May 22, 2023 – Two recent studies suggest that even when an individual swallows something potentially harmful, like a razor blade or a magnet, it could be best for a physician to let nature take its course.
Some adults who come to the emergency room after swallowing a razor blade, battery, magnet or other object accomplish that to acquire a “secondary benefit.” They want medical care, an overnight stay within the hospital or other perceived advantages, experts say.
Some develop into “frequent flyers” – they return to the identical hospital time and again after swallowing something potentially harmful. This group may include prisoners and other people with mental health problems.
Other adults swallow things by accident. These include individuals with limited mental capability, people popping up, and elderly individuals with dentures who only notice too late that there are chicken or fish bones of their food.
In each cases, doctors often order an X-ray, determine what they're coping with, after which make a call: Do they put a tube with a tool down the patient's throat to get the foreign objects out, or do they leave them there and “let nature take its course”? Do they admit the patient to the hospital overnight, or do they send them home with a listing of symptoms that mean they need to come back immediately?
Two recent studies tend towards conservative management, i.e. letting nature take its course typically.
The length is crucial
A team of researchers on the University of Southern California found that removal doesn't rely on how “risky” an object is – equivalent to a battery that would leak acid or a pointy razor blade.
It also didn't matter what number of items someone swallowed directly. There were no internal cuts, intestinal obstructions or fistulas after they reviewed the medical records of 302 cases. Fistulas are narrow channels between organs or between an organ and the skin that may result in leaks, infections, and other problems.
Only the length made a difference. If an adult swallowed an object longer than 6 cm, it was best to remove it. Otherwise, typically, it didn't matter whether or not they took it out or waited for the body to maneuver it along.
“We work at USC, a large safety-net hospital for all of Los Angeles County, and we happen to see this frequently,” said Shea Gallagher, MD, a general surgery resident at Keck Medicine at USC.
“We basically treat the entire spectrum of the patient population that does this,” he said earlier this month at Digestive Disease Week (DDW) 2023 in Chicago, a global meeting for health care providers who treat gastrointestinal diseases.
They studied individuals who had swallowed foreign objects from 2015 to 2021. The average age was 29 years, 83% were men, and the patients were each hospitalized about thrice.
In the 302 cases, 67% of the swallowed objects were sharp or pointed, 38% were blunt, 8% were magnetic and 5% were corrosive, equivalent to batteries. Almost one in five patients (18%) swallowed multiple objects.
In 40% of cases, doctors removed the foreign bodies endoscopically through the throat. In the remaining cases, conservative treatment was chosen.
Twelve of the patients had surgery. In ten cases, the objects cut into something inside, and in two cases an object got stuck. The twelve patients who had surgery had objects that were longer, about 4.5 inches, in comparison with just over 1 inch within the individuals who didn't have surgery.
“The take-home message is that conservative management is probably fine in most cases,” Gallagher said.
Remove “secondary profit”
In one other study presented on the conference, Australian researchers reported 157 cases of swallowed objects involving 62 patients.
“Our prisoners like to swallow things,” said lead study researcher George Tambakis, MBBS, who works in a hospital with an attached prison ward. Prisoners are often hospitalized, x-rayed, observed, endoscoped or operated on, and receive numerous medical attention. He and his colleagues want to alter that.
“We prefer a conservative approach with an emphasis on behavioral change,” said Tambakis, a gastroenterologist at St. Vincent's Hospital in Melbourne.
Educating people after which sending them home where nature takes its course – without hospitalization or a series of procedures – could deprive them of much of their “secondary benefit,” he said.
The general approach is to retrieve objects after they perforation or get stuck within the esophagus. Otherwise, treatment is finished on an outpatient basis.
That can have a deterrent effect, says Tambakis. For example, if doctors sent seven patients home without further treatment, five of them never got here back. The other two got here back, but less incessantly.
In the retrospective study – which looks at past behavior – researchers examined the medical records of 157 cases during which people had swallowed a foreign object. The average age was 30, half were men, and about two-thirds were prison inmates. More than 4 in 5 had a history of mental illness.
In 23 percent of cases, batteries were swallowed, in 17 percent, balloons allegedly containing drugs, and in 16 percent, razor blades. Only a small percentage, namely 4 percent, swallowed magnets. In about 40 percent of cases, it was “miscellaneous” objects. In one case, he said, a patient needed to undergo surgery to remove about 500 swallowed coins.
Just over half (55%) of the patients were treated conservatively. Higher-risk cases were treated conservatively or endoscopically in roughly equal numbers. Similar to the USC study, no perforations or bowel obstructions were reported.
When asked for his suggestions for other doctors, Tambakis recommends removing the objects endoscopically “if it is the first or second time and if there is a high risk – a long object or batteries or magnets. But we are moving towards [conservative management for] People who are presenting for the fifth, sixth or sixtieth time.”
“Important” studies
“This is an important study because we actually see these cases quite frequently in the clinical setting,” said Walter W. Chan, MD, MPH, director of the Center for Gastrointestinal Motility at Brigham and Women's Hospital in Boston.
He said research like this is useful because guidelines for treating these patients are based partly on expert opinion. For example, the American Society for Gastrointestinal Endoscopy (ASGE) Management of Guidelines for ingested foreign bodies and food residues are based on each studies and expert consensus.
“Hopefully, over time, studies like this can help answer some of these questions,” Chan said, agreeing that each time someone is admitted after swallowing a foreign object, numerous medical resources are needed for foreign body investigation and retrieval.
Chan said the restrictions of the Australian study were that it was retrospective and the variety of participants was relatively small. “So it's a bit difficult to draw conclusions because these patients are probably coming in with different items that they've ingested.”
Referring to the USC study, Chan said, “I think it's an important study as well.”
“We know from the ASGE guidelines that length is a risk factor,” he said.
“This study is interesting because it looks at it from a surgical perspective, who actually had surgery – which is probably the most important outcome.” However, only 12 of 302 patients underwent surgery, so the scale of the study was also a limitation, Chan said.
He said the 2 studies attempted to reply similar questions. “They both have limitations that make it difficult to draw firm conclusions from them. But I find them fascinating and hopefully they will lead to further and larger studies to really answer these questions.”