Foreign body in the digestive tract: clinical guidelines

List of Abbreviations

ATC – Anatomical Therapeutic Chemical classification system

Du – duodenum

GI – gastrointestinal tract

VLEL – vital and essential drugs

PPI – proton pump inhibitors

FB – foreign body

CT – computed tomography

MRI – magnetic resonance imaging

НПВС – non-steroidal anti-inflammatory and antirheumatic drugs

RRS – rectosigmoidoscopy

LCE – level of confidence of evidence

US – ultrasound examination

GRS – grade of recommendation strength

EGD – esophagogastroduodenoscopy

ESGE – European Society of Gastrointestinal Endoscopy

ESPGHAN – European Society for Paediatric Gastroenterology, Hepatology and Nutrition

Terms and Definitions

Gastrointestinal foreign body – any object of organic, inorganic, or artificial origin, accidentally or intentionally swallowed, introduced into the lumen of the gastrointestinal tract, or formed within the body itself, which by its composition and/or location cannot be used as food.

Inert foreign bodies – foreign bodies that do not exert a pronounced pathological effect on the wall of the gastrointestinal tract (coins, small toys, clips, glass and metal balls).

Aggressive foreign bodies – chemically, physically, and mechanically active foreign bodies that exert a damaging effect on the wall of the gastrointestinal tract organs.

Mechanically active foreign bodies – foreign bodies that exert a damaging mechanical effect on the organ wall of the gastrointestinal tract (needles, pins, self-tapping screws, wire).

Physically active foreign bodies – foreign bodies that exert a pronounced physical, compressive effect on the organ wall of the gastrointestinal tract (magnets).

Chemically active foreign bodies – foreign bodies that cause chemical and thermal burns up to the formation of organ wall perforation (disc-type button batteries).

Foreign bodies with combined effects – foreign bodies that exert both mechanical (obstruation, compression) and chemical effects on the organ wall of the gastrointestinal tract (bezoars, silica gel beads).

Turner's sign – a sensation of a foreign body in the laryngopharynx/esophagus, even after it has passed into the stomach.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Gastrointestinal foreign body – any object of organic, inorganic, or artificial origin, accidentally or intentionally swallowed, introduced into the lumen of the gastrointestinal tract, or formed within the body itself, which by its composition and location cannot be used as food.

True/absolute foreign bodies enter the GI lumen from the outside, do not serve as human food, and do not form or parasitize within the human body.

Conditionally foreign bodies are those that are not classified as FBs by definition per se (e.g., food), or have their own ICD-10 codes (e.g., gallstones or parasites), but become such under certain circumstances, for example, when a food bolus impacts in an area of organic esophageal stricture; when migrating from the site of formation into the lumen of the gastrointestinal tract (e.g., gallstones); or when conglomerates form in the GI lumen (e.g., a parasite conglomerate leading to acute intestinal obstruction).

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Gastrointestinal foreign bodies are a common problem. The ingestion of true FBs occurs more frequently in children than in adults [6, 12]. This is due to the fact that children, especially at an early age, put objects they encounter into their mouths and thus explore their environment. Even the most conscientious parents are not always able to prevent this process. Most FBs pass naturally without causing harm to health. The most common GI FBs in children are coins [32, 41]. Factors influencing the possibility of spontaneous passage of a coin through the GI tract include its location, size, and the child's age, along with concomitant GI pathology. According to literature, spontaneous passage of a coin through the esophagus without any complaints is observed in 30–60% of children [10, 56, 61].

At the same time, the retention of an FB at any level of the GI tract can lead to the development of severe complications. A button battery stuck in the esophagus, which can lead to serious life-threatening complications for the child – tracheoesophageal and tracheo-aortic fistulas, mediastinitis, neck abscess, etc., is an extremely dangerous and emergency situation [29]. In recent years, due to the widespread availability of consumer electronics containing small power sources, as well as magnetic constructor sets, the number of foreign bodies exerting pronounced damaging (electrochemical and compressive) effects on GI organs has increased. The peak incidence occurs between the ages of 6 months and 6 years [10, 15].

Adult patients may swallow FBs accidentally; however, situations are not uncommon where patients suffering from mental illness or serving a prison sentence intentionally swallow or insert FBs, including for the purpose of sexual gratification, via the anus [11, 78]. In addition, there is the problem of smuggling various illicit substances by couriers who swallow or insert containers of packaged substances into the GI lumen for concealment.

A special group of "iatrogenic" FBs can also be distinguished, which are intentionally introduced (e.g., video capsules, various stents, drains, bariatric balloons, etc.) or accidentally enter (e.g., dental drills, dentures, enema tips, etc.) the GI lumen.

1.3 Epidemiology of the Disease or Condition

Among adult patients requiring emergency endoscopic care, 28–33% present with suspected upper GI foreign bodies [71]. According to the Chief Surgeon and Endoscopist of the Russian Ministry of Health A.Sh. Revishvili (Rosstat, Federal Statistical Observation; form No. 30), in 2020 in our country, 21,179 EGDs and 477 rectosigmoidoscopies/colonoscopies were performed to remove gastrointestinal foreign bodies. The diagnosis of a foreign body is confirmed in 25–30% of patients; complications develop in 0.5–1% of cases [51]. The detection rate of food bolus impaction is estimated at 13 per 100,000 population [71]. The ingestion of non-food objects, intentional or unintentional, is more frequently observed in the elderly, individuals under the influence of alcohol, patients with developmental delays and mental disorders, as well as prisoners pursuing a specific goal. In recent years, the frequency of button battery ingestion by children has increased significantly. Batteries account for up to 10% of all GI foreign bodies in children. The incidence of battery ingestion is approximately 10–15 cases per 1 million population, and every 1,000th episode annually leads to severe consequences. According to data from the National Poison Data System, from 1985 to 2009 in the US, there were 56,535 pediatric esophageal injuries caused by batteries, with fatalities in 13 (0.02%) children [17, 53].

1.4 Features of Coding the Disease or Condition

T18. – Foreign body in digestive tract. The diagnosis code T18 includes 8 specifying diagnoses (ICD-10 subcategories):

T18.0 – Foreign body in mouth

T18.1 – Foreign body in esophagus

T18.2 – Foreign body in stomach

T18.3 – Foreign body in small intestine

T18.4 – Foreign body in colon

T18.5 – Foreign body in anus and rectum

T18.8 – Foreign body in other and multiple parts of alimentary tract

T18.9 – Foreign body of alimentary tract, part unspecified

1.5 Classification of the disease or condition

There is no single universally accepted classification of foreign bodies. Working classifications are most commonly used, according to which foreign bodies are subdivided into the following categories.

By nature and origin:

True / absolute foreign bodies

1. Ingested FBs: a) intentionally ingested; b) accidentally ingested; c) unnoticed ingestion

2. FBs introduced into the lumen of the gastrointestinal tract via antegrade/ascending route (through the anus)

3. FBs introduced/left in the lumen of the gastrointestinal tract consciously or forgotten during endoscopic, surgical, and other diagnostic/therapeutic interventions.

4. FBs entering the gastrointestinal tract via traumatic pathways.

Conditional foreign bodies

5. Impacted food bolus.

6. FBs formed within the body: a) gallstones; b) gastric and intestinal bezoars; c) fecaliths

7. Living foreign bodies, including parasite conglomerates.

By localization:

1. Esophagus – 68.4%

2. Stomach – 18.9%

3. Small intestine – 7.1%

4. Large intestine – 3%

5. Rectum – 2.6%

Table No. 1 Classification of ingested foreign bodies by radiopacity degree [25]:

By quantity:

1. Single

2. Multiple

By dynamics:

1. Migrating

2. Freely lying

3. Fixed

By size:

1. Small – up to 2-2.5 cm in diameter or up to 5 cm in length

2. Medium – from 2.5 to 5 cm in diameter or up to 10 cm in length

3. Large – greater than 5 cm in diameter or greater than 10 cm in length

By pathological impact on the body

1. Inert foreign bodies – not exerting a pronounced pathological effect on the body and organ wall (coins, small toys, clips, glass and metal spheres.)

2. Potentially aggressive foreign bodies:

a) Containers with drugs and other toxic substances.

b) Fragile objects (e.g., made of thin glass)

3. Aggressive foreign bodies:

a) Chemically active foreign bodies – causing chemical and thermal burns up to organ wall perforation (disc batteries).

b) Physically active foreign bodies – exerting a pronounced physical, compressive effect on the organ wall (magnets; jars; mercury).

c) Mechanically active (sharp) foreign bodies – exerting a damaging mechanical effect on the organ wall (needles, pins, self-tapping screws, springs, wire, including those with sharp elements such as concertina wire).

d) Foreign bodies with combined effects – exerting mechanical (obstructive, compressive) and chemical effects on the body and organ wall (bezoars, silica gel spheres).

Table No. 2 Classification of ingested foreign bodies according to the European Society of Gastrointestinal Endoscopy [25]

1.6 Clinical presentation of the disease or condition

There are three clinical presentation forms of GI foreign bodies (FBs): latent, overt, and complicated [9]. Clinical manifestations depend on the size, nature, and quantity of the object(s), duration of presence, location, depth of penetration into the mucous membrane, mental status and age of the patient, as well as the presence or absence of complications.

In children, the clinical presentation has several distinctive features because the pharyngoesophageal transition zone in infants and toddlers is narrower and longer; FBs are predominantly localized in the cervical esophagus, and the majority of foreign bodies (75–90%) are non-food items. Children are more likely to develop respiratory syndrome (cough, dyspnea, salivation, pseudocroup). According to studies, the main clinical manifestations of esophageal FBs in children vary and include hypersalivation, choking, vomiting, dysphagia and odynophagia, food refusal, foreign body sensation in the throat, cough, wheezing, stridor, and others [61]. When children swallow coins, the predominant symptoms are vomiting and hypersalivation [54]. It is worth noting that some children with esophageal foreign bodies may remain completely asymptomatic until complications develop.

Approximately 50–68% of adult patients with pharyngeal and esophageal FBs present with a pronounced clinical picture. The most frequent clinical symptoms of an impacted esophageal foreign body include pain along the esophagus, salivation, inability to swallow solid and liquid food, pain in the jugular notch, occiput, back, and epigastrium, dysphagia, regurgitation, and dyspnea. A forced body position is characteristic of "anchor-like" FBs [14]. Secondary manifestations include fever, dehydration, salivation, halitosis, hoarseness, infiltration of the soft tissues of the neck, subcutaneous emphysema, pneumothorax, etc. Cold sweat, skin pallor, and sometimes cardiac arrhythmias are characteristic. Ten percent of esophageal FBs cause no symptoms whatsoever.

If the FB has passed through the esophagus into the stomach, most patients are asymptomatic, but the sensation of an FB with dysphagia may persist for several hours and thus mimic the presence of an esophageal FB (Turner's sign) [12]. The sensation of a "foreign body" is common in emotionally labile individuals; such "phantom" foreign bodies occur in 10–15% of cases.

When FBs are located in the stomach and duodenum, clinical manifestations are often mild. Only large, long, and sharp objects present clinically. When large FBs are present in the stomach, patients are often troubled by dull epigastric pain that worsens after meals, as well as a metallic taste in the mouth, nausea, and a feeling of heaviness in the epigastric region. Small FBs usually cause no complaints. With prolonged presence of an FB in the lumen of the stomach or duodenum, pressure sores and subsequent perforation of the organ wall lead to peritoneal signs or the formation of a retroperitoneal infiltrate [56]. The latter is characteristic of FBs fixed in a vertical position at the transition of the descending part of the duodenum to the inferior horizontal part [14].

Large foreign bodies in the rectum (large toys, bottles, and other vessels, oblong fruits and vegetables) intentionally introduced into the rectal lumen, especially in children, can cause tenesmus, perineal pain, blood in the stool, and constipation/gas retention [24].

The absence of clinical manifestations should not be a reason to refuse further evaluation of a patient with a suspected gastrointestinal foreign body.

Most FBs (80–90%) pass spontaneously. However, in 10–20% of cases, patients require endoscopic intervention, and in less than 1% of cases, surgery is necessary to remove the FB or treat FB-related complications [2, 81, 88].

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the disease or condition

• The diagnostic criterion is the detection of a foreign body via radiologic/endoscopic examination or during intraoperative revision [28, 62, 81, 84].

(RRR – B, LOR – 3).

Comments: The basis for diagnosing a "gastrointestinal foreign body" at the pre-hospital stage and upon admission to the hospital is the history and physical examination data.

2.1 Complaints and Anamnesis

(Level of Evidence – C, Grade of Recommendation – 5).

Comments: Taking a history in adults is usually straightforward, except for patients with mental disorders or those concealing the circumstances of the incident. Patients with esophageal foreign bodies, especially impacted food boluses, almost always have complaints and can accurately determine the onset of symptoms and localize the discomfort zone. However, the discomfort area often does not correlate with the site of impaction [49, 53]. Foreign bodies in the esophagus cause symptoms such as dysphagia, odynophagia, or retrosternal pain; sore throat, foreign body sensation, nausea, and vomiting are also frequent. Respiratory symptoms include choking, stridor, or dyspnea and may result from saliva aspiration or tracheal compression by the foreign body. Hypersalivation and the inability to swallow any liquids are symptoms indicating complete esophageal obstruction [81, 88].

In pediatric practice, it is essential to remember the diagnostic features of foreign bodies in patients with organic esophageal pathology (congenital esophageal strictures, esophageal burns, previous surgeries for esophageal atresia and hernia). The onset of complaints such as dysphagia, drooling, food refusal, choking, or apnea during attempted feeding in such a child raises suspicion of a foreign body and is an indication for diagnostic esophagoscopy [6].

When taking the history, an important point is to clarify the nature of the ingested foreign body, the time elapsed since ingestion, the time and volume of the last food and water intake. It should be noted that the radiographic appearance of coins is very similar to button batteries; therefore, a meticulous review of anamnestic data is necessary [32, 41]. In addition to the fact of ingestion, taking a history from the parents or legal representatives of the child is crucial for other foreign bodies that are aggressive in their physical, chemical, and mechanical impact.

It is important to find out whether the patient attempted self-extraction or "pushing" the foreign body, for example, by swallowing large amounts of dry bread. If the patient was evaluated in an outpatient setting or transferred from another hospital, it must be ascertained whether attempts at endoscopic foreign body removal were performed.

The history-taking should clarify the presence/absence of episodes with similar symptoms in the past; the presence/absence of a previously diagnosed eosinophilic esophagitis, gastroesophageal reflux disease, cicatricial esophageal stricture, or achalasia cardia, which may have significant diagnostic value in patients with alimentary esophageal FBs, particularly in elderly and senile patients. Comorbidities, as well as indications and contraindications for endoscopic and other types of instrumental examinations, should be specified.

2.2 Physical Examination

• Upon admission of a patient with suspected GI FB to the hospital, it is recommended to have an appointment (examination, consultation) with an otorhinolaryngologist including physical examination of the patient (in case of FB ingestion) and an appointment (examination, consultation) with a surgeon including physical examination, focusing on the assessment of the patient's general condition and clinical symptoms of potential complications [26, 28, 53].

(Level of Evidence – C, Grade of Recommendation – 5).

Comments: The presence of hyperthermia and tachycardia in a patient with an FB are warning signs of developing complications. If a long-standing esophageal FB is suspected, given the absence of a thoracic department, planning the patient's transfer to a specialized hospital should occur at the emergency admission level; if impossible, an on-call specialist should be requested. During the physical examination, the otorhinolaryngologist (or a covering physician in their absence) must confirm or exclude the presence of the ingested foreign body in the oral cavity and pharynx. The surgeon excludes/confirms signs of esophageal perforation (examines and palpates the neck and submandibular regions to rule out subcutaneous emphysema, edema, or infiltrates) and rules out/confirms signs of complications involving the stomach, small intestine, and colon (presence of abdominal infiltrates, peritoneal signs, symptoms of intestinal obstruction, etc.). Examination of the lungs should also be performed to assess for wheezing or aspiration. If a rectal foreign body is suspected, a transrectal digital examination must be performed.

2.3 Laboratory Diagnostics

• Upon admission to the hospital, patients with a foreign body are recommended to undergo a standard list of laboratory diagnostic tests for the timely diagnosis of signs of inflammation, detection of comorbid conditions, homeostasis disorders, and blood coagulation abnormalities [9, 15, 34]

(Level of Evidence – C, Grade of Recommendation – 5).

Comments: The set of laboratory tests generally differs very little from the standard panel of tests performed upon hospital admission. All patients undergo a complete blood count; general general-health blood biochemistry panel (glucose, urea, creatinine, amylase, bilirubin, ALT, AST). The complete blood count focuses on signs of inflammation, which may indicate a potentially developed complication associated with the foreign body. Additional tests (as clinically indicated) include: blood potassium and sodium levels; blood platelet count; activated partial thromboplastin time (APTT), international normalized ratio (INR), blood fibrinolytic activity, AB0 blood grouping and D antigen (Rh factor) testing.

2.4 Instrumental Diagnostics

• Emergency soft tissue radiography of the neck, targeted chest radiography, and plain abdominal radiography are recommended for patients with suspected radiopaque foreign bodies of the gastrointestinal tract, as well as when the nature of the foreign body is unknown – to detect it, determine its localization, size, configuration, and number [7, 26, 28, 84, 90]

(RRR – B, LVE – 1).

Comments: Plain radiography (soft tissue radiography of the neck, targeted chest radiography, and plain abdominal radiography) allows determining the structure and quantity of the foreign body, its location level, and the presence of any complications caused by the foreign body. To minimize radiation exposure, standard fluoroscopy/radiography (A06.30.004.001 Plain abdominal radiography, A06.09.007.001 Targeted chest radiography) in the anteroposterior (AP) projection is recommended as the initial imaging method. The false-negative rate reaches 47% [77], which is why if the foreign body is not detected in the AP projection, the next step is fluoroscopy/radiography in a lateral projection (A06.09.007.001 Targeted chest radiography (anteroposterior or lateral)) [90].

If a foreign body of the cervical esophagus is suspected, the patient undergoes plain fluoroscopy and soft tissue radiography of the neck (A06.01.003 Soft tissue radiography of the neck) in lateral and anteroposterior projections with the head elevated so as not to obscure the cervical esophagus and pharyngoesophageal junction.

If a foreign body of the thoracic esophagus is suspected, plain radiography of both the cervical esophagus in a lateral projection and targeted chest radiography are performed, since patient complaints do not always allow determining the suspected localization level of the foreign body.

Plain abdominal radiography is performed when a foreign body of the stomach and lower gastrointestinal tract is suspected. If a foreign body of the rectum is suspected, plain radiography of the pelvis is performed (A06.30.004 Plain radiograph of the abdomen and pelvic organs).

• Children with suspected foreign body ingestion, even in the absence of convincing clinical symptoms, are recommended to undergo emergency soft tissue radiography of the neck, targeted chest radiography, and plain radiography of the abdomen and pelvis in 2 projections, as clinically indicated (A06.01.003 Soft tissue radiography of the neck, A06.09.007.001 Targeted chest radiography (anteroposterior or lateral), A06.30.004 Plain radiograph of the abdomen and pelvic organs) [23]

(BRL – C, LE – 4).

Comments: Most true radiopaque foreign bodies can be identified radiologically; however, thin metal objects (such as aluminum pull tabs from beverage cans and bottles), wood, plastic, glass, and thin fish or chicken bones are often difficult to detect (Table 1), which limits the utility of fluoroscopy in the initial diagnosis of this condition [50, 53]. In addition to identifying the foreign body, plain radiography can detect complications such as aspiration, pneumomediastinum, pneumoperitoneum, or subcutaneous emphysema [57, 59, 81].

• Plain radiography (A06.01.003 Soft tissue radiography of the neck, A06.09.007.001 Targeted chest radiography (anteroposterior or lateral)) in patients with an impacted bone-free food bolus without signs of complications is generally not recommended [26, 81]

(Level of Evidence – C, Grade of Recommendation – 5).

Comments: The false-negative rate of plain radiography in patients with an impacted bone-free food bolus without signs of complications reaches 87% [26, 57, 59, 81].

• Pharyngoscopy (A06.08.001.001 Contrast pharyngography) and contrast esophagoscopy (A06.16.001.002 Contrast esophagoscopy) are recommended when esophageal obstruction and/or perforation is suspected; when a radiolucent foreign body in the esophagus is suspected; and when there is doubt regarding the localization of the foreign body in the stomach or lower gastrointestinal tract [12, 34, 81]

(Level of Evidence – C, Grade of Recommendation – 5).

Comments: The use of a water-soluble iodine-containing radiopaque agent subsequently allows for unhindered endoscopic examination of internal organs, and contrast fluoroscopy data (A06.16.001.002 Contrast esophagoscopy) assist in assessing the state of the esophagus and the risks of performing subsequent endoscopic intervention [12]. At the same time, pharyngoscopy (A06.08.001.001 Contrast pharyngography) and contrast esophagoscopy (A06.16.001.002 Contrast esophagoscopy) should not delay the endoscopic intervention.

When performing this imaging study for suspected esophageal obstruction, the patient should be warned to drink the iodine-containing radiopaque agent in small portions. In case of swallowing dysfunction caused by the localization of the obstructing foreign body at the pharyngoesophageal junction, as well as in patients with swallowing disorders of any other etiology (neurological diseases, etc.), water-soluble iodine-containing radiopaque agents should not be used at all, as this may lead to aspiration and subsequent pulmonary edema [83].

(RRR – B, LOR – 3).

Comments: Contrast imaging of the esophagus and stomach with barium sulfate** carries a high risk of aspiration and complicates, or in some cases makes impossible, the subsequent endoscopic examination [12, 70].                       

• Computed tomography of the chest and abdomen is recommended for patients with clinical signs of esophageal perforation, neck phlegmon, mediastinitis, and other complications caused by a gastrointestinal foreign body requiring surgical treatment, or long-standing esophageal foreign bodies [26, 33, 34, 39, 70]

(RRR – B, LOR – 3).

Comments: In adult patients, fish bones and bone fragments are the most frequently ingested foreign bodies. They most commonly lodge in the upper esophagus and pose a high risk of organ perforation [23, 35, 42, 52, 81-83, 89, 92]. However, plain radiography does not always reliably detect low-contrast foreign bodies, especially fish bones. Even when fish bones, albeit with minimal calcium content, are radiopaque enough to be visualized on radiographs, large masses of soft tissue and fluid can obscure them, particularly in obese patients [48]. According to a prospective study of 358 patients who ingested fish bones, radiography had a sensitivity of only 32% [74]. In such cases, CT, which has a sensitivity of 90% to 100% and a specificity of 93.7% to 100%, significantly outperforms X-ray [81, 48, 67, 72, 91]. In children, computed tomography is recommended for radiolucent foreign bodies.

If perforation is suspected based on clinical or radiological findings, CT is indicated – it can be used to visualize the shape, size, location, and depth of penetration of the foreign body, as well as the condition of the surrounding tissues, which is important in determining treatment options and assessing the risk of endoscopic intervention. CT not only provides more detailed topographic and anatomical information, but can also reveal other complications such as abscess formation, mediastinitis, or aorto-esophageal/tracheo-esophageal fistulas [31, 45, 47, 64, 67, 72, 73, 91].

Another difficulty is that free gas under the diaphragm is almost never observed in gastrointestinal foreign body perforation. Since the perforation is caused by the foreign body acting on the intestinal wall, with gradual progressive penetration of the FB from the inside – outward, the perforation site has time to be covered by fibrin, the greater omentum, or adjacent intestinal loops. This limits the entry of a large amount of intraluminal gas into the abdominal cavity. Thus, free air in the abdominal cavity on a plain abdominal radiograph is an unreliable radiological sign. In contrast, during computed tomography, the perforation site can be identified as a thickened intestinal segment, localized pneumoperitoneum, regional adipose tissue infiltration, or concomitant intestinal obstruction [47].

(LoE – C, GoR – 5).

Comments: Studying the clinical picture as well as diagnostic imaging data makes it possible to choose the optimal endoscopic tactics and the necessary conditions for performing the endoscopic procedure, such as the choice of anesthesia method, endoscope, etc. [12].

• Upper GI endoscopy (A03.16.001 esophagogastroduodenoscopy) is recommended for all patients with suspected FBs in these sections – to detect them, especially when radiological findings are negative; to clarify the nature of the FB; to assess the condition of the lumen and mucosa of the digestive tract; and as the first diagnostic stage of therapeutic endoscopic intervention [7-9, 26, 33, 84, 94, 95]

(Reliability of Evidence – B, Level of Evidence – 2).

Comments: FB ingestion is the most common indication for emergency endoscopy in pediatric practice. It serves as a key method in the diagnosis of ingested FBs in both children and adult patients and is recommended for all patients with a history and clinical presentation suggestive of ingestion, even in the presence of negative radiological findings [26].

The timing of endoscopy depends on many factors, including the patient's age, clinical condition, time of last meal, type of foreign body, its location, and the time elapsed since ingestion. Foreign and domestic literature sources agree that esophageal FBs in children require emergency endoscopic diagnosis and removal less than 24 hours after ingestion, as any delay reduces the likelihood of successful intraluminal extraction and increases the risk of complications, including esophageal perforation [10, 75].

• Endoscopic examination of the rectum and, if necessary, the sigmoid colon (sigmoidoscopy) is recommended for patients with suspected foreign body in the rectum/sigmoid colon [19, 62]

(Level of Evidence – A, Grade of Recommendation – 3).

2.5 Other Procedures

• Differential diagnosis of FBs is recommended to be carried out with diseases that can mimic the clinical picture of a gastrointestinal foreign body [2, 7, 15, 70]

(LoE – C, GoR – 5).

Comments: As a rule, the diagnosis of a digestive tract foreign body, especially in its upper sections, is unquestionable. However, in some cases, symptoms similar to the clinical picture of a foreign body occur in candidal esophagitis, reflux esophagitis, eosinophilic esophagitis, achalasia of the cardia, after acute cerebrovascular accidents, at the onset of various systemic diseases (multiple sclerosis, ALS, myasthenia gravis), in esophageal tumors, as well as in various nervous system disorders (hysteria, etc.). In case of intense retrosternal pain, acute coronary syndrome must be excluded. When the FB is localized in the stomach or intestines, differential diagnosis is performed with all diseases included in the acute abdomen syndrome, such as complicated gastric and duodenal ulcer, acute cholecystitis, acute pancreatitis, acute appendicitis, and acute intestinal obstruction.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

Conservative management of patients

• Conservative management of patients, namely dynamic observation of the ingested gastrointestinal foreign body without endoscopic extraction, is recommended in situations where the FB is not localized in the esophagus, there are no clinical symptoms, and the foreign body itself is blunt, inert, and small, i.e., when there is a guarantee of its safe spontaneous passage [4, 26, 88, 96, 97]

(BRL – C, LE – 4).

Comments: Conservative management of patients is possible if the dimensions of an inert foreign body without sharp edges do not exceed 2-2.5 cm in diameter or 5 cm in length [52]. This recommendation is especially valid in cases where the ingested FB is already located in the jejunum, ileum, or colon at the time of patient examination. It should be emphasized once again that batteries, especially button batteries, and magnets are aggressive FBs and, therefore, such patients cannot be managed conservatively, even if only one magnet is visible on radiographs or only a single magnet ingestion is suspected based on the history. Additional undetected magnets or metal objects swallowed together with a magnet can lead to severe damage to the digestive tract organs [22, 42, 52, 77].

Most ingested foreign bodies (80-90%) pass through the gastrointestinal tract spontaneously and without complications [22, 27, 42, 52, 81, 83]. It is known that in children as well, 80% of foreign bodies leave the gastrointestinal tract naturally without the need for any intervention [34, 58]. Impaction, perforation, or obstruction often occur at sites of physiological narrowing or angulation. Areas of physiological narrowing include: the upper esophageal sphincter, the projection of the aortic arch and the left main bronchus, the lower esophageal sphincter, the pylorus, the duodenojejunal junction, the ileocecal valve, and the anus; the duodenal "loop" represents a physiological angulation. Once foreign bodies have passed the esophagus, most of them pass through the entire GI tract within 4-6 days or, in rare cases, up to 4 weeks. As a rule, objects with a diameter greater than 2-2.5 cm do not pass through the pylorus or ileocecal valve, and items longer than 5-6 cm do not pass through the duodenal loop [22, 27, 52, 75, 83].

Outpatient monitoring of patients is possible in the absence of symptoms if FBs located in the stomach are smaller than 2-2.5 cm in diameter and 5-6 cm in length. Patients must be instructed on the possibility of perforation or small bowel obstruction and know their symptoms, as well as monitor their stool.

(LoE – C, GoR – 5).

Comments: The term "body packing" refers to drug smuggling by concealing drugs in the gastrointestinal tract. Illicit drugs (most commonly cocaine or heroin) are packaged in latex condoms or balloons and swallowed or inserted into the rectum in multiple pieces. Drug packets are usually visible on radiographs. Rupture and release of the contents into the GI lumen can lead to fatal intoxication. Therefore, attempts at endoscopic removal should not be made; instead, a conservative approach is recommended, including inpatient clinical observation, bowel cleansing, and radiological monitoring of packet transit. Since the failure rate of conservative management is only 2-5%, it is always recommended for asymptomatic body packers. Symptoms may manifest as signs of intoxication or intestinal obstruction in case of packet impaction, requiring emergency surgery [22, 42, 52, 81, 83].

• During dynamic observation of a small, blunt, inert, radiopaque FB, it is recommended to periodically perform radiological monitoring (A06.30.004 Plain radiograph of the abdominal and pelvic organs) of the foreign body's progression through the GI tract [26, 84]

(Level of Evidence – C, Grade of Recommendation – 5).

Comments: In the absence of symptoms, weekly radiographs are sufficient to document the progression of the foreign body. If the foreign body does not pass beyond the stomach within 3–4 weeks, it should be removed endoscopically [27, 22, 42, 52, 81, 83]. This recommendation is frequently used in pediatric practice.

• In cases of gastric bezoars, it is recommended to begin treatment with conservative therapy, including the intake of a 5–10% sodium bicarbonate solution or beverages containing phosphoric acid [3, 9, 18, 20].

(RRR – B, LOR – 3).

Comments: Even if this type of treatment does not achieve full efficacy, it helps soften plant-based bezoars, facilitating subsequent endoscopic intervention. Conservative therapy should be continued between therapeutic endoscopy sessions. It has a more pronounced therapeutic effect on partially disrupted bezoars.

Comments: A more detailed diagnostic and treatment algorithm for trichobezoars in children is presented in Appendix B, Table 6.

(RRR – B, LOR – 3).

Comments: Chemically active FBs and FBs with combined effects require emergency removal [26], even if radiographs show only a single magnet or history suggests the ingestion of only one magnet. Additional, undetected magnets or metal objects swallowed along with a magnet can lead to severe gastrointestinal tract injury [22, 42, 52, 76]. Recommended timeframes for endoscopic intervention, depending on the type and localization of the FB, are presented in Appendix A3, Table 3.

Endoscopic treatment

(BRL – C, LE – 4).

Comments: Studying the clinical presentation and diagnostic imaging data allows for the selection of optimal endoscopic tactics and necessary conditions for performing the endoscopic procedure (choice of anesthesia, endoscope, foreign body extractors, etc.) [12]. Protocols for endoscopic foreign body retrieval from the digestive tract in adults generally do not differ from pediatric ones; however, due to objective reasons, there are a number of specific features in childhood—in particular, the choice of endoscope depends on the patient's age (Tables 4, 5, 6).

(Level of Evidence – C, Grade of Recommendation – 5).

Comments: More detailed recommended timeframes for endoscopic intervention are presented in Appendix A3, Table 3. Patients with clinical signs of complete esophageal obstruction (hypersalivation and inability to swallow liquids) are at high risk for aspiration and require emergency (preferably within 2 hours, but no later than 6 hours) endoscopic intervention. This applies equally to children: if a child has symptoms of complete obstruction (drooling, neck pain), emergency extraction of the food bolus from the esophagus is recommended (within up to 2 hours); if the child has no clinical symptoms, urgent removal of the food bolus is indicated (within up to 24 hours).

The incidence of perforation caused by the ingestion of sharp objects is up to 35%, so it is recommended to remove these foreign bodies from the esophagus on an emergency basis as well [22, 31, 42, 45, 52, 60, 66, 69, 77, 81-83]. Button batteries or small disk batteries (used in watches, hearing aids, calculators, and other small electronic devices) can very rapidly cause esophageal damage, leading to perforation or fistula formation due to pressure necrosis, electrical discharge, or chemical injury. The narrow lumen of the esophagus brings the mucosa into contact with both poles of the battery, resulting in electrical burns. In addition, necrosis may occur as a result of leakage of alkaline substances contained within the battery. Batteries also contain heavy metals, but in small quantities, and these metals are unlikely to cause intoxication. Cylindrical battery ingestion is rare (0.6% of cases) and less frequently causes symptoms [22, 42, 45, 52, 77, 81, 83]. In children, when a single cylindrical battery is ingested and located in the esophagus, emergency endoscopic removal is recommended (A16.16.041.003 Endoscopic removal of foreign bodies from the esophagus) (preferably within 2 hours, but no later than 6 hours), and removal as soon as possible if it is located in other parts of the gastrointestinal tract.

Foreign bodies of the esophagus and food boluses impacted in the esophagus must be removed within 24 hours, as delay reduces the likelihood of successful removal and increases the risk of complications [22, 42, 52, 60, 77, 81-83]. The risk of serious complications (e.g., perforation with or without mediastinitis, retropharyngeal abscess, and aortoesophageal fistula) increases 14.1-fold when foreign bodies remain in the esophagus for more than 24 hours [69].

(Level of Evidence – C, Grade of Recommendation – 5).

Comments: More detailed recommended timeframes for endoscopic intervention in adults are presented in Appendix A3, Table 3.

Despite the fact that most sharp objects can pass through the gastrointestinal tract without adverse events, the risk of complications is still quite high, reaching 35%. Therefore, it is recommended to remove sharp objects from the stomach or proximal duodenum endoscopically if it can be done safely considering the patient's condition and the risk of aspiration, provided the patient has eaten recently [52, 81, 83].

Due to the attractive force between ingested magnets, or between a single magnet and metal foreign bodies ingested simultaneously, pressure necrosis, fistulae, perforation, obstruction, or volvulus may occur. Urgent endoscopic removal (within 24 hours) is recommended, even if radiographs show only a single magnet or history suggests the ingestion of only one magnet. Additional, undetected magnets or metal objects swallowed along with a magnet can lead to severe gastrointestinal tract injury [22, 42, 52, 77].

Some authors suggest emergency endoscopic removal of batteries that have already passed beyond the esophagus, while others recommend it only in the presence of concomitant signs of gastrointestinal tract injury [22, 42, 52, 77, 83]. Most button and small disc batteries that reach the stomach will pass through the gastrointestinal tract without any complications. The risk of electrical burns from batteries that have passed into the stomach is low compared to the risk from those lodged in the esophagus. Considering the danger of liquefaction necrosis due to battery content leakage, endoscopic removal of a battery from the stomach within 24 hours appears appropriate. Once a battery has passed the duodenum, it passes through the remainder of the intestine within 72 hours in 85% of cases.

Unlike adults, in children regardless of age, clinical symptoms, size, and number of button batteries, urgent removal is recommended (preferably within 12 hours, but no later than 24 hours from ingestion), especially in cases where the child has a known or suspected anatomical gastrointestinal pathology (e.g., Meckel's diverticulum) and/or if the child has simultaneously swallowed a magnet. Retention of button batteries in the stomach causes erosive and ulcerative mucosal changes in more than 60% of cases, up to and including gastric perforation. When button batteries are removed 12 hours after ingestion, the risk of complications increases 4.5-fold [56].

Medium-sized foreign bodies of the stomach with a diameter greater than 2–2.5 cm usually do not pass through the pylorus and should be extracted endoscopically within 24–48 hours of presentation. Objects longer than 5–6 cm usually become trapped in the duodenal sweep and must be removed urgently due to the risk of perforation, which occurs in 15–35% of cases.

If a blunt, inert, small foreign body does not pass beyond the stomach within 3–4 weeks (preferably no more than 1 week), it should be removed endoscopically [22, 27, 42, 81, 83].

(RRR – B, LOR – 3).

Comments: The procedure should be performed under general anesthesia after preliminary anal dilatation. The rectum should be inspected using proctoscopy to visualize the foreign body (A03.19.002 Proctosigmoidoscopy). Surgical instruments such as Kocher forceps and fenestrated forceps are used for extraction.

• It is recommended to perform endoscopic removal of GI foreign bodies (A16.16.048 Endoscopic removal of foreign bodies from the stomach, A16.16.041.003 Endoscopic removal of foreign bodies from the esophagus, A16.17.023 Endoscopic removal of foreign bodies from the small intestine) with anesthetic support under general anesthesia B 01.003.004.012 Combined inhalation anesthesia (including the use of xenon) [9, 13, 85]

(Level of Evidence – C, Grade of Recommendation – 5).

Comments: The preferred method of anesthetic support, especially during the extraction of potentially hazardous FBs, is general anesthesia with the administration of muscle relaxants. Tracheal intubation provides ideal conditions for the safe extraction of FBs and protects the patient's airway from potential aspiration [26]. Endotracheal intubation may be required if the patient does not respond adequately to the procedure or if there is a high risk of aspiration (e.g., full stomach, proximal location of the foreign body in the esophagus, food impaction). Endoscopic removal of non-hazardous FBs in adult patients can be performed under intravenous anesthesia with preservation of spontaneous breathing or under deep sedation [12]. If it is not possible to perform the procedure under intravenous sedation, extraction of the FB under local anesthesia may be considered [7].

In children, unlike adults, all FB extractions must be performed exclusively under general anesthesia with endotracheal intubation (B01.003.004.010 Combined endotracheal anesthesia) to protect the airway from potential aspiration and safely remove the swallowed object, or under intravenous anesthesia with preservation of spontaneous breathing or under deep sedation [10, 15].

• In the absence of contraindications, extraction of upper gastrointestinal foreign bodies (A16.16.048 Endoscopic removal of foreign bodies from the stomach, A16.16.041.003 Endoscopic removal of foreign bodies from the esophagus, A16.17.023 Endoscopic removal of foreign bodies from the small intestine) is recommended to be performed endoscopically using fiberoptic video endoscopic equipment [7, 12, 26, 94, 95]

(Reliability of Evidence – B, Level of Evidence – 2).

Comments: Fiberoptic endoscopy is the best diagnostic and therapeutic method for foreign bodies and food impactions in the upper gastrointestinal tract, with a success rate of over 95% and a complication rate of 0-5% [31, 35, 38, 42, 43, 52, 66, 73, 77, 81, 89]. Rigid esophagoscopy carries a higher rate of complications when removing foreign bodies from the esophagus and therefore its routine use is not recommended [55]. The use of rigid esophagoscopy may be considered when foreign bodies are localized in the upper third of the esophagus and cannot be removed with flexible endoscopes; in diagnosed esophageal perforation for foreign body removal in the operating room prior to mediastinal opening and drainage; and it may also be used in exceptional situations where the hospital lacks the capability to perform fiberoptic endoscopy.

For long-standing GI foreign bodies, as well as when previous unsuccessful extraction attempts have been made, it is recommended to perform extraction in an operating room with carbon dioxide insufflation. All manipulations should be performed under direct visual control. It is safer to extract the foreign body with adequate carbon dioxide insufflation. Grasping of the foreign body must be secure, and extraction smooth, without force, especially at sites of physiological narrowing. If a mechanically active body is positioned at an angle in the esophagus (e.g., an open safety pin), making safe extraction impossible, it must be pushed into the stomach, repositioned, and extracted in a favorable and maximally safe position. An FB in the shape of an unfolding 'cross' must be removed using an endoscope with an overtube, after closing/folding all branches of this FB into a single axis [14]. When extracting a narrow foreign body (e.g., thin pieces of wire, small fish bones, needles, etc.), it should be grasped by the tip in such a way that its axis coincides with the axis of the instrument; then it is smoothly introduced into the instrument channel and removed together with the endoscope [12]. Sharp foreign bodies should be grasped in such a position that the sharp or pointed end is directed distally, i.e.– away from the endoscope lens, thereby reducing the risk of perforation or mucosal damage during extraction. Long foreign bodies must be grasped by the very tip to ensure retrograde removal through the esophagus. Grasping the object near the center will turn it transversely across the lumen, making passage through the sphincters and esophagus difficult.

• During endoscopic extraction of sharp-pointed foreign bodies, it is recommended to use protective devices on the endoscope to prevent damage to the stomach, esophagus, and pharynx, as well as aspiration of contents [7, 26]

(Level of Evidence – C, Grade of Recommendation – 5).

Comments: In the presence of sharp edges of the foreign body, a distal cap, protective hood, or overtube can be used, which is pre-loaded onto the endoscope and advanced beyond its distal tip as needed. Airway protection is of particular importance during foreign body removal and food bolus extraction. A standard-sized overtube passed beyond the upper esophageal sphincter not only protects the airway but also facilitates endoscope advancement when removing multiple items or extracting food bolus fragments. The overtube also helps protect the esophageal/pharyngeal mucosa from tears and ruptures during the extraction of sharp objects. When removing sharp objects located distal to the esophagus, a longer (45-60 cm) overtube should be used, which is placed past the lower esophageal sphincter. The use of a transparent cap or latex rubber hood is recommended to prevent mucosal damage by sharp objects if an overtube is not available. A randomized controlled trial demonstrates that endoscopy with a transparent distal cap is a safe and effective method for foreign body extraction in the upper esophagus, with a significantly shorter procedure time and a clearer visual field compared to standard EGD [38, 42, 52, 60, 66, 77, 81, 83, 93].

• For endoscopic extraction of a foreign body, it is recommended to use specially designed endoscopic instruments, the choice of which depends on the type and location of the swallowed foreign body [26]

(Level of Evidence – C, Grade of Recommendation – 5).

Comments: The choice of instrument for foreign body (FB) extraction is determined by the size and shape of the latter (Appendix A3, Tables 7 and 8), the length of the endoscope and its working channel, as well as the endoscopist's preferences and experience. Removal of foreign bodies with standard biopsy forceps is rarely successful due to their small opening width and is therefore not recommended [42]. Forceps used for FB extraction have a significant variety of working jaw configurations: "rat tooth", "alligator tooth" or "shark tooth". Two- to five-prong FB retrieval graspers may be useful for soft objects, but not for hard or heavy objects because these graspers do not secure them firmly enough. Polypectomy snares are widely available and inexpensive. Endoscopic baskets can be useful for round objects, while net or plastic traps can provide a more secure grip for certain foreign bodies (coins, batteries, magnets) and for removing food boluses en bloc.

Prior to endoscopy, it is useful to practice grasping an object similar in shape to the ingested foreign body using various instruments to determine the most suitable instrument and extraction method [42, 52, 60, 77, 81, 83].

• Impaction of a food bolus in the esophagus is recommended to be managed by carefully advancing/pushing the food bolus down into the stomach. If this fails, its extraction outward should be attempted (A16.16.041.003 Endoscopic removal of foreign bodies of the esophagus) [26, 79]

(Level of Evidence – C, Grade of Recommendation – 5).

Comments: When a food bolus is impacted in the esophagus, the primary treatment method is careful advancement by the endoscope, with a success rate of over 90% and a minimal complication rate. Before pushing the food bolus into the stomach, an attempt should be made to pass it with the endoscope in order to examine the esophagus beyond the impaction site for obstructive pathology. Even if this is not possible, most food boluses can be safely pushed down into the stomach using gas insufflation and gentle pressure. Passing the endoscope on the right side of the bolus may provide easier and safer access to the stomach, as the esophagogastric junction curves to the left side of the patient's body. Larger food boluses can be fragmented using an endoscopic instrument and then these smaller fragments can be safely pushed down into the stomach.

If significant resistance is encountered, pushing should not be continued due to the high incidence of pathological changes in the esophagus distal to the bolus. The use of excessive force increases the risk of perforation. Food boluses that cannot be moved into the stomach, especially those containing bones or having sharp edges, must be extracted en bloc or in pieces after fragmentation using various types of grasping forceps, polypectomy snares, net traps, or Dormia baskets [22, 37, 40, 42, 52, 55, 60, 66, 77, 81, 83, 89].

(Level of Evidence – C, Grade of Recommendation – 5).

Comments: The risk of accidental damage to the integrity of the drug packet during endoscopic removal is quite high. Opening the packet within the gastrointestinal lumen is fraught with severe intoxication and fatal outcome.

(Level of Evidence – C, Grade of Recommendation – 5).

Comments: Endoscopic extraction of a foreign body from the organ lumen in the operating room during surgical intervention is a possible option [7]. In the case of surgical drainage of the mediastinum, an attempt at flexible (less often rigid) esophagoscopy during surgery is possible, preferably with carbon dioxide insufflation.

(Level of Evidence – C, Grade of Recommendation – 5).

Comments: In a small number of cases, when the foreign body has a complex configuration and multiple fixation points in the esophagus (e.g., a fish hook, concertina wire), excessive persistence in attempts at endoscopic removal can lead to a significant increase in the volume of trauma and subsequent surgical intervention [9, 43].

• Following endoscopic FB removal, it is mandatory to inspect the site of its fixation and assess the degree of damage to the hollow organ wall, both in the zone of the initial FB location and along its extraction path [7, 12]

(BRL – C, LE – 4).

Comments: Assessment of the condition of the mucosa and the proper wall of the hollow organ will allow determining the further management tactics for the patient, as well as the duration of their hospital stay [12].

In the presence of a "fresh" (up to 6 hours) esophageal perforation by a foreign body, endoscopic closure of the esophageal wall defect by endoscopic clipping is possible [12]

(Level of Evidence – C, Grade of Recommendation – 5).

Comments: Currently, the availability of a wide range of endoscopic clips makes it possible to close significant esophageal wall defects, and adequate antibacterial therapy will help avoid purulent-septic complications [33]. The clipping procedure should be performed by an experienced specialist with carbon dioxide insufflation.

• After resolving food bolus impaction or removing a small inert and blunt FB, it is recommended to thoroughly examine the fixation site/obstacle to the passage of the FB to clarify the cause of passage disturbance in this gastrointestinal tract segment [26, 79, 88]

(BRL – C, LE – 4).

Comments: The cause of problems with the passage of a food bolus, as well as inert FBs, is usually diseases leading to organic, and less commonly functional, obstruction of the gastrointestinal tract. These include tumors; cicatricial-inflammatory strictures, including in Crohn's disease; achalasia cardiae; eosinophilic esophagitis. To exclude or confirm the underlying disease, a thorough examination is indicated, and in some cases, a biopsy from the site of foreign body fixation [25].

Esophageal pathology is detected in more than 75% of patients presenting with food bolus impaction symptoms [22, 31, 37, 40, 38, 42, 52, 61, 73, 77, 81, 83, 89]. The most frequent pathologies are esophageal strictures (mostly peptic)—more than 50%—and eosinophilic esophagitis—about 40%. Less common causes of food bolus impaction include esophageal cancer or neuromuscular diseases with esophageal motility disorders, such as achalasia, diffuse esophageal spasm, and "nutcracker esophagus". Lack of proper monitoring and treatment of patients after the first impaction episode is a predictor of recurrent food impaction [77]. Therefore, diagnostic evaluation is recommended for all patients after foreign body removal to identify esophageal pathology [66, 89]. Typical endoscopic signs of eosinophilic esophagitis include longitudinal and vertical furrows, esophageal "trachealization", mucosal edema and friability ("crepe paper esophagus"). The presence of white exudates (eosinophilic abscesses) is an additional typical finding. Formed rings and strictures are complications of eosinophilic esophagitis and potentially lead to permanent esophageal narrowing. However, in approximately 10% of patients, manifestations of the pathology are either very subtle or the esophagus appears normal. Esophageal biopsy via endoscopy (upper, middle, and third thirds of the esophagus, as well as from areas where visible white exudates suggest eosinophil accumulation) should be performed during the initial intervention or upon repeat endoscopy to evaluate for eosinophilic esophagitis [41, 45, 56, 87].

Esophageal strictures or Schatzki rings can be safely and effectively dilated simultaneously with foreign body removal, provided there is no significant mucosal damage. However, mucosal abrasion or erythema is often observed as a result of prolonged food retention in the esophagus. In this case, the patient should be prescribed proton pump inhibitor therapy (Appendix A3, Table 9) with dilation performed 2–4 weeks later [42, 60, 77, 81, 83].

Management of patients after endoscopic foreign body removal

• Following endoscopic foreign body removal, in the presence of significant mucosal damage at its fixation site, as well as deep wounds of the esophageal wall by a sharp foreign body, it is recommended that patients undergo a water-soluble contrast X-ray examination (A06.16.001.002 Contrast esophagography) to rule out perforation [12, 59]

(Level of Evidence – C, Grade of Recommendation – 5).

Comments: It should be remembered that a long-standing foreign body in the esophagus can cause a pressure sore, which may lead to delayed esophageal perforation on days 2–5. In such cases, inpatient monitoring with fluoroscopic control using a water-soluble contrast agent (A06.16.001.002 Esophageal fluoroscopy with contrast) is required [12].

• In a patient who presents with esophageal wall injury and marked edema, but no FB detected, after anti-inflammatory and anti-edematous therapy, it is recommended to re-perform a thorough radiological (A06.16.001.002 Esophageal fluoroscopy with contrast) and endoscopic examination (A03.08.003 Esophagoscopy, A16.16.041.003 Endoscopic removal of foreign bodies from the esophagus) to re-search for and remove the FB, especially if there is a history of swallowed fish bone [12, 26]

(Level of Evidence – C, Grade of Recommendation – 5).

Comments: Treatment of patients with traumatic esophageal injuries depends on the severity of the damage and should be carried out in a hospital setting under dynamic radiological and endoscopic monitoring. Patients are discharged only after a follow-up radiological (A06.09.007.001 Targeted chest X-ray) and endoscopic examination (A03.08.003 Esophagoscopy).

Pharmacotherapy in patients with foreign bodies of the digestive tract (Appendix A3, Tab. 9)

• In case of pronounced edema of the esophageal mucosa and the esophagogastric junction in a patient with an undetected or endoscopically removed FB, a sparing diet is recommended for 3–4 days (predominantly liquid and cool food), along with anti-inflammatory drugs (M01AE propionic acid derivatives, N02BE anilides) to relieve inflammatory changes [12, 34, 59]

(Level of Evidence – C, Grade of Recommendation – 5).

Comments: Anti-inflammatory and analgesic medications may include non-steroidal anti-inflammatory and antirheumatic drugs (M01A) (Appendix A3, Tab. 9), as well as oral administration of oil solutions of beta-carotene or sea buckthorn oil [14], hyaluronic acid solution, and PPIs.

• If there are signs of rectal mucosa inflammation, ulcerations, or fissures in a patient with a removed FB, it is recommended to prescribe local treatment using suppositories containing non-steroidal anti-inflammatory and antirheumatic drugs (M01A) (Appendix A3, Tab. 9) [11, 78]

(Level of Evidence – C, Grade of Recommendation – 5).

• In case of significant mucosal damage after endoscopic removal of an esophageal foreign body and/or after endoscopic closure of a fresh esophageal perforation, it is recommended that patients receive a short course of antibacterial therapy to relieve inflammatory changes and prevent purulent-septic complications [12, 34, 59]

(Level of Evidence – C, Grade of Recommendation – 5).

Comments: Even in the absence of perforation, the patient remains under inpatient observation for 2–3 days and receives medical therapy including anti-inflammatory drugs (M01AE propionic acid derivatives, N02BE anilides) and systemic antibacterials to combat confirmed infection (Appendix A3, Tab. 9). Antibacterial therapy may involve antibacterial drugs from the group of other beta-lactam antibacterials (J01DB, J01DC, J01DD, J01DE, J01DH) or beta-lactam antibacterials: penicillins (J01CA, J01CF, J01CR). In severe cases, reserve antibacterial groups may be used [7, 9] (Appendix A3, Tab. 9). Empirical intravenous administration of broad-spectrum antibacterial drugs is recommended to be started as early as possible [63].

• Patients who underwent surgery for complications caused by a foreign body in the form of organ perforation, phlegmon, mediastinitis, or peritonitis are mandatorily recommended to receive a course of broad-spectrum antibacterial therapy to relieve inflammatory and purulent-septic complications [12, 34, 59]

(Level of Evidence – C, Grade of Recommendation – 5).

Comments: It is recommended to start intravenous administration of broad-spectrum antibacterial drugs as early as possible [61]. Antibacterial therapy may involve drugs from the group of other beta-lactam antibacterials (J01DB, J01DC, J01DD, J01DE, J01DH) or beta-lactam antibacterials: penicillins (J01CA, J01CF, J01CR), but considering the severity of the patients' condition, preference should be given to reserve groups, such as carbapenems (J01DH) [30] (Appendix A3, Tab. 9).

Surgical treatment

• Surgical intervention is recommended for patients in whom the FB cannot be extracted endoscopically; patients with a long-standing FB in the lumen of the small intestine without signs of progression that cannot be retrieved using overtube- (balloon-) assisted enteroscopy; patients with organ perforation complicated by severe purulent-septic conditions – phlegmon, mediastinitis, peritonitis; patients in whom the FB caused small bowel obstruction; patients with massive FB-associated bleeding that cannot be stopped endoscopically [7, 9, 11, 34, 78, 98-100]

(BRL – C, LE – 4).

Comments: Indications for surgical treatment of an esophageal foreign body include: a long-standing esophageal foreign body with marked surrounding inflammation and embedding into the organ wall; failed attempts at endoscopic FB removal; as well as esophageal perforation by the foreign body.

Long objects stuck in the duodenum require surgical treatment when endoscopic attempts at removal fail [22, 27, 42, 52, 77, 81, 83]. Indications for laparoscopy or laparotomy are a long-standing foreign body in the intestine that cannot be retrieved using overtube- (balloon-) assisted enteroscopy, the development of intestinal obstruction, or the presence of peritonitis.

Surgical intervention should be considered for the removal of dangerous FBs that have passed beyond the Treitz ligament, show no progression within 3 days after ingestion, and cannot be extracted endoscopically. True capsule retention in the small intestine is defined as its presence in the intestinal lumen for more than 2 weeks. It is precisely after this period (in the absence of clinical symptoms) that the question of the necessity and feasibility of video capsule removal using overtube-assisted enteroscopy or surgical intervention is discussed.

• Radical surgical intervention (A16.16.010 Gastrotomy, A16.30.025.002 Removal of foreign bodies in the abdominal cavity) is recommended for patients with narcotic drug container(s) in the GI lumen when packaging integrity is suspected to be compromised; if the container fails to progress through the GI tract; or in the event of intestinal obstruction [26]

(Level of Evidence – C, Grade of Recommendation – 5).

Comments: Symptoms of packaging damage and release of the narcotic substance into the GI lumen usually manifest as signs of intoxication. In case of container impaction and GI lumen obstruction, the clinical picture of intestinal obstruction develops [22, 42, 52, 81, 83].

• In patients with GI FBs who have indications for surgical treatment, it is recommended to determine the scope and method of surgical intervention depending on the localization of the foreign body and the complications it caused [7, 9, 12]

(Level of Evidence – C, Grade of Recommendation – 5).

Comments: Esophageal perforation by a foreign body may occur during the removal of an FB with sharp edges (fresh perforation). In this case, the esophagus may be closed with endoscopic clips, provided mediastinitis has not yet developed. Endoscopic closure of the esophageal defect is possible within the first 6 hours from the moment of perforation; after that, it is advisable to place a gastric tube for patient enteral nutrition.

If the perforation occurred more than 6 hours ago, mediastinitis is highly likely already present. In such cases, thoracotomy (right- or left-sided depending on perforation localization), mediastinotomy, esophagotomy, FB removal (A16.16.002 Removal of foreign body of esophagus using incision), and esophageal repair (A16.16.055 Suturing of esophageal rupture) are indicated. In some cases, when the FB is fixed in the esophagus, it may be possible during thoracotomy to manually release the fixation and extract the FB endoscopically. This maneuver avoids a wide esophagotomy for FB extraction. Thoracotomy for esophageal perforation should always conclude with drainage of the mediastinum and pleural cavity. Gastrostomy creation (A16.16.034.001 Gastrostomy using video-endoscopic technologies) is indicated when there are technical difficulties in closing the esophageal perforation site and when the patient has already developed purulent-septic complications, particularly purulent mediastinitis, as a result of the perforation.

The scope of surgical intervention in the event of intestinal obstruction or peritonitis is determined in accordance with the clinical guidelines of the Russian Society of Surgeons "Acute Non-Tumor Intestinal Obstruction" and "Acute Peritonitis".

• In the presence of signs of rectal perforation by a foreign body with full-thickness wall damage, it is recommended to perform a protective colostomy (A16.18.007 Colostomy) [11, 19, 78]

(RRR – B, LOR – 3).

4. Medical Rehabilitation and Sanatorium-Resort Treatment

• Patients in whom a foreign body has led to complications, as well as patients who underwent surgery for a foreign body, are recommended to undergo rehabilitation measures, which depend on the complication the patient experienced; the type of surgical treatment; and the nature and severity of the postoperative course [7, 12]

(LoE – C, GoR – 5).

Comments. Detailed recommendations on medical rehabilitation for patients with peritonitis and following abdominal and thoracic surgery are outlined in the relevant clinical guidelines of the Russian Society of Surgeons.

Patients in whom a foreign body passed spontaneously without causing complications, or in whom it was effectively and safely removed endoscopically, generally do not require special rehabilitation.

5. Prevention and Dispensary Observation

(Level of Evidence – C, Grade of Recommendation – 5).

Comments. In most cases of children swallowing foreign bodies, parents, for one reason or another, failed to supervise them. Sometimes purchasing toys that were inappropriate for the children's age group or did not meet safety certificates also leads to an increased number of foreign body cases in children [15, 85].

• All patients with trichobezoars are strongly recommended to be registered and placed under dispensary observation by a psychiatrist and/or neurologist for the treatment of neuroses [12]

(Level of Evidence – C, Grade of Recommendation – 5).

Comments. The treatment of neuroses causing the formation of trichobezoars must involve psychologists and mandatory discussions with the parents of children presenting with such disorders [15].

• All patients with trichobezoars, following the removal of the foreign body, are recommended to undergo routine diagnostic EGDS every 6–12 months for 2–3 years to prevent re-formation of the bezoar [12]

(Level of Evidence – C, Grade of Recommendation – 5).

(Level of Evidence – C, Grade of Recommendation – 5).

Comments. After verifying the disease that caused the fixation of the food bolus in the esophageal lumen, treatment should be initiated immediately to prevent re-ingestion of a foreign body [25].

6. Organization of Medical Care

Uncomplicated gastrointestinal foreign bodies do not require treatment at the pre-hospital emergency care stage [9]. When a patient presents with suspected esophageal foreign body to an outpatient clinic, a plain radiograph of the cervical esophagus should be performed, and the patient should be referred to a hospital with otolaryngology and endoscopic services. The patient should not be advised to induce vomiting or attempt to push the foreign body down using solid food.

For emergency physicians: when responding to a call for a patient with an esophageal or gastric foreign body, do not attempt gastric or esophageal lavage. If there are complaints of pain upon swallowing, a foreign body sensation, etc., the patient must be transported to a multidisciplinary hospital for examination and diagnosis. If the patient refuses medical evacuation to the hospital, a follow-up alert ("aktiv") must be sent to the polyclinic [9].

All patients with suspected gastrointestinal foreign bodies must be transported to a multidisciplinary hospital with a 24/7 endoscopic service. In the presence of aspiration syndrome, signs of peritonitis, or decompensated acute intestinal obstruction, patients are hospitalized in the ICU for further evaluation and subsequent specialized treatment.

The endoscopist providing care to patients with foreign bodies must possess adequate qualifications.

The endoscopic room or operating theater must be equipped with the necessary equipment and instruments in accordance with the list below. For the examination and treatment of children, it is important to select an endoscope according to the anatomical and physiological developmental features of the child (Tables 4–6) and accessories according to the working channel size (Table 8).

Equipment of the endoscopic room required to provide care for patients with gastrointestinal foreign bodies:

1. Video endoscopic system

2. Video endoscopes (gastroscopes and colonoscopes), preferably with a large instrument channel and an auxiliary water jet channel

3. Water irrigation pump

4. Suction pump

5. Carbon dioxide insufflator

6. Electrosurgical unit with argon plasma coagulation capabilities

7. Grasping forceps ("crocodile" type, "rat tooth" type)

8. Polypectomy snares

9. Net-type retrieval baskets; retrieval baskets with solid or perforated film

10. Biopsy forceps

11. Dormia baskets

12. Soft distal caps

13. Soft "cone" fitted to the distal end of the endoscope

14. Overtube for endoscopes

15. Clipping device

16. Clips

17. Injector

18. Coagulation forceps

Conservative management of patients (dynamic observation of a blunt, inert, and small [up to 2–2.5 cm] gastrointestinal foreign body without clinical manifestations) may be performed on an outpatient basis.

A patient may be discharged from the hospital immediately after the successful and safe removal of the foreign body if there are no clinical manifestations of foreign body-associated complications, and examination of the site of foreign body location/fixation reveals no serious damage to the wall of the esophagus, stomach, or duodenum.

Hospitalization for observation should be considered following technically difficult extraction, when multiple items or foreign bodies with a high risk of complications have been ingested (e.g., sharp objects, batteries, magnets, items larger than 5–6 cm), and when there is extensive mucosal damage caused by the foreign body itself or resulting from endoscopic removal.

If a foreign body cannot be removed endoscopically, inpatient treatment and careful clinical observation are required in cases of ingestion of sharp objects and batteries. Radiographic examination should be performed to assess the passage of the item through the gastrointestinal tract. Daily radiographs are recommended for sharp foreign bodies. For batteries located beyond the duodenum, plain radiography every 3–4 days is sufficient.

Patients with 3rd–5th degree esophageal injuries (Appendix G1) must receive treatment in an inpatient setting. Also subject to admission to a surgical hospital are patients with an unconfirmed foreign body but identified esophageal wall trauma; patients with identified esophageal pathology mimicking a foreign body (candidal esophagitis, reflux esophagitis, eosinophilic esophagitis, following acute cerebrovascular accidents, debut of various systemic diseases [multiple sclerosis, ALS, myasthenia gravis], esophageal tumors), as well as those with various nervous system disorders (hysteria, neuroses, etc.).

7. Additional Information

The condition of the esophagus is of substantial importance in the presence of esophageal foreign bodies. If the esophagus is unchanged and the cause of foreign body fixation is the foreign body itself (size, sharp edges, hooks, etc.), one must act in accordance with these guidelines. Frequently, the cause of foreign body fixation in the esophagus is underlying esophageal disease: tumors of the esophagus (both malignant and benign), achalasia cardia, esophageal diverticula, corrosive strictures, esophagitis, congenital esophageal pathology. In each specific case, the problem of foreign body removal and treatment of the disease must be addressed individually, depending on the condition of the patient, the esophagus, and the nature of the esophageal foreign body

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

Head of the Working Group: Professor Mikhail Pavlovich Korolev

1. Maria Vladimirovna Antipova – Cand. of Med. Sci., Associate Professor at the Department of General Surgery with a Course of Endoscopy and Patient Care, Saint Petersburg State Pediatric Medical Academy (SPS PMA), City Mariinsky Hospital, Saint Petersburg.

2. Evgeny Aleksandrovich Drobyazgin – Doctor of Medical Sciences, Associate Professor, Professor at the Department of Hospital and Pediatric Surgery, Novosibirsk State Medical University; thoracic surgeon, endoscopist, Head of the Endoscopy Department, State Novosibirsk Regional Clinical Hospital.

3. Aleksandr Anatolyevich Zakharenko – Doctor of Medical Sciences, Professor, Deputy Chief Medical Officer for Oncology, Head of the Oncosurgery Department at the Research Institute of Surgery and Emergency Medicine, Professor at the Department of Oncology, Pavlov First Saint Petersburg State Medical University.

4. Mikhail Pavlovich Korolev – Doctor of Medical Sciences, Professor, Head of the Department of General Surgery with a Course of Endoscopy, Saint Petersburg State Pediatric Medical University, Chairman of the RENDO Endoscopic Society Association.

5. Anastasia Sergeevna Koshurnikova – Cand. of Med. Sci., Head of the Endoscopy Department, City Clinical Hospital named after Z.A. Bashlyayeva of the Moscow Healthcare Department.

6. Aleksey Vladimirovich Meshkov – Assistant at the Department of Pediatric Surgery, Traumatology and Orthopedics, Far Eastern State Medical University. Head of the Endoscopy Department, Children's Regional Clinical Hospital, Khabarovsk.

7. Andrey Igorevich Mikhin – Endoscopist, City Clinical Hospital No. 1 named after N.I. Pirogov, staff member of the Department of Faculty Surgery No. 1, Pirogov Russian National Research Medical University.

8. Victoria Nikolaevna Panfilova – Doctor of Medical Sciences, Associate Professor at the Department of Pediatrics, Institute of Postgraduate Education, Voyno-Yasenetsky Krasnoyarsk State Medical University of the Russian Ministry of Health, pediatrician, gastroenterologist.

9. Aleksey Gennadievich Pinigin – Cand. of Med. Sci., Head of the Department of Pediatric Surgery, Traumatology and Orthopedics, Far Eastern State Medical University.

10. Aleksandr Yuryevich Razumovsky – Doctor of Medical Sciences, Professor, Corresponding Member of the RAS. Head of the Department of Pediatric Surgery, Pirogov Russian National Research Medical University; President of the Russian Association of Pediatric Surgeons, Chief Pediatric Surgeon of the Moscow Healthcare Department, Honored Doctor of Russia.

11. Valentin Evgenyevich Sinitsyn – Doctor of Medical Sciences, Professor. Head of the Department of Radiation Diagnostics and Therapy, Faculty of Fundamental Medicine, Lomonosov Moscow State University. Head of the Department of Radiation Diagnostics, Medical Research and Educational Center, Lomonosov Moscow State University. President of the Russian Society of Roentgenologists and Radiologists (RSRR)

12. Evgeny D. Fedorov – MD, PhD, Professor, Chief Research Fellow, Department of Hospital Surgery No. 2 with the Research Laboratory of Surgical Gastroenterology and Endoscopy, Institute of Surgery, Pirogov Russian National Research Medical University (RNRMU) at City Clinical Hospital No. 31 named after Academician G.M. Savelieva of the Moscow Healthcare Department; Chairman of the RENDO Endoscopic Society Association.

13. Anastasia Yu. Kharitonova – PhD, Head of the Endoscopy Department, Research Institute of Emergency Pediatric Surgery and Traumatology of the Moscow Healthcare Department

14. Andrey A. Shavrov – MD, PhD, Chief Research Fellow, Department of Polytrauma, Endoscopist at the Endoscopy Department, Research Institute of Emergency Pediatric Surgery and Traumatology of the Moscow Healthcare Department; Professor, Department of Gastroenterology, Faculty of Additional Professional Education, Institute of Continuing Medical Education and Professional Development, Pirogov Russian National Research Medical University (RNRMU) of the Russian Ministry of Health.

15. Anton A. Shavrov – PhD, Head of the Endoscopy Department, Sechenov Center for Mother and Child, I.M. Sechenov First Moscow State Medical University (Sechenov University) of the Russian Ministry of Health; Assistant Professor, L.P. Alexandrov Department of Pediatric Surgery and Urology-Andrology, Sechenov First Moscow State Medical University (Sechenov University) of the Russian Ministry of Health.

16. Petr L. Shcherbakov – MD, PhD, Professor, Endoscopist, Gastroenterologist, Professor at the Department of Gastroenterology, Moscow Regional Research Clinical Institute (MONIKI) named after M.F. Vladimirsky, MEDSI Clinical and Diagnostic Center at Krasnaya Presnya.

17. Alexander A. Shchegolev – MD, PhD, Professor, Head of the Department of Hospital Surgery, Pediatric Faculty, Pirogov Russian National Research Medical University (RNRMU) of the Russian Ministry of Health, Head of the Surgical Clinic at City Clinical Hospital named after F.I. Inozemtsev, Honored Doctor of the Russian Federation, Moscow

Conflict of interest: none declared by any members of the working group.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Anesthesiologists.

2. Gastroenterologists.

3. Surgeons.

4. Endoscopists.

Methods used for evidence collection/selection: electronic database searches; analysis of current scientific developments regarding epithelial neoplasms of the colon in Russia and abroad; generalization of practical experience from Russian and foreign specialists.

1. Scale for evaluating levels of evidentiary validity (LEV) for diagnostic methods (diagnostic interventions)

2. Levels of Evidence (LoE) rating scale for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

3. Scale for evaluating levels of recommendation certainty (LRC) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitation interventions)

Methods used for formulating recommendations – expert consensus.

Economic analysis

Cost analysis was not performed, and pharmacoeconomic publications were not analyzed.

Method of recommendation validation:

• External expert review.

• Internal expert review.

Description of the recommendation validation method:

The preliminary version of these clinical guidelines was reviewed by independent experts who were asked to comment primarily on how accessible the interpretation of the evidence underlying the recommendations is for understanding.

Comments were received from primary care endoscopists regarding the clarity of the presentation of the recommendations and their importance as a working tool in daily practice.

The comments received from experts were carefully systematized and discussed by the chairman and members of the working group. Each item was discussed, and the resulting changes made to the recommendations were recorded. If no changes were made, the reasons for refusing to make changes were recorded.

Consultations and peer review: the draft recommendations were also reviewed by independent experts who were asked to comment primarily on the clarity and accuracy of the interpretation of the evidence base underlying the recommendations.

For final editing and quality control, the clinical guidelines were re-analyzed by the working group members, who concluded that all comments and feedback from the experts had been taken into account, and the risk of bias in the development of the guidelines was minimized.

Updates to clinical guidelines: updates are performed at least once every three years, taking into account new information regarding the diagnosis and treatment of digestive tract foreign bodies. The decision to update is made by the Russian Ministry of Health based on proposals submitted by professional medical non-profit organizations. The formulated proposals must take into account the results of a comprehensive assessment of medicinal products and medical devices, as well as the results of clinical approbation.

When selecting publications as potential sources of evidence, the methodology used in each study is examined to ensure its reliability. The result of this examination affects the level of evidence assigned to the publication, which in turn affects the strength of the recommendations derived from it.

Appendix A3. Reference Materials

Related Documents

Order of the Ministry of Health of the Russian Federation No. 922n dated November 15, 2012, "On Approval of the Procedure for Providing Medical Care to the Adult Population in the Profile 'Surgery'"

Order of the Russian Ministry of Health No. 974 dated December 6, 2017, "On Approval of the Rules for Performing Endoscopic Examinations"

Table No. 3. Recommended timing for endoscopic intervention for upper GI foreign bodies: emergency – preferably within 2 hours, but no later than 6 hours; urgent – within 24 hours; delayed – within 72 hours from admission [25].

Table No. 4. Esophageal diameter in children and adults under normal physiological conditions.

Table No. 5. Selection of equipment for upper GI endoscopic examinations in children.

Table No. 6. Selection of equipment for lower GI endoscopic examinations in children.

*Colonoscopy in children aged 0–2 years is recommended to be performed using ultrathin or standard gastroscopes, since there are no colonoscopes with a diameter of less than 9.8 mm, and the length of the intestine at birth is about 60 cm

Table No. 7. Endoscopic instruments recommended for foreign body removal in adults [25]

Table No. 8. Instruments compatible with a 2 mm working channel of pediatric endoscopes

Table No. 9. List of medicinal products included in the VLED list used as analgesics and anti-inflammatory agents and for antibacterial prophylaxis and/or therapy in the pre- and postoperative period.

Appendix B. Physician Action Algorithms

Fig. 1. Management and diagnostic algorithm upon hospital admission of a patient with suspected ingested foreign body in the digestive tract

(1) B01.046.001 Initial appointment (examination, consultation) of an otolaryngologist-audiologist;

(2) B01.057.001 Initial appointment (examination, consultation) of a surgeon; B01.010.001 Initial appointment (examination, consultation) of a pediatric surgeon;

(3) A06.01.003 X-ray of the soft tissues of the neck in two projections; A06.09.007.001 Targeted chest X-ray; A06.09.001 Fluoroscopy of the lungs;

(4) A.06.08.001.001 Contrast X-ray of the pharynx; A.006.16.001.002 Contrast fluoroscopy of the esophagus; A06.09.005 Computed tomography of the chest cavity; A06.30.005 Computed tomography of the abdominal cavity;

(5) A.03.16.001 Esophagogastroduodenoscopy; A.16.16.041.003 Endoscopic removal of foreign bodies of the esophagus; A16.16.048 Endoscopic removal of foreign bodies from the stomach; A.16.17.023 Endoscopic removal of foreign bodies from the small intestine; A16.17.010 Surgical removal of a foreign body of the small intestine; A16.19.018 Removal of a foreign body of the rectum without incision; A16.18.011 Surgical removal of a foreign body of the large intestine.

Fig. 2. Algorithm of actions in case of foreign body ingestion in children.

Fig. 3. Management and diagnostic algorithm for inert foreign bodies of the gastrointestinal tract

Fig. 4. Management and diagnostic algorithm for chemically active foreign bodies of the gastrointestinal tract.

Fig. 5. Management and diagnostic algorithm for mechanically active foreign bodies of the gastrointestinal tract.

Fig. 6. Management and diagnostic algorithm for foreign bodies of the gastrointestinal tract with combined effects.

Appendix C. Patient Information

Ingestion of a foreign body is a life-threatening and health-threatening condition requiring emergency medical care in a multidisciplinary hospital setting. When a foreign body is ingested, independent attempts to remove it using fingers or various objects not intended for this purpose should not be undertaken. Do not attempt to push a foreign body fixed in the esophagus by eating dry bread or other types of solid and hard food. In case of foreign body ingestion or esophageal obstruction by a food bolus, medical assistance should be sought immediately.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. Classification of ESOPHAGEAL injuries (MODIFIED classification of Bassett H., 1980) [12].

Grade 1 – mucosal edema and hyperemia, abundant mucus (catarrhal esophagitis);

Grade 2 – single scratches on the apices of the mucous membrane (damage only to the superficial layers of the mucous membrane);

Grade 3 – significant edema and hyperemia of the mucosa, with discrete small hemorrhages into the submucosal layer and scanty bleeding from mucosal wounds (damage to the full thickness of the mucous membrane);

Grade 4 – mucous membrane destroyed over a significant distance with large submucosal hematomas and small defects, fibrinous deposits in some areas, bleeding easily at the slightest touch of the endoscope (damage to the mucosal and submucosal layers);

Grade 5 – deep blind wounds involving the full thickness of the mucosa and extending to the submucosal layers, extensive mucosal detachment (1–2 cm), deep and extensive submucosal hemorrhages, pressure sore (damage to the internal muscular layer).

Grade 6 – perforation, deep non-penetrating wound with profuse bleeding.