CHICAGO—In adults, foreign body ingestion poses a low risk for complications no matter how sharp the object, if it is less than 6 cm long, according to a single-center cohort study.

“The dogma is that sharpness is the key, but our study shows that it is length—not sharpness—that should be the most important consideration,” reported Shea Gallagher, MD, MBA, a surgical resident at Keck Medicine of the University of Southern California, Los Angeles.

Numerous guidelines have been published on this topic for treatment of adults and children, but they are based largely on expert opinion, according to Dr. Gallagher. In this single-center, observational study, he and his co-investigators evaluated 302 adult emergency room visits for foreign body ingestion over a recent six-year period. They considered the length and sharpness of the objects, along with patient characteristics and other variables in the context of outcome.

Two or more foreign objects were ingested by 61% of patients. Two-thirds of the objects were sharp or pointed, and the remainder were dull. Batteries or other corrosive objects accounted for 5% and magnetic objects accounted for 8% of the total.

On multivariate regression analysis, each centimeter greater than 6 cm was associated with a more than 50% increased odds ratio of failure to progress or need for surgery (OR, 1.67; 95% CI, 1.33-2.01; P<0.001). However, no complications occurred in any patient with an object that was less than 6 cm long, noted Dr. Gallagher, presenting the data at the 2023 Digestive Disease Week (abstract 1106).

When the investigators compared ingestion of multiple foreign objects with ingestion of a single object, they did not find a significantly increased risk for complications (OR, 1.23; P=0.39). In addition, compared with blunt objects, sharp or pointed objects actually trended toward a reduced risk for complications (OR, 0.21; P=0.07).

Conservative management was employed for 178 (59%) of the patients. Endoscopic procedures were used to retrieve objects in 40% of cases, including gastroduodenoscopy in 107 patients (35%) and colonoscopy in 12 (4%). Surgery was performed for perforation in 10 patients and failure to progress in two patients. The average length of objects requiring surgery was 11 cm, whereas the average length for those not requiring surgery was 3 cm.

The last set of guidelines from the American Society of Gastrointestinal Endoscopy was published in 2011 (Gastrointest Endosc 2011;73[6]:1085-1091). They recommended against invasive procedures (endoscopic removal or surgery) for small blunt objects except in the case of magnets or batteries.

“Small” is not defined in these guidelines, but Dr. Gallagher suggested his data argue against limiting the avoidance of object removal to blunt objects. He suggested that corroborating evidence is needed, but guidelines might need to be rewritten to specify small size as less than 6 cm and consider removal regardless of the degree of sharpness or shape.

“The risk-to-benefit analysis appears to benefit a conservative approach after it is confirmed that the object is progressing through the digestive tract in the absence of significant nausea and vomiting or acute pain,” Dr. Gallagher said.

He recommended further data collection using the criteria identified in the study and then expansion to other centers in a prospective study. The goal would be to create an evidence-based approach to this common clinical challenge, he said.

Concern About Blanket Statements

The literature suggests that 80% or more of ingested foreign objects will pass through without complications, which is actually a higher proportion than was reported in this series, according to George Triadafilopoulos, MD, a clinical professor of medicine at Stanford University, in California. However, he is not convinced that blanket statements can be made about the need for retrieval on the basis of size alone.

As an example, he said batteries or other objects with corrosive potential are justifiably included in current guidelines for prompt removal based on the risk for damage to the gastrointestinal tract. He also said he believes there is evidence that ignoring sharp or pointed objects, even if far smaller than the 6 cm size identified as safe in this new analysis, can result in complications. “Fish bones can be small but quite penetrating, and may cause abscess,” he warned.

Whether or not 6 cm is an appropriate cutoff for determining if an object should be removed, Dr. Triadafilopoulos pointed out that the length of foreign bodies in the GI tract is not always easily measured unless it is done by x-ray. Furthermore, he noted that conservative management appears to include endoscopic retrieval, which was performed in 40% of patients—not just waiting for the object to pass through.

“It is important to emphasize that the word ‘operative’ means need for surgery,” Dr. Triadafilopoulos said. Operative endoscopy, which might regard an invasive procedure beyond simple retrieval, “was not included in their report.”

—Ted Bosworth

Drs. Gallagher and Triadafilopoulos reported no relevant financial disclosures.