients will commonly complain of a globus after such an event like getting a chicken bone stuck. The inflammation from the temporary lodging of the bone in the esophagus will produce such a sensation. If the patient is able to swallow and doesn't exhibit any signs of toxicity, its probably just that, but doing a CT isn't necessarily a bad idea if you are worried its still in there.

 

[macdaddy23]

Information like this is what originally drew me to this forum, You get to see what other hospitals and training programs do. I truly appreciate that info and your perspective.
One comment on the sharp foreign bodies.
If it was me or a family member/friend who ingested the sharp foreign body, god forbid, I would take the risk with endoscopy it if it was in the stomach.
5-10%risk is still too much in my opinion. If I told someone they had a 5-10%risk of perforation I think others would too.
Also, have you seen any articles on the sensitivity of CT with chicken/fish bones, etc? Can you confidently tell someone there is nothing stuck with a negative CT?
Thanks

 

[Gastrapathy]

The final call was not mine.

Again, I really am needing some insight into what is standardly done in your facilities. Do the surgeons/GI scope to remove the item? Do they go directly to the OR? Does anyone else actually do this watch-and-wait approach?

In my opinion, the correct answer is to intubate the patient to facilitate deep sedation adn then do the EGD. Your gastroenterologist should then pass either an EGD scope with an FB hood (probably what you need for a standard size razor blade), or, if its a smaller blade, a long overtube. Both of these approaches will minimize the risk of injury. If you don't have that equipment, you shouldn't do the scope. An esophageal perf is a much bigger deal than a gastric or small bowel perf. If I wasn't going to scope the patient, I would have admitted him and tried to flush it through with a bowel prep. No evidence for this approach but it would get it over with.

 

[Winged Scapula]

If it was me or a family member/friend who ingested the sharp foreign body, god forbid, I would take the risk with endoscopy it if it was in the stomach. 5-10%risk is still too much in my opinion. If I told someone they had a 5-10%risk of perforation I think others would too.

and so would I! We can quote numbers, risks, etc. all day long but it comes down to how much of an odds taker are you, how sick is the patient/you, etc. The risk of perf for those poor vets I learned to scope on was probably much higher than 5-10%, but they still took the chance (then again, they were VA patients and you know what they say...). I think I would lie awake at night imaging that razor blade sawing through my gastric mucosa or fear that if I ate a big meal, the mucosa would be stretched thin and...pop!

Also, have you seen any articles on the sensitivity of CT with chicken/fish bones, etc? Can you confidently tell someone there is nothing stuck with a negative CT?
Thanks

I have not and I suspect the sensitivity increases with actual bones over chicken cartilage. Here's an interesting article about CT with FB in airway (10 years after aspiration!): http://radiology.rsnajnls.org/cgi/content/full/218/2/523

Here's another one that claimed to find the bone with CT but not on CXR or EGD (sorry, can't remember my password, so only have abstract): http://www.springerlink.com/content/g808548436334q41/

This study from the EM version of BMJ claims a 100% PPV for chicken or fish bones with CT: http://emj.bmj.com/cgi/reprint/24/1/48 (free registration) so you should feel fairly confident with a negative CT although not with a negative CXR.

 

[Aloha Kid]

I had a few bad nights of sleep after discharging a 17y female with a complaint of "I think I have a salmon bone stuck in my throat." I kept wondering if she would bounce back with esophageal perforation and mediastinitis. Or worse yet, a fish bone which migrated and lodged in the prevertebral tissue causing an abscess formation.

Our workup included a soft tissue neck and chest films which were negative. We tried a GI cocktail with the premise of obtaining diagnostic data - If the FB sensation went away then maybe the bone was gone and all that remained was irritation or a scratch. On the other hand, if the the sensation persisted maybe a bone was still lodged and irritating the area. Of course, the GI cocktail failed to relieve her symptoms. My attempt at bedside NPL after atomized nasopharyngeal lidocaine failed miserably. We ended up discharging to ENT for next day FU visit.

Would you have kept this girl and insisted on in patient EGD?
What exactly is the standard of care for fish/chicken bones?
Is there a difference between fresh water fish bone vs salt water fish bone?
Can a GI cocktail give diagnostic information about the presence of FB?

 

[EctopicFetus]

In these high risk cases I would talk to my attending and get risk management involved. If I am still unhappy I would ask my attending to call the GI attending/service chief and then chief of staff. You really have to advocate for your patient.

 

[southerndoc]

Had a lady the other night who claimed to have a chicken bone stuck in her throat. Got the x-ray, and sure enough, you could easily see it (a fairly large one too).

Called ENT and 15 minutes later he was in the ED taking her to the OR. Apparently it's institutional policy that they do it in the OR at my hospital. He was a little grumpy when I called him at 10:30pm, but was fine when he was in the ED.

 

[bartleby]

It's a tough one. There are always cases of the people who've swallowed sharp objects which pass if there has been a successful transit of the esophagus. In medicine, as we know, there are always exceptions. It is hard to imagine that the right place for this guy is jail with a razor blade in his stomache. At least if he is an inpatient and he starts having melena, hematemesis or abdominal pain it will be noted by someone SOONER than 24 hours later.

If you are put in a bad position by a consultant who has a difference of opinion in regard to disposition, it is well within your rights to politely explain that as the on-call person you are formally requesting a consult and that you are not discharging the person (as they suggest) without a written consult from them. If they refuse, as others suggest, I would get the hospital administrator involved sooner rather than later. In the current medicolegal environment, one thing that is for sure is that if it wasn't documented, it didn't happen. If you don't have a written consult, you can let your mind wander through all of the life-saving things that someone will claim they told you to do but that you didn't do. I had a neurology attending say, "You know, you don't need a written informed consent to push TPA on a stroke patient". I said, "You know, you're right... I might not. But if this guy has a hemorrhagic conversion up in the ICU in 2 hours we're both going to be very glad that this piece of paper is in his chart".

As a corollary, there is seemingly no end to the self-abusive behavior exhibited by patients in prison. This is relatively minor compared to some of the subcutaneous metal foreign bodies (over 25 random bits of metal in ONE forearm) and penile/rectal foreign bodies I've seen. I did a local field block after 60mg of IM toradol on one guy as I was preparing to use ultrasound to fish his 15th self-inflicted metal foreign body out of the middle of an abscess on his thigh. He says, "Hey doc, is there any chance I can get some IV dilaudid before you do this?" I politely suggested that, no, there wasn't much of a chance of that.