May 17, 2023 – Two new studies suggest that even when a person swallows something as potentially harmful as a razor blade or a magnet, a doctor’s best course of action may be to let nature take its course .
Some adults who present to the emergency room after swallowing a razor blade, battery, magnet, or more objects do so for “secondary gain.” They want medical attention, an overnight stay or other perceived benefits, experts say.
Some become “frequent travelers” – returning to the same hospital again and again after swallowing something potentially harmful. This group may include prisoners and people with psychiatric problems.
Other adults swallow things by accident, such as those with impaired mental capacity, people who are inebriated, and elderly people with dentures who don’t realize there’s a chicken or fish bone there. in their food before it’s too late.
In either case, doctors usually order an X-ray, figure out what they’re dealing with, and then decide: stick a tube down the patient’s throat with a device to retrieve the objects, or leave them there and “let nature take its course.” “. “? Admit the person to hospital overnight or send them home with a list of symptoms that mean they should return immediately?
Two new studies lean towards conservative management, or letting nature take its course, in most cases.
Length is key
A team of researchers from the University of Southern California found that removal did not depend on how “high risk” an object was, such as a battery that could leak acid or a sharp razor blade.
It also didn’t matter how many objects someone swallowed at once. There were no internal cuts, bowel obstructions or fistulas when they reviewed the medical records of 302 cases. Fistulas are narrow channels formed between organs or an organ and the skin that can cause leaks, infections, and other problems.
Only the length made the difference. If an adult swallowed an object larger than 6 cm (about 2.5 inches), it was best to remove it. Otherwise, it didn’t matter in most cases whether they took it out or waited for the body to move it.
“We work at USC, which is a big safety net hospital for all of Los Angeles County, and we see that often,” said Shea Gallagher, MD, general surgery resident at Keck Medicine at USC. .
“We’re basically treating the full spectrum of the patient population who do this,” he said earlier this month at Digestive Disease Week (DDW) 2023 in Chicago, an international meeting for healthcare providers. healthcare that treat gastrointestinal disorders.
They studied people who swallowed foreign objects from 2015 to 2021. The median age was 29, 83% were male, and patients were admitted to hospital about three times each.
Of the 302 cases, 67% of the objects swallowed were sharp or pointed, 38% were dull, 8% were magnetic, and 5% were corrosive, such as batteries. Nearly 1 in 5 patients, 18%, swallowed multiple objects.
In 40% of cases, doctors used endoscopy to go down the throat and remove the objects. The rest had conservative management.
Twelve of the patients were operated on. In 10 cases the objects cut something inside and in two cases an object got stuck. The 12 operated patients had longer objects, around 4.5 inches compared to just over 1 inch in the non-operated people.
“The take-home message is that conservative management is probably correct in most cases,” Gallagher said.
Removed “secondary gain”
In another study presented at the conference, Australian researchers reported 157 cases of swallowed objects involving 62 patients.
“Our prisoners like to swallow things,” said study lead researcher George Tambakis, MBBS. He works in a hospital with an adjoining prison ward. Traditionally, prisoners are admitted to the hospital, undergo X-rays, observation, endoscopy or surgery and receive a lot of medical attention. He and his colleagues seek to change that.
“We prefer a conservative approach that focuses on behavior change,” said Tambakis, a gastroenterologist at St. Vincent’s Hospital in Melbourne.
Educating people and sending them home to let nature take its course — without hospital stays or a slew of procedures — can remove much of their “secondary gain,” he said.
The general approach is to recover objects if they cause a perforation or get stuck in the esophagus. Otherwise, people are treated on an outpatient basis.
This can act as a deterrent, Tambakis said. When doctors sent seven patients home without further work, for example, five of them never returned. The other two came back but less often.
In the retrospective study – which examines past behavior – researchers reviewed medical records of 157 times people swallowed a foreign object. The median age was 30, half were male, and about two-thirds were prisoners. More than 4 in 5 had a history of mental health.
Batteries were swallowed in 23% of cases, balloons suspected of containing drugs in 17% and razor blades in 16%. Only a small percentage, 4%, have swallowed magnets. About 40% of cases were “miscellaneous” objects. In one case, he said, a patient required surgery to remove about 500 swallowed coins.
Just over half, 55%, of the patients were treated conservatively. High-risk cases were about as likely to be managed conservatively or endoscopically. Similar to the USC study, no intestinal perforation or obstruction was reported.
Asked about his suggestions for other doctors, Tambakis recommends removing objects endoscopically “when it’s the patient’s first or second time, and if there’s a high risk — a long object or batteries or batteries.” magnets. But what we’re headed for is [conservative management for] people who are coming for the fifth, sixth or sixtieth time.
“This is an important study because we often see them in a clinical setting,” said Walter W. Chan, MD, MPH, director of the Center for Gastrointestinal Motility at Brigham and Women’s Hospital in Boston.
He said research like this is helpful because guidelines for the management of these patients derive in part from expert opinion. For example, the American Society for Gastrointestinal Endoscopy (ASGE) Management of Guidelines on ingested foreign bodies and dietary impacts are based on both studies and expert consensus.
“Hopefully over time, studies like this can help answer some of these questions,” Chan said. He agreed that it takes a lot of healthcare resources to measure and retrieve items every time someone walks in after swallowing a foreign object.
Chan said limitations of the Australian study include its retrospective design and relatively small population size. “So it’s a bit difficult to draw conclusions because these patients probably arrive with different objects that they ingested.”
As for the USC study, “I think it’s also an important study,” Chan said.
“We know that length is a risk factor according to ASGE guidelines,” he said.
“This study is interesting because they’re looking at it from a surgical perspective, like who actually had surgery – which is probably the most important outcome.” However, only 12 out of 302 patients had surgery, so size was also a limitation of this study, Chan said.
He said both studies attempt to answer similar questions. “Both have limitations that limit the possibility of drawing strong conclusions from them. But I think they are intriguing and hopefully will lead to more and larger studies to really answer these questions.