Glass Half Empty or Half Full: Single-Session Endoscopic Removal of Multiple Glass Vials in the Upper Gastrointestinal Tract Using a Novel Approach

Abstract

Foreign body ingestion is a commonly encountered problem clinically with management targeted at early radiological imaging to identify high-risk features that can increase the risk of perforation. We present a 23-year-old patient with no known medical or psychiatric history who presented with epigastric tenderness after ingesting multiple glass vials. The initial workup consisted of a thorough physical examination and an abdominal X-ray which revealed multiple radiopaque densities in the stomach, with some extending to the duodenum and distal colon. She underwent an emergent upper endoscopy to retrieve those glass vials given the high risk of perforation and obstruction. During the procedure, various endoscopic retrieval devices were used, however, they were unsuccessful. A novel approach was then utilized by dilating a 15-mm extraction balloon inside the lumen of the glass vials and using a snare to pull the vials out individually. Twenty-seven 6 cm × 1 cm glass vials were safely removed in a single session. The patient tolerated the procedure well and reported a complete resolution of her symptoms the next day. This case highlights the importance of obtaining prompt imaging when managing foreign body ingestion and highlights a novel endoscopic approach in safely extracting multiple glass vials that were refractory to conventional endoscopic techniques.

Keywords

endoscopic foreign body removal - glass vials - extraction balloon - snare - ingestion of multiple foreign bodies

Introduction

Foreign body ingestion is a relatively common clinical problem that comprises 80% of pediatric gastroenterology (gastrointestinal [GI]) emergencies with coins, toys, and magnets being the most commonly ingested objects.[1] In adults, foreign body impaction is frequently seen in the setting of bone or meat bolus impaction from underlying structural pathologies.[1] [2] Note that 80 to 90% of ingested foreign bodies will pass spontaneously, with only 10 to 20% necessitating endoscopic removal and less than 1% needing surgical intervention.[1] [2] [3] Impaction, perforation, or obstruction are feared complications and typically occur in areas of anatomical narrowing or acute angles.[1] [2] Long slender objects more than 5 cm long, have a difficult time traversing through the GI tract and have a higher tendency to get lodged in the duodenal sweep further increasing the perforation rate.[4] Here, we present an interesting case of a patient who intentionally ingested multiple 6-cm glass vials which were removed endoscopically in a single session using a novel approach.

Case Report

A 23-year-old transgender female presented to the emergency department with a chief complaint of epigastric tenderness and nonbloody but bilious emesis that started 1 day before admission. She reported ingesting approximately 20 glass vials before the onset of her symptoms. A general examination was largely unremarkable with mild tenderness to deep palpation in the epigastric region with no evidence of rebound tenderness or guarding. An urgent abdominal X-ray (kidney, ureter, and bladder [KUB]) revealed close to 30 radiopaque densities in the stomach, with some extending to the duodenum and distal colon ([Fig. 1A]).

Fig. 1 (A) Abdominal kidney, ureter, and bladder (KUB) on presentation revealing multiple glass vials in the stomach with extension to the duodenum and one vial in the distal colon. (B) Postprocedure KUB with migration of three glass vials to the ascending colon.

An emergent esophagogastroduodenoscopy (EGD) was planned for the endoscopic removal of these objects. During the procedure, a Maloney dilator was utilized and dilated to 60 Fr to allow for easier removal of these multiple glass vials. An overtube was then placed to help facilitate the removal of the objects, however, the inner diameter was too small to accommodate the transoral removal of the vials. Multiple retrieval tools were utilized including a polypectomy snare, retrieval basket, and alligator forceps, however, given their smooth round edges, the vials were not able to transverse through the upper esophageal sphincter (UES). A novel approach was utilized through a combination of both a snare and a 15-mm extraction balloon. The 15-mm extraction balloon was inflated inside the lumen of the glass vials to increase the intraluminal pressure and allow for the safe removal of these vials individually ([Fig. 2A]).

Fig. 2 (A) Endoscopic retrieval of the glass vials using a combination of both a snare and a 15-mm extraction balloon. (B) Twenty-seven 6 cm × 1 cm glass vials successfully removed endoscopically from the stomach and proximal duodenum.

Twenty-seven 6 cm × 1 cm glass vials were successfully and safely removed from the stomach and proximal duodenum ([Fig. 2B]). A repeat KUB postprocedure revealed three glass vials that migrated to the ascending colon with plans for a colonoscopy the next day if the vials failed to pass spontaneously ([Fig. 1B]). The patient felt much better with a complete resolution of her symptoms and decided to leave against medical advice.

Discussion

Ingested foreign bodies are typically classified by the presence of high-risk features which increase the risk of perforation, obstruction, and bleeding.[2] [3] [4] Indications for emergent endoscopic removal include sharp-pointed edges, objects causing esophageal obstruction, objects containing poison like a button battery, and long foreign bodies ≥ 6 cm.[2] Once the object passes the ileocecal valve, the foreign body is usually excreted through without any complications.[5]

Long slender objects more than 5 cm long, have a difficult time traversing through the GI tract and have a higher tendency to get lodged in the duodenal sweep.[4] Interestingly, as seen in our case above, one 6 cm glass vial transversed through the duodenal sweep and was seen in the distal colon. Fortunately, there are a wide array of different retrieval tools that endoscopists can deploy depending on the features of the foreign object. Long slender objects more than 5 cm, can be difficult to remove endoscopically due to challenges in orientation and grasping.[5] As seen in our case above, the round smooth edges of the glass vial made it difficult to grasp the glass vials. Endoscopists can overcome this challenge through a combination of a snare and a 15-mm extraction balloon to increase the luminal pressure and successfully pull the vials across the UES and out of the mouth. Extraction balloons are typically used in the endoscopic removal of biliary stones and sludge from the bile duct and have not been widely used in the endoscopic removal of ingested foreign objects.[4] [5]

In summary, we present a rare case of a patient who ingested over 30 glass vials. Initial management is aimed at obtaining a KUB to identify high-risk features and location. Given the size of these vials, there was a high probability of perforation and a low likelihood of passing spontaneously. An emergent EGD was planned, and the glass vials were successfully and safely removed in a single session using a 15-mm extraction balloon and a snare.

Conflict of Interest

None declared.

Copyright Statement

Submission of this manuscript implies that it represents original research not previously published and that it is not being considered for publication. The corresponding author declares that the manuscript is submitted on behalf of all authors.

Ethical Approval

An appropriate informed consent was obtained before the writing of this manuscript.

Patient's Consent

Appropriate informed consent was obtained for this case.

• References

• 1 Sugawa C, Ono H, Taleb M, Lucas CE. Endoscopic management of foreign bodies in the upper gastrointestinal tract: a review. World J Gastrointest Endosc 2014; 6 (10) 475-481
• 2 Ambe P, Weber SA, Schauer M, Knoefel WT. Swallowed foreign bodies in adults. Dtsch Arztebl Int 2012; 109 (50) 869-875
• 3 Fung BM, Sweetser S, Wong Kee Song LM, Tabibian JH. Foreign object ingestion and esophageal food impaction: an update and review on endoscopic management. World J Gastrointest Endosc 2019; 11 (03) 174-192
• 4 Inayat F, Zafar F, Lodhi HT. et al. Endoscopic removal of large sharp-edged foreign bodies in the gastrointestinal tract using an innovative modification of the overtube. Cureus 2018; 10 (09) e3264
• 5 Chung YS, Chung YW, Moon SY. et al. Toothpick impaction with sigmoid colon pseudodiverticulum formation successfully treated with colonoscopy. World J Gastroenterol 2008; 14 (06) 948-950

Publication History

Article published online:
21 November 2024