Swallowed razors, magnets and more: new advice for doctors
May 17, 2023 — Two new studies suggest that even if someone ingests something as potentially harmful as a razor blade or a magnet, the doctor’s best course of action may be to let nature take its course.
Some adults who present to the emergency department after ingesting a razor blade, battery, magnet, or multiple objects do so for “secondary gain.” According to experts, they want medical care, an overnight stay in the hospital or some other perceived benefit.
Some people become ‘regulars’ – returning to the same hospital again and again after ingesting something potentially harmful. This group may include prisoners and those with psychiatric problems.
Other adults swallow things by accident, such as the mentally challenged, drunk people, and elderly people with dentures who don’t realize they have chicken or fish bones 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 whether to stick a tube down the patient’s throat with a device to retrieve the objects, or leave it there and let nature take its course. “? Should the person be taken to the hospital overnight or sent home with a list of symptoms that means they need to come back right away?
Two new studies lean toward conservative management, or letting nature take its course, in most cases.
Length is the key
A team of researchers from the University of Southern California found that removal does not depend on how “dangerous” an object is – such as a battery that can leak acid or a sharp razor blade.
It didn’t matter how many objects someone swallowed at once. There were no internal cuts, bowel obstructions, or fistulas when the medical records of 302 cases were reviewed. Fistulas narrow passages between organs or between an organ and the skin, which can cause leakage, infections, and other problems.
Only the 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, in most cases it didn’t matter whether they took it out or waited for the body to carry it on.
“We work at USC, which is a large safety-net hospital throughout Los Angeles County, and we happen to see a lot of that,” said Shea Gallagher, MD, a general surgery resident at Keck Medicine.
“Basically, we treat the entire spectrum of the patient population that deals with this,” he said earlier this month in Chicago at Digestive Disease Week (DDW) 2023, an international gathering of health care providers dealing with GI disorders.
Between 2015 and 2021, people who swallowed foreign objects were examined. The median age was 29 years, 83% were male, and patients had about three hospitalizations.
Of the 302 cases, 67% of ingested objects were sharp or pointed, 38% were dull, 8% were magnetic, and 5% were corrosive, such as batteries. Almost 1 out of 5 patients, 18%, swallowed several objects.
In 40% of cases, doctors used endoscopy to go down the throat and remove objects. The remainder received conservative leadership.
Twelve of the patients underwent surgery. In 10 cases, the objects cut something from the inside, and in two cases an object got stuck. The objects in the 12 patients who underwent surgery were longer, about 4.5 inches, compared to just over 1 inch in the non-surgery patients.
“The take-home message is that conservative leadership is probably fine in most cases,” Gallagher said.
Remove “Secondary Reinforcement”.
In another study presented at the conference, Australian researchers reported on 157 swallowed objects involving 62 patients.
“Our captives like to swallow things,” said study lead researcher George Tambakis, MBBS. He works in a hospital that also has a prison ward. Traditionally, prisoners are admitted to the hospital, undergo x-rays, observations, endoscopy or surgery, and receive a lot of medical care. He and his colleagues want to change that.
“We prefer a conservative approach, focusing 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 lots of procedures — can remove a lot of the “secondary benefits,” he said.
The general approach is to retrieve objects if they are a perforation or gets stuck in the esophagus. Otherwise, people are treated as outpatients.
That can be a deterrent, Tambakis said. For example, when doctors sent seven patients home without further work, five of them did not return. The other two came back, but less frequently.
In a retrospective study of past behavior, researchers reviewed medical records of 157 times when people swallowed a foreign object. The average age was 30, half were men and two-thirds were prisoners. More than 4 out of 5 had a mental health condition.
In 23% of the cases, they swallowed a battery, 17% allegedly swallowed balloons containing medicine, and 16% a razor blade. Only a small percentage, 4%, swallowed the magnets. About 40% of the cases were “mixed” items. In one case, he said, a patient had to undergo surgery to remove about 500 coins he had swallowed.
More than half of the patients, 55%, received conservative treatment. Higher-risk cases were about equally likely to have been treated conservatively or with endoscopy. Similar to the USC study, no perforation or bowel obstruction was reported.
When asked to make recommendations to other doctors, Tambakis recommends that objects be removed by endoscopy “when the patient is for the first time or the second time, and if he is at high risk — a long object, a battery or a magnet. But that’s what we’re moving towards [conservative management for] who present themselves for the fifth, sixth or sixtieth time.”
“This is an important study because we actually see these not infrequently in the 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 useful because guidelines for treating such patients come in part from expert opinion. For example, the American Society for Gastrointestinal Endoscopy (ASGE) Management of Guidelines for Ingested Foreign Bodies and Effects on Food they are also based on studies and expert consensus.
“Hopefully, over time, studies like this can help answer these questions,” Chan said. He agreed that it takes a lot of healthcare resources to map and retrieve objects every time someone comes in after swallowing a foreign object.
Chan said limitations of the Australian study included its retrospective design and relatively small population. “So it’s a bit hard to draw conclusions because these patients are probably coming in with different objects that they’ve ingested.”
As for the USC study, “I think it’s an important study as well,” Chan said.
“We know length is a risk factor based on ASGE guidelines,” he said.
“This study is interesting because they look at it from a surgical point of view, like who actually had the surgery — which is probably the most important finding.” However, only 12 of the 302 patients underwent surgery, according to Chan, so the study was limited by size.
He said that the two studies are trying to answer similar questions. “Both have limitations that limit the ability to draw strong conclusions. But I think they’re interesting and will hopefully lead to more and bigger studies to really answer these questions.”