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May 22, 2023 – Two new studies suggest that even when a person ingests 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 department after swallowing a razor blade, battery, magnet, or various other objects do so for “secondary gain.” They want medical care, an overnight stay in the hospital or other perceived benefits, experts say.
Some become “frequent travelers,” returning to the same hospital over and over 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 diminished mental capacity, people who are intoxicated, and older people with dentures who don’t realize there’s a chicken or fish bone in their food until it’s too late.
In either case, doctors often order an X-ray, find 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 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 key
A team of researchers from the University of Southern California found that disposal 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, intestinal obstructions or fistulas when they reviewed the medical records of 302 cases. fistulas They are narrow channels that form between organs or an organ and the skin that can cause leakage, infection, 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 if they pulled it out or waited for the body to move it.
“We work at USC, which is a huge safety net hospital for all of Los Angeles County, and we see this frequently,” said Shea Gallagher, MD, general surgery resident at Keck Medicine at USC.
“Basically, we treat the entire spectrum of the patient population that does this,” he said earlier this month at Digestive Disease Week (DDW) 2023 in Chicago, an international gathering for healthcare providers who treat gastrointestinal disorders. .
They studied people who swallowed foreign objects between 2015 and 2021. The median age was 29 years, 83% were men, and the patients were admitted to the hospital about three times each.
Among the 302 cases, 67% of the swallowed objects were sharp or pointed, 38% were blunt, 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 underwent 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 with just over 1 inch in people who did not have surgery.
“The bottom line is that conservative management is probably fine in most cases,” Gallagher said.
Removal of “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 the study’s principal investigator, George Tambakis, MBBS. He works in a hospital with an attached prison ward. Traditionally, prisoners are admitted to the hospital, undergo X-rays, observation, endoscopy, or surgery, and receive extensive medical attention. He and his colleagues are looking to change that.
“We prefer a conservative approach with a focus 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 hospitalization or a series of procedures, can eliminate much of their “secondary gain,” he said.
The general approach is to recover items if they cause a drilling 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 with no more work, for example, five of them never came back. The other two returned but less frequently.
In the retrospective study, which looks at past behavior, the researchers reviewed medical records on the 157 occasions people swallowed a foreign object. The median age was 30 years, half were men, and about two-thirds were prisoners. More than 4 in 5 had a history of mental health.
Batteries were swallowed in 23% of cases, suspected drug-containing balloons in 17%, and razor blades in 16%. Only a small percentage, 4%, swallowed magnets. About 40% of the cases were “miscellaneous” objects. In one case, he said, a patient had to undergo surgery to remove about 500 swallowed coins.
Just over half, 55%, of the patients were treated conservatively. Higher-risk cases were just as likely to be treated conservatively or endoscopically. As in the USC study, no intestinal perforations or obstructions were reported.
Asked about his suggestions for other doctors, Tambakis recommends removing the objects by endoscopy “when it is the first or second time for the patient, and if it is high risk: a long object or batteries or magnets. But what we’re moving towards is to [conservative management for] people appearing for the fifth, sixth, or sixtieth time.”
“Important” Studies
“That’s an important study because we actually see them 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 useful because guidelines for managing these patients are derived in part from expert opinion. For example, the American Society for Gastrointestinal Endoscopy (ASGE) Management of Guidelines on ingested foreign bodies and food impacts They are based on both studies and expert consensus.
“Hopefully, over time, studies like this can help address some of these questions,” Chan said. She agreed that it takes a lot of health care resources to examine and retrieve objects every time someone is brought in after swallowing a foreign object.
Chan said the 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 come in with different objects that they ingested.”
Regarding the USC study, “I think it’s also an important study,” Chan said.
“We know that length is a risk factor per the ASGE guidelines,” he said.
“This study is interesting because they look at it from a surgical perspective, like who actually had the surgery, which is probably the most important outcome.” However, only 12 of 302 patients underwent surgery, so size was also a limitation of this study, 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 are intriguing and will hopefully lead to more and larger studies to really address these questions.”
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