Esophageal foreign bodies: a retrospective analysis of 275 cases

Introduction

Esophageal foreign body ingestion is one of the common emergencies encountered in otolaryngology and gastroenterology. The chief symptoms commonly observed in patients include swallowing pain, difficulty swallowing, and chest pain (1). If not promptly addressed, foreign bodies can lead to serious complications such as esophageal perforation, cervical abscess, mediastinal abscess, esophageal aortic fistula, and esophagotracheal fistula (2-4). Fortunately, with the exception of a few patients experiencing severe complications that require surgical intervention, the majority of patients can be successfully managed through endoscopy (5). However, due to the complexity of this condition, the endoscopic management of esophageal foreign bodies does not follow a fixed routine as in other endoscopic procedures such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). Therefore, endoscopists face significant psychological and technical challenges in such cases. For the management of esophageal foreign bodies under endoscopy, developing appropriate strategies can improve success rates and prevent complications. We conducted a retrospective analysis of the diagnostic and treatment processes for 275 adult patients with esophageal foreign bodies successfully managed under endoscopy in the Department of Gastroenterology of Henan Provincial People’s Hospital from January 2017 to August 2023. This paper provides a summary of the findings and a description of the experiences from the Department of Gastroenterology of Henan Provincial People’s Hospital. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-758/rc).

Methods

Patients

We retrospectively reviewed the medical records of patients diagnosed with esophageal foreign bodies confirmed by endoscopy at the Department of Gastroenterology of Henan Provincial People’s Hospital from January 2017 to August 2023. After patients who did not receive treatment at our hospital and those with incomplete information were excluded, a total of 275 patients were enrolled in the study. The retrospective study protocol received approval from the institutional review board of Henan Provincial People’s Hospital (No. 2024-098). This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Individual consent for this retrospective analysis was waived.

Endoscopic procedures

Before endoscopic surgery was conducted, the patients were queried about their medical history, and their imaging data were reviewed. The anesthesiologist was then consulted to inform the selection of the appropriate anesthetic method, such as intravenous anesthesia or endotracheal intubation anesthesia, based on the patient’s condition, and the vital signs were monitored during the procedure. All patients underwent flexible endoscopic removal of esophageal foreign bodies. The procedures were performed by experienced endoscopists in the endoscopy unit under standard monitoring. A flexible video endoscope (Olympus GIF-H290, Tokyo, Japan) was used in all cases. The equipment used for the removal of foreign bodies included transparent cap, biopsy forceps, foreign body forceps, snare, and retrieval basket. After removal, the esophageal mucosa was re-examined for signs of injury, laceration, or perforation.

Data collection and statistical analysis

Patient data including sex, age, impaction time, symptoms, associated diseases, and complications were collected. Information on the type and location of the foreign bodies, as well as the accessories used for removal of foreign bodies, was also collected. Data were analyzed with SPSS software (IBM Corp., Armonk, NY, USA). Group comparisons of categorical data were performed via the chi-squared test. A P value <0.05 was considered statistically significant.

Results

Patient characteristics

A total of 275 patients were enrolled, including 133 males (48.36%) and 142 females (51.64%). The age ranged from 18 to 97 years, with a mean age of 59.55±18.30 years. Among them, there were 56 (20.36%) individuals aged 18–40 years, 63 (22.91%) aged 41–60 years, and 156 (56.73%) aged 61–97 years. Common symptoms in patients included sore throat, swallowing pain, dysphagia, neck pain, chest pain, and choking sensation while eating. Less common symptoms included fever and difficulty breathing.

Impaction time

Out of the 275 included cases, 65 involved esophageal stricture caused by various reasons leading to foreign body ingestion. The impaction time could not be accurately confirmed. In the other 210 patients, the impaction time ranged from 1 hour to 40 days, with a median time of 20 hours. Specifically, 132 (62.9%) patients sought medical attention within 24 hours of ingestion, 24 (11.4%) sought medical attention between 24 and 48 hours after ingestion, and 54 (25.7%) sought medical attention more than 48 hours after ingestion. There was a statistically significant difference in the impaction time between different age groups (P<0.05) (Table 1).

Types and location of foreign bodies

Among the 210 patients without underlying diseases, the types of esophageal foreign bodies included animal foreign bodies, plant foreign bodies, metallic foreign bodies, plastic foreign bodies, dentures, and medications. The specific types of foreign bodies are detailed in Table 2. Foreign bodies were located in the upper esophagus in 163 (77.62%) cases, the middle esophagus in 41 (19.52%), and the lower esophagus in 6 (2.86%).

Among the patients, 65 experienced esophageal strictures due to various conditions. These conditions included esophageal cancer, esophageal cancer radiotherapy, esophagogastric anastomotic stenosis, esophagojejunal anastomotic stenosis, lung cancer with esophageal metastasis or mediastinal lymph node compression of the esophagus, esophageal ESD, achalasia, reflux esophagitis, and idiopathic esophageal stricture. The types of esophageal foreign bodies included large food bolus, vegetable pieces, meat chunks, and tablets. Additionally, there was one case of an iatrogenic foreign body (capsule endoscope) lodged in the narrowed segment.

Endoscopic methods and accessory devices

Among the 275 patients, tracheal intubation anesthesia was performed on 16. The primary endoscopic instruments used were transparent cap, foreign body forceps, biopsy forceps, snare, and net basket. In 203 (73.82%) cases, the foreign body was removed by forceps alone; in 14 (5.09%) cases, by biopsy forceps; in 3 (1.09%) cases, by snare alone; in 1 (0.36%) case, by net basket; in 10 (3.64%) cases, by snare combined with foreign body forceps; in 25 (9.09%) cases, by transparent cap attraction; and in 19 (6.91%) cases, by the pushing technique. The representative endoscopic procedures are illustrated in Figures 1,2.

Figure 1 A fish bone foreign body embedded in the esophageal wall. Computed tomography indicated the presence of high-density shadows in the upper esophagus across the (A) transverse, (B) coronal, and (C) sagittal planes. In the transverse view, punctate shadows were observed, while in the coronal and sagittal views, stripes of shadows were visible. (D) After repeated exploration, a white bulge was discovered on the esophageal wall although no foreign body was initially detected under endoscopy. (E) It was determined that the foreign body was embedded in the esophageal wall, and it was successfully removed after the head end was grasped with foreign body forceps.

Figure 2 A plant-based foreign body lodged in the esophagus. (A) Computed tomography revealed a thickening of the middle esophagus wall without any evident high-density shadows. (B,C) Upon endoscopic examination, an irregular foreign object, which was penetrating through the esophagus wall at both ends, was discovered. This plant-based foreign body was radiolucent and not easily visible on X-rays.

Complications

Of the 275 patients, 20 had esophageal perforation, while the remaining patients showed various degrees of congestion, erosion, or ulceration during endoscopy. The clinical data of 20 patients with esophageal perforation are presented in Table 3.

Discussion

Foreign body ingestion is more common among older adults, individuals with underlying psychiatric disorders or alcohol intoxication, prison inmates, and those who may be trafficking drugs (6). However, it is often observed that healthy adults without underlying conditions ingest foreign objects. This may be attributed to a lack of concentration during eating, perhaps due to talking, laughing, or being engrossed in electronic devices (7). As the esophagus has three physiological narrowings, it is the most common site of obstruction in the gastrointestinal tract. Similar to other work (8-10), our findings also indicate that the most common site of esophageal foreign body impaction is the upper esophagus.

Although esophageal foreign body ingestion is a clinical emergency requiring urgent intervention, we found the impaction times in our study ranged from as short as 1 hour to as long as 40 days. In our cohort, 54 patients (19.6%) presented more than 48 hours after symptom onset. Although the specific reasons for delayed presentation were not consistently documented, available clinical records and retrospective review suggest several contributing factors. Some patients initially attempted self-management at home, including drinking large amounts of water or inducing vomiting in an effort to dislodge the foreign body. Others first visited local healthcare facilities without endoscopic capabilities, resulting in delayed referral to the Department of Gastroenterology of Henan Provincial People’s Hospital. In some cases, patients underestimated the severity of their symptoms and chose to observe their condition before seeking medical attention. There have been no previous studies on the relationship between impaction duration and patient age. Our results suggest that older adult patients tend to experience longer impaction durations, possibly due to physiological, psychological, or social factors such as decreased sensitivity, lack of care, or reluctance to inconvenience relatives. As China’s population ages, this issue may require heightened attention.

The types of foreign bodies can vary across different countries and regions due to differences in dietary customs, cultural norms, and sociocultural factors (11). In the Department of Gastroenterology of Henan Provincial People’s Hospital, the most common types of foreign bodies include jujube pits, fish bones, chicken bones, and duck bones. This may be explained by the fact that people in Henan Province enjoy adding jujubes to their soup, drinking fish soup, and eating meat off the bone. This finding is in line with previous studies on adults in China and other Asian countries (12-14).

Guidelines recommend computed tomography (CT) examination as the preferred imaging modality for esophageal foreign bodies (15,16). However, in clinical practice, foreign bodies such as food particles, plastic objects, and small bones that may not be visible on CT scans should not immediately ruled out, as these foreign bodies may be penetrated by X-rays. Occasionally, small-fish-bone foreign bodies may present as slightly dense shadows on CT scans, making them challenging to differentiate from surrounding artifacts (17), and thus further endoscopic examination may be necessary. However, some sharp foreign bodies such as fish bones may penetrate the esophageal wall and remain undetected on endoscopy (18). Clinicians should be aware of the possibility of fully embedded or migrated foreign bodies, and it is suggested that repeat CT scans be performed following a negative endoscopic examination for a suspected foreign body (19). In such cases, endoscopic ultrasonography can be applied (20). In the diagnostic and treatment processes at the Department of Gastroenterology of Henan Provincial People’s Hospital, this situation frequently occurs. Indeed, we previously reported removal of a foreign body embedded in the esophageal wall (21).

Foreign body ingestion and food impaction are two distinct conditions. Foreign body ingestion primarily occurs in individuals without underlying medical conditions, whereas food impaction tends to occur more frequently in populations with pre-existing esophageal conditions (22). In addition, a rare esophageal disorder that can cause food impaction, eosinophilic esophagitis, should also be considered. Although there is no obvious esophageal stricture, multiple biopsies are needed to confirm the diagnosis (23). The significance of distinguishing between them lies in the potential differences in anesthetic methods, extraction techniques, and complications (24). In our study, 23.6% of patients had underlying conditions, such as esophageal cancer, that caused esophageal stricture. Compared to patients with esophageal foreign body ingestion, those with food impaction face a higher risk of anesthesia-related aspiration. Because these patients often have postoperative stenosis at the anastomotic site or narrowing due to other reasons, there is a greater likelihood for food, liquid, or residue retention to be present, increasing the risk of aspiration. Therefore, it is necessary to carefully assess the anesthesia-related risk and avoid anesthesia if the risk is high. Other possible indications for endotracheal intubation include situations in which object retrieval is challenging, multiple objects are present, the duration of esophageal foreign body impaction is uncertain, or when rigid esophagoscopy is required (25). In our study, all 20 cases of esophageal perforation were caused by foreign body ingestion, while not a single case of esophageal perforation occurred due to food impaction.

Several factors are considered in selecting the approach to endoscopic treatment, such as the patient’s age and health status, the size and shape of the swallowed object, its location in the body, the expertise of the physician, the equipment available, and the preference of the endoscopist (26). In this study, the main types of foreign bodies were sharp and bone foreign bodies, so the most commonly used instruments were foreign body forceps. Some small foreign objects located at the level of the cervical esophagus level, which entails a limited working space, can be retrieved with biopsy forceps. Food impaction caused by esophageal stricture is primarily treated via transparent catheter suction or direct pushing into the stomach. However, for some complex esophageal foreign bodies, specific devices (e.g., dual-channel endoscopes, endoscopic retrograde cholangiopancreatography balloons, and urinary catheters) and surgical approaches (e.g., invasive percutaneous technique, burrowing technique, and tunnel endoscopy) may be employed (27-31).

Although the complications of endoscopic foreign body removal are predominantly related to the type, size, shape, and impaction time of the foreign objects, one study investigated non-foreign body risk factors for complications during esophageal foreign body removal (32). This result indicated that complaint time, visiting time, and same-day treatment were the significant and practical factors influencing the complications of endoscopic foreign body removal. After removal of the foreign body, it is necessary to assess the extent of esophageal mucosal injury at the site of impaction and determine whether there is overt perforation. Patients with confirmed perforation should be placed on fasting, receive nutritional support, and undergo antimicrobial therapy. One study reported that age, duration of impaction, the longest diameter of the foreign body, perforation, and intravenous anesthesia were risk factors for a prolonged postoperative fasting time (33). In our study, among the 20 cases with esophageal perforation, none required surgical intervention. All perforations were either small, contained, or managed conservatively with close monitoring, fasting, and intravenous antibiotics, which proved effective without the need for referral to thoracic surgery. However, for some patients with esophageal perforation, according to Eroğlu et al., minimally invasive methods can accelerate the recovery of patients and decrease the period of hospitalization, patient morbidity, and costs (34). For patients with food impaction, after clearance of the foreign body, the nature of the stricture site should be clearly identified, and if necessary, biopsy or endoscopic dilation may be performed to improve the patient’s eating situation. Following treatment, repeat endoscopy or upper gastrointestinal imaging should be conducted to assess the recovery progress.

Conclusions

Older adult patients may be more likely to experience prolonged impaction. Overall, endoscopic management of esophageal foreign bodies is safe and effective. Prior to the removal foreign bodies, particularly complex ones, it is necessary to develop an appropriate strategy based on the size, type, and site of impaction to increase success rates, reduce risks, and avoid surgical intervention.

Acknowledgments

We would like to express our gratitude for the excellent clinical work of gastroenterologists specializing in digestive endoscopy at the Gastroenterology Department of Henan Provincial People’s Hospital.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-758/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-758/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-758/prf

Funding: This study was supported by Henan Provincial Medical Science and Technology Research Joint Venture Project (No. LHGJ20240033).

Conflicts of Interest: The authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-758/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study protocol was approved by the Institutional Review Board of Henan Provincial People’s Hospital (No. 2024-098) and adhered to the principles of the Declaration of Helsinki and its subsequent amendments. Individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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