May 22, 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 takes it course.
Some adults who show up to the emergency department after swallowing a razor blade, a battery, magnet, or multiple objects do it for "secondary gain." They want to get medical attention, an overnight stay in the hospital or other perceived benefits, experts say.
Some become "frequent flyers" – returning again and again to the same hospital after swallowing something potentially harmful. This group can include prisoners and people with psychiatric issues.
Other adults swallow things by accident, such as those with diminished mental capacity, intoxicated people, and older people with dentures who don’t realize there is a chicken or fish bone in their food until 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 the hospital overnight or send them home with a list of symptoms that mean they should come right back?
Two new studies lean toward conservative management, or letting nature take its course, in most cases.
Length Is Key
A team of University of Southern California researchers found removal didn’t depend on how “high risk” an object was – like 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 medical records for 302 cases. Fistulas are narrow channels formed between organs or an organ and the skin that can cause leaking, infections, and other problems.
Only length made a difference. If an adult swallowed an object longer than 6 cm (about 2.5 inches), it was best to remove it. Otherwise, it didn’t matter in most cases if they took it out or waited for the body to move it along.
“We work at USC, which is a big safety net hospital for all of Los Angeles County, and we happen to see this a lot,” said Shea Gallagher, MD, a general surgery resident at Keck Medicine at USC.
“We basically treat the full spectrum of the patient population that does this,” he said earlier this month at Digestive Disease Week (DDW) 2023 in Chicago, an international meeting for health care providers who treat GI disorders.
They studied people who swallowed foreign objects from 2015 to 2021. The median age was 29, 83% were men, and patients were admitted to the hospital about three times each.
Among the 302 cases, 67% of the objects swallowed were sharp or pointed, 38% were dull, 8% were magnetic, and 5% were corrosive, like batteries. Almost 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 remainder had conservative management.
Twelve of the patients had surgery. In 10 cases, the objects cut something internally and in two cases, an object got stuck. The 12 surgery patients had objects that were longer, about 4.5 inches compared to just over 1 inch in people who didn’t have surgery.
“The take-home message is that conservative management is probably OK in most cases,” Gallagher said.
Removing "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 lead study investigator George Tambakis, MBBS. He works at a hospital with a prison ward attached. Traditionally, the prisoners get admitted to the hospital, undergo X-rays, observation, endoscopy, or surgery and get a lot of medical attention. He and his colleagues are looking to change that.
“We prefer a conservative approach with a focus on changing behaviors,” said Tambakis, a gastroenterologist at St. Vincent’s Hospital in Melbourne.
Educating people and sending them home for nature to take its course -- without a hospital stay or a slew of procedures – can remove a lot of their "secondary gain," he said.
The general approach is to retrieve objects if they cause a perforation or get stuck in the esophagus. Otherwise, people are treated as outpatients.
It 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 frequently.
In the retrospective study – which looks at past behavior -- researchers looked through medical records at the 157 times when people swallowed a foreign object. The median age was 30, half were men, and about two-thirds were prisoners. More than 4 in 5 had a mental health history.
Batteries were swallowed in 23% of cases, alleged drug-containing balloons in 17%, and razor blades in 16%. Only a small percentage, 4%, swallowed magnets. About 40% of cases were "miscellaneous" objects. In one case, he said, a patient had to have surgery to remove about 500 swallowed coins.
Just more than half, 55%, of patients were treated conservatively. Higher-risk cases were about as likely to be managed conservatively or with endoscopy. Similar to the USC study, no perforations or bowel obstructions were reported.
Asked for his suggestions for other doctors, Tambakis recommends taking the objects out using endoscopy “when it’s the patient’s first or second time, and if it’s high risk – a long object or batteries or magnets. But what we’re moving toward is for [conservative management for] people who present for the fifth, sixth, or sixtieth time.”
“That's an important study because we actually do see these in a clinical setting not infrequently,” 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 on managing these patients stem in part from expert opinion. For example, the American Society for Gastrointestinal Endoscopy (ASGE) Management of Ingested Foreign Bodies and Food Impactions guidelines are based on both studies and expert consensus.
“Hopefully over time studies like this can help address some of these questions,” Chan said. He agreed it takes a lot of health care resources to scope and retrieve objects every time someone comes 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 little bit hard to draw conclusions because these patients probably come in with different objects that they ingested.”
Regarding the USC study, “I think it’s an important study too,” Chan said.
“We know that length is a risk factor from the ASGE guidelines,” he said.
“This study is interesting because they're looking at it from a surgical perspective, like who actually got surgery -- which is probably the most important outcome.” Only 12 patients out of 302 went to surgery, however, so size was a limitation of this study too, Chan said.
He said the two studies are trying to answer similar questions. “Both have limitations that limit drawing strong conclusions from them. But I think they're intriguing and hopefully will lead to more and bigger studies to really address these questions.”