Ingestion of foreign bodies and food mass impaction are not uncommon in clinical practice. 80-90% of foreign bodies can be expelled spontaneously, 10-20% of foreign bodies in the upper gastrointestinal tract require endoscopic removal, and approximately 1% of foreign bodies require surgical removal. Diagnosis of foreign bodies Fully conscious, communicating older children and adults are generally able to identify the swallowed foreign body and point out the site of discomfort. However, some patients are unaware that they have swallowed a foreign body and develop symptoms associated with complications hours, days, or years later. Young children and psychiatric patients may have poorly stated medical histories. The possibility of swallowing a foreign body should be highly suspected if signs and symptoms such as choking, refusal to eat, vomiting, salivation, croup, bloody saliva, or dyspnea are present. The presence of swelling, erythema, distention and twisting of the neck suggests perforation of the oropharynx and upper esophagus. The patient should be evaluated for ventilatory function, airway compromise, and risk of aspiration. Frontal and lateral chest and abdominal radiographs can diagnose most GI foreign bodies and their location. Routine barium meal examination is not recommended because of the risk of misaspiration, and CT scan + 3D reconstruction is feasible if necessary. For children, a handheld metal detector can be used. Endoscopy is the most commonly used tool. Management of foreign bodies Principles of management: Once a foreign body in the GI tract is diagnosed, a decision must be made as to whether treatment is needed, the degree of urgency, and the method of treatment. The following factors influence the treatment: the patient’s age and clinical condition, the size and shape classification of the ingested foreign body, the site of foreign body retention, and the technical level of the endoscopist. Timing of endoscopic intervention: depends on the likelihood of risk of aspiration or perforation. A sharp object or a button battery lodged in the esophagus, a foreign body or an ingested food mass causing a high degree of obstruction requires urgent endoscopic treatment. If the patient’s symptoms are not severe and there is no evidence of high obstruction, urgent treatment is rarely needed because the foreign body may pass spontaneously. In no case should the foreign body or mass remain in the esophagus for more than 24 h. The duration of foreign body retention in the esophagus may be uncertain in pediatric patients and, therefore, complications such as transmural erosion and receiver formation can occur. Instruments: Instruments that must be prepared for foreign body retrieval include: rat-tooth forceps alligator forceps, polyp traps, polyp graspers, Dormier baskets, retrieval nets, foreign body protection caps, etc. The use of an outer cuff protects the airway when removing foreign bodies, allows repeated passage of the endoscope when removing multiple foreign bodies or food impaction, and protects the esophageal mucosa from damage when removing sharp foreign bodies. In children, an over-the-cuff tube is not commonly used because of the risk of damage to the esophagus during insertion of the over-the-cuff tube. To protect the esophagus, foreign body protection caps are used to remove sharp or pointed objects. To ensure airway patency, tracheal intubation is an alternative method. Management of an embedded food mass: In adults, the most common foreign body in the esophagus is an embedded piece of meat or other food mass. Patients who are in pain or unable to swallow oral secretions require immediate management, and endoscopic intervention should not be delayed if the foreign body is retained for more than 24 h, as the risk of complications is increased. Food masses are usually removed whole, or piece by piece. An external sleeve facilitates repeated passage of the endoscope and protects the esophageal lining. The esophagus is dilated by gas injection, and if the endoscope is able to cross the food mass and enter the stomach, the endoscope is returned to the proximal end of the food mass and then the food mass is gently pushed into the stomach. The esophageal mass is often embedded with primary esophageal disease, and blindly pushing the mass with the endoscope or dilator tends to increase the associated risk. Therefore, a rubber band set can be attached to the front of the endoscope and used to remove the embedded food under direct vision. Handling of blunt foreign bodies: Coins can be easily removed by using foreign body forceps, alligator pliers, traps or retrieval nets. Smooth spherical objects are best handled with a retrieval net or retrieval basket. Objects that are not easily grasped in the esophagus can be pushed into the stomach and grasped more easily. If a foreign body enters the stomach, most of them are expelled within 4-6 d. If the end expels itself and there are no symptoms, a weekly x-ray can be sufficient to follow its course. In adults, round foreign bodies >2.5 cm in diameter do not easily pass through the pylorus. If the foreign body is still in the stomach after 3 weeks, it should be treated endoscopically. Once the foreign body has passed through the stomach and remained in a particular area for more than 1 week, surgical treatment should be considered. Fever, vomiting, and abdominal pain are indications for urgent surgical exploration. Management of long foreign bodies: foreign bodies longer than 6-10 cm, such as toothbrushes and spoons, are difficult to pass through the duodenum, and there is a longer (>45 cm) cuff that can be passed through the esophage-gastric junction. foreign body, the outer casing and the endoscope can be pulled out together. Management of sharp foreign bodies: Sharp foreign bodies lodged in the esophagus should be treated urgently. Foreign bodies in or on the cricopharynx can also be removed by direct laryngoscopy. Although most sharp foreign bodies can pass through the gastrointestinal tract without accident, the associated complication rate can be as high as 35%. Therefore, sharp foreign bodies should be removed endoscopically if they have reached the stomach or proximal duodenum and can be safely removed endoscopically. Otherwise, daily x-rays should be performed to determine its location. Surgical treatment should be considered for sharp foreign bodies that do not advance in the intestine for 3 consecutive days. When removing sharp foreign bodies endoscopically using foreign body forceps or traps, to prevent damage to the teaching membrane, use an outer cuff or put a protective pocket on the endoscope end to determine the direction of the sharp needle and minimize the danger. Handling of button batteries: Usually, lithotripsy baskets or retrieval nets are successful. Another method is to use an endoscope with an airbag under direct vision, which can be passed through the working channel of the endoscope to reach the distal end of the foreign body, inflate the airbag, and then pull it backwards to fix the battery and remove it together. During the operation, an outer cuff and tracheal cannula should be used, which is important to protect the airway. If the battery cannot be removed directly from the esophagus, it should be pushed into the stomach, where it can usually be removed with a retrieval basket. The battery is positioned below the esophagus unless there are signs and symptoms of gastrointestinal compromise. or repeated x-rays show that larger batteries (>20 mm in diameter) remain in the stomach for more than 48 h, there is no need to remove them. Once the cell has passed through the duodenum, 85% will pass within 72h. In this case, an x-ray every 3,4d is appropriate. Drug pouch handling: In places where drug trafficking is more prevalent, drugs are wrapped in plastic or latex condoms and swallowed, called “internal drug pouches”. These pouches are usually visible on x-ray, and CT scans can be helpful. A broken or leaking drug bag can be fatal, and there is a risk of rupture if removed by endoscopy, so don’t try to remove it by endoscopy, remember! Drug pouches require surgery if they cannot move forward in the body, if the patient has signs of intestinal obstruction, or if there is a suspicion that the drug pouch may be broken.