G a s t r o i n t e s t i n a l I m a g i n g R ev i ew

Guelfguat et al.
Imaging of Ingested Foreign Bodies

FOCUS ON:

Downloaded from www.ajronline.org by 112.215.66.70 on 08/18/14 from IP address 112.215.66.70. Copyright ARRS. For personal use only; all rights reserved

Gastrointestinal Imaging
Review

Mark Guelfguat 1
Vladimir Kaplinskiy 2
Srinivas H. Reddy 3
Jason DiPoce 4,5
Guelfguat M, Kaplinskiy V, Reddy SH, DiPoce CJ

Clinical Guidelines for Imaging and

Reporting Ingested Foreign Bodies
OBJECTIVE. The purpose of this article is to familiarize radiologists with the specific characteristics of foreign bodies, obtained from image interpretation, to guide further
management. Details of object morphologic characteristics and location in the body gained
through imaging form the backbone of the classification used in the treatment of ingested foreign bodies.
CONCLUSION. The characteristics of foreign bodies and predisposing bowel abnormalities affect the decision to follow ingested objects radiographically, perform additional
imaging, or proceed with endoscopic or surgical removal.

Keywords: foreign bodies, gastrointestinal tract,

ingestion
DOI:10.2214/AJR.13.12185
Received October 30, 2013; accepted after revision
February 8, 2014.
Presented at the 2013 annual meeting of the ARRS,
Washington, DC (Education Exhibit E183).
1
Department of Radiology, Jacobi Medical Center, 1400 S
Pelham Pkwy, Bronx, NY 10461. Address correspondence to
M. Guelfguat (mguelfguat@gmail.com).
2
Department of Internal Medicine, Beth Israel Deaconess
Medical Center, Boston, MA.
3

Department of Surgery, Jacobi Medical Center, Bronx, NY.

4
Radiology Department, Columbia University Medical
Center, New York, NY.
5
Present address: Department of Radiology, Hadassah
Medical Center, Jerusalem, Israel.

This article is available for credit.

AJR 2014; 203:3753
0361803X/14/203137
American Roentgen Ray Society

oreign body ingestion is a common problem that often requires

little intervention. For example,
8090% of ingested foreign bodies are able to pass without intervention, 10
20% must be removed endoscopically, and
only approximately 1% require surgery [1].
However, intentional ingestion results in intervention rates as high as 76% [2], and surgical intervention is performed in as many as
28% of patients [3]. Foreign body ingestion
results in the death of approximately 1500
people annually in the United States [4]. As
noted by Palta et al. [2], immediate clinical
manifestations of foreign body ingestion
range from epigastric pain (55%), vomiting
(16%), dysphagia (7%), pharyngeal discomfort (4%), and chest pain (3%) to the absence
of symptoms (30%). Pediatric and mentally
handicapped patients may present immediate symptoms of foreign body ingestion,
commonly including choking, refusal to eat,
hypersalivation, wheezing, and respiratory
distress [5]. Some patients may remain asymp
tomatic for many years [6]. Without treatment, complications may include perforation
[7], obstruction [8], esophageal-aortic fistula
[9] or tracheoesophageal fistula formation
[10], and sepsis [11].
Guidelines outlined by the American Society of Gastrointestinal Endoscopy establish multiple parameters for the clinical management of foreign body ingestion based on
knowledge of the chemical properties, size,
sharpness, and location of the object [5, 12].

Although the guidelines are set primarily for

clinicians to determine the next step in clinical
management, the guidelines require knowledge of the foreign bodys characteristics,
such as its position and composition. Radiologic examination can frequently provide this
information. Therefore, radiologists should be
familiar with these guidelines (Table 1).
Imaging Modalities
Radiographs
Indications for radiography can be subdivided according to the purposes of initial
diagnosis or elimination follow-up. For the
purpose of initial diagnosis, radiographs can
confirm the location, size, shape, and number of ingested foreign bodies and can help
to exclude aspirated objects [5]. Radiographs
identify most foreign bodies, especially if the
object is likely to be radiopaque [13]. Nevertheless, nonradiopaque foreign bodies are
common, which limits the reliability of radiographs for initial evaluation [14]. Fish and
chicken bones, wood, plastic, and thin metal
objects are some of the most common radiolucent objects [5, 15, 16]. Thin fragments of
aluminum, such as pull-tabs or pop-tabs of
beverages, are not radiopaque [15]. Once a
radiographically identified object is deemed
likely to pass without intervention, serial imaging is conducted to ensure prompt progression and elimination [5].
On the basis of the location of a foreign
object in the body determined by a preceding clinical evaluation, frontal and lateral

AJR:203, July 2014 37

Downloaded from www.ajronline.org by 112.215.66.70 on 08/18/14 from IP address 112.215.66.70. Copyright ARRS. For personal use only; all rights reserved

Guelfguat et al.
radiographs of the neck, chest, or abdomen
can be obtained. Additional views, such as
an oblique projection or a supplementary expiratory view of the thorax in the setting of
a suspected endobronchial foreign body, can
be used to confirm the diagnosis [5, 17, 18].
The visibility of low-opacity foreign bodies on head and neck radiographs can be improved by using a low-peak-kilovoltage technique, at settings such as 6570 kVp [19, 20].
This low-kilovoltage technique would increase the contrast between tissues and radiopaque objects. At that level, image characteristics rely mostly on the photoelectric
effect and depend on atomic number differences. Thus, the higher atomic numbers
of iron, silicon, and calcium in the foreign
bodies will be in greater contrast with lower atomic numbers of hydrogen, oxygen, and
carbon in the soft tissues. A suggested radiographic protocol for monitoring progress of
foreign body passage through the gastrointestinal tract is summarized in Table 2.
CT
CT is considered to be a sensitive tool for
foreign body detection [21, 22]. However,
inconsistencies in detecting radiolucent foreign bodies have been reported [5].
The sensitivity of radiographs relative to
CT in foreign body detection has been extensively studied in the orofacial region [19, 20].
Naturally, the ease of detection is directly related to the opacity of an object. In addition,
visualization also depends on the densities of
the surrounding tissues. Proximity to osseous structures and intramuscular location diminishes the visualization of faintly opaque
objects on both radiographs and CT. The
higher sensitivity of CT in foreign body detection relative to radiographs is even more
apparent with faintly opaque objects, particularly when surrounded by air. Some authors
have found that the sensitivity of CT can be
improved with use of 3D reformations [23]
by enhancing the visualization of the foreign
body, reassessing the extent of intestinal injury, and directing preprocedural planning.
The use of IV contrast agent in the detection of foreign bodies is not clearly defined in
the literature. However, the use of IV contrast
agent has been long established for the diagnosis of intraabdominal inflammatory processes, such as diverticulitis [24]. Therefore, if
foreign bodyrelated complications, such as
an abscess, peritonitis, or fistula formation, are
suspected, IV contrast agent would enhance
the diagnostic quality of the examination.

38

TABLE 1: Indications for Foreign Body Removal by Endoscopy or Surgery,

According to Our Institutional Experience and Literature Review
Object Type

Endoscopic Removal

Surgery

Long and short blunt objects

If longer than 6 cm and proximal to Surgical removal should be

the first portion of the duodenum considered if objects remain in the
[5]; if wider than 2.5 cm [5]
same location distal to the
duodenum for more than 1 week [30]

Coins

If they remain longer than 1224

hours in the esophagus and 34
weeks in the stomach in an
asymptomatic patient [1, 5]

Sharp and sharp-pointed

objects

In the esophagus, they constitute a

medical emergency and
endoscopic removal should be
attempted; in the stomach or
duodenum, they require urgent
endoscopic removal [5];
endoscopy should still follow a
radiologic examination with
negative findings because many
sharp-pointed objects are not
radiographically visible [5]

If the sharp foreign body beyond the

duodenum fails to progress
radiographically for 3 consecutive
days, surgical intervention should
be considered [1, 5]

Magnets

Magnets within endoscopic

reach are a reason for urgent
endoscopy [5]

Failure of a magnet to move through

the lumen on sequential radiographs, and location beyond
endoscopic reach, should prompt
surgical evaluation [29]; radiographic findings suggesting bowel
entrapment, obstruction, or
perforation should prompt
emergent surgical evaluation [29]

Disk batteries

Emergent endoscopic removal is

indicated for a suspected disk
battery discovered in the
esophagus [5]

Formal laparotomy with removal

should be considered if it appears
that the passage of the battery in
the bowel has been arrested [68]

Endoscopic capsule

Effective removal can be achieved Effective removal can be achieved

by endoscopic or surgical
by endoscopic or surgical
intervention [84]
intervention [84]

Narcotic packets

Endoscopic removal should not be Surgical intervention is indicated

attempted if concerned for rupture when drug packets fail to progress or
and leakage of the contents [1, 5]
if there is intestinal obstruction [1, 5]

Bezoars

In the acute clinical setting,

Many bezoars require surgical
endoscopic disruption and removal removal [89]
of the mass can be performed [89]

TABLE 2: Suggested Radiographic Protocol for Monitoring Progress of

Foreign Body Passage Through the Gastrointestinal Tract,
According to Our Institutional Experience and Literature Review
Object Type

Radiographic Follow-Up

Long and short blunt objects

Weekly radiographs to follow the progression in the absence of

symptoms [5]

Coins

Radiographic follow-up once a week is sufficient, unless symptomatic [1]

Sharp and sharp-pointed objects

If past the duodenum, should be followed radiographically daily to

document passage [5]

Magnets

Serial radiographs are advised if the object continues to show

mobility and the patient remains asymptomatic [29]

Disk batteries

If in the stomach and beyond, radiographic follow-up every 34 days

should be obtained to monitor passage [5]; batteries remaining
within the stomach longer than 48 hours should be retrieved
endoscopically [5]

AJR:203, July 2014

Downloaded from www.ajronline.org by 112.215.66.70 on 08/18/14 from IP address 112.215.66.70. Copyright ARRS. For personal use only; all rights reserved

Imaging of Ingested Foreign Bodies

The ability of low-dose CT to diagnose
acute appendicitis [25] and nephrolithiasis
[26] has been shown to be comparable with
that of conventional CT. There are studies
showing the reliability of low-dose CT in
the detection of intrabronchial foreign bodies
[27] and ingested drug packets [28]. Thus, although we are not aware of a trial evaluating
the use of low-dose CT for detecting ingested
foreign bodies across the board, it would be
reasonable to consider this option, especially
in pregnant and pediatric patients. Low-dose
CT already has been suggested for identification of magnet ingestion in children [29].
Oral contrast agent administration for
foreign body diagnosis is controversial. Opponents of oral contrast agent use, influenced by endoscopists and surgeons, advise
against oral contrast material administration because of a potential aspiration risk.
Contrast material coating the foreign body
and esophageal mucosa can compromise a
subsequent endoscopy [5]. Moreover, an unsuspected foreign body may be obscured
by intraluminal contrast media [30] (Fig.
1). Review of the scout images and the use
of bone windows help to accentuate a radiopaque subject in a less dense pool of oral
contrast material.
Recommendations for oral contrast agent
use are based on its ability to outline the
esophageal foreign body on fluoroscopy and
to aid in the identification of esophageal and
bowel perforation [31, 32] (Fig. 2). Watersoluble media should be used if perforation
is suspected [31].
With the exception of American College
of Radiology guidelines listing a suspected thoracic foreign body in children as an
indication for CT of the chest [33], we are
not aware of other definitive guidelines determining general indications for CT in the
evaluation of suspected ingestion of foreign
bodies. If the location of the object in the
body is indeterminate according to radiographs, CT has been used to provide more
precise information. It can also unmask
complications suggested by or even occult
on radiographic evaluation. Indications pertaining to the specific type of ingested material are provided in the following individual
sections of this article.
General Foreign Body Evaluation and
Removal Guidelines
Pharyngeal or Proximal Esophageal Considerations
Because pharyngeal and esophageal perforations are the most ominous complica-

tions of foreign body ingestion to be recognized by imaging, this section will serve as
an opening topic for this article. Esophageal
perforation is a potentially life-threatening
condition with high morbidity and mortality
(> 20% of cases) [34], and foreign body ingestion is a common cause of perforation (3
35% of cases) [35, 36]. The pyriform sinuses
and cervical esophagus are common sites of
foreign body impaction and perforation, especially with sharp objects [31]. The extent
of inflammation, the perforation site, and the
relationship of the extraluminal object to the
vital organs are the crucial pieces of imaging
information to be reported to the clinicians.
If perforation occurs in the cervical region, prevertebral soft-tissue emphysema can
be seen on lateral cervical radiographs. Perforation of the thoracic esophagus presents as
hydrothorax, pneumothorax, or hydropneumo
thorax on chest radiographs. The radiographic
appearance of pneumomediastinum and subcutaneous emphysema may lag for at least 1
hour subsequent to injury [36, 37].
Currently, the diagnosis of esophageal foreign bodies heavily relies on CT use [38, 39].
The sensitivity (97%) and accuracy (98%) of
CT are higher when compared with radiography (47% and 52%, respectively) [39]. To
our knowledge, no clear guidelines regarding the use of fluoroscopic contrast esophagram versus CT with oral contrast agent
versus CT without oral contrast agent exist.
Anecdotal cases illustrate that fluoroscopic
contrast esophagram can be beneficial for localization of radiolucent foreign bodies [40].
Wall thickening, surrounding soft-tissue
stranding, extraluminal air, and esophageal
wall laceration have been described with visceral perforation by foreign bodies on CT.
More-specific signs include the presence of a
radiopaque object in an abscess or inflammatory mass [38, 39, 41] (Figs. 35).
The presence of extraluminal orally administered contrast agent is a known CT sign
of esophageal perforation [41, 42] and has
been found to be highly sensitive and specific [43]. Unfortunately, no data regarding the
negative predictive value of this finding are
currently available, to our knowledge. The
absence of extraluminal oral contrast agent
does not exclude esophageal perforation, and
in a setting of other findings suggestive of
esophageal perforation, surgical consultation is warranted.
To achieve a good outcome, early clinical suspicion and imaging are important features in case management [34]. With sus-

pected foreign body ingestion, persistent

esophageal symptoms should be evaluated
by endoscopy, even in the setting of a negative radiographic evaluation [5]. Esophageal
foreign objects and food impactions should
be removed within 24 hours. Further delay
increases the likelihood of perforation and
fistula formation [5, 30]. Sharp-pointed objects in the esophagus require emergent endoscopic removal [5]. Most foreign bodies,
including sharp objects, pass uneventfully
once through the esophagus [5].
Size of Foreign Body
Uncomplicated passage of foreign bodies
through the gastrointestinal tract largely depends on their shape and size [29]. Urgent
endoscopy is recommended for objects longer than 6 cm and proximal to the first portion of the duodenum [5]. Long objects are
likely to be arrested in the duodenum because of their length relative to the duodenal
curvature. They may perforate viscera anywhere but are most likely to penetrate the duodenum at the level of the ligament of Treitz
[31]. Nonurgent endoscopic removal of objects wider than 2.5 cm is also recommended
because they are less likely to pass the pylorus [5]. The ileocecal valve may also impede passage of large foreign bodies. Thus,
the dimensions of an ingested foreign body
in multiple planes should be measured and
reported to the clinician (Fig. 6). Because
the passage of small blunt objects may take
up to 4 weeks, weekly radiographs are sufficient to follow the progression in the absence
of symptoms [5]. Surgical removal should be
considered if objects remain in the same location distal to the duodenum for more than
1 week [30].
Ingestion of coins occurs most commonly
in young children [5]. The most likely positions of the coins irrespective of their sizes are
the postcricoid area (upper esophagus) and the
stomach [44]. Larger coins (such as quarters,
measuring 23 mm) have a higher propensity to
lodge at the level of the cricopharyngeus muscle or just distal to it, compared with a dime or
a penny (measuring 17 and 18 mm, respectively) [45]. On a lateral radiograph of the neck, a
coin in the esophagus will be projected on end
(in profile) and positioned posterior to the tracheal air column (Fig. 7). However, a coin in
the trachea will project en face on a lateral radiograph [1].
Coins may be observed for 1224 hours in
the esophagus and for 34 weeks in the stomach before nonurgent endoscopic removal in

AJR:203, July 2014 39

Downloaded from www.ajronline.org by 112.215.66.70 on 08/18/14 from IP address 112.215.66.70. Copyright ARRS. For personal use only; all rights reserved

Guelfguat et al.
an asymptomatic patient, because they commonly pass spontaneously. Most coins will
eventually leave the stomach and pass through
the gastrointestinal tract without obstruction
[1, 5]. A radiographic follow-up once a week
is sufficient, unless the patient is symptomatic
[1]. Patients with marked symptoms, including drooling, chest pain, and stridor, should
have emergent intervention to remove the coin
[5]. Metal detector use has been advocated for
the localization of most swallowed metal objects, including coins, especially in pediatric
patients [1, 5, 46].
Shape of Foreign Body
Patients suspected of swallowing sharppointed objects must be evaluated to define
the location of the object and the directions
of its sharp ends [5]. The risk of perforation
with sharp objects is higher than that with
blunt objects. In the esophagus and hypopharynx, complications of perforation range
from more common retropharyngeal abscess
and mediastinitis to less frequent fistula formations. Foreign body migration into the
surrounding tissues, including airway and
blood vessels, also has been described [47].
The sensitivity of neck radiographs for foreign body detection has been reported in the
range of 80% [48]. When viewing the radiographs, particular attention should be paid to
the assessment of the soft tissues at the level of the lower cervical spine, because sharp
objects are more likely to impact at the region of the cricopharyngeus muscle. Besides
direct visualization of a foreign body, additional signs include retropharyngeal soft-tissue thickening and straightening of the cervical lordosis [47, 48].
Superior sensitivity and specificity of CT
(100% and 93.7%, respectively) relative to radiographs in detection of sharp foreign bodies
has been found in cases of bones lodging in
the upper alimentary tract [21]. Sharp foreign
body complications of perforation, fistula, and
abscess can be also detected with CT [47].
Sharp-pointed objects detected in the
stomach or duodenum require urgent endoscopic removal [5]. If sharp-pointed objects
pass the duodenum, then they should be followed radiographically daily to document
passage. Such cases should be managed cautiously, because 1535% of sharp objects
that pass the stomach cause intestinal perforation, usually in the area of the ileocecal
valve [1]. If the sharp foreign body fails to
progress radiographically for 3 consecutive
days, surgical intervention should be consid-

40

ered [1, 5]. Many sharp-pointed objects are

not radiographically visible, and therefore
endoscopy should still follow a radiologic
examination with negative findings [5]. In
a setting of negative or inconclusive radiographs for the presence of sharp objects, CT
can be considered for planning before endoscopy, because it has been found to be an effective tool used in the diagnosis of traumarelated complications [49].
Sharp elongated objects are the most likely to penetrate or perforate the bowel. Perforations may produce chronic inflammation,
being discovered months or years later [16].
Complications include mucosal ulceration,
perforation, obstruction, intussusception, fistula formation, or abdominal abscess [11, 50].
Toothpicks and bones are the most common foreign bodies requiring surgery in the
United States [1]. If a razor blade passes the
stomach and duodenum, then it usually passes through the lower gastrointestinal tract
without difficulty [51] (Fig. 8).
Glass can either escape detection or be
readily identifiable on radiographs [16, 44,
52], depending on the fragment size, composition, and surrounding material [31, 53]. CT,
however, is consistently accurate in the detection of glass fragments (Fig. 9).
Fish bones are the most commonly seen
objects leading to bowel perforation in
southeast Asia and Korea [54, 55]. Radiography poorly visualizes fish bones in soft tissues, with visibility varying by fish species
and the location and orientation of the bone.
Clinical presentation and radiography are
unreliable in the preoperative diagnosis of
fish bone perforation of the gastrointestinal
tract [38]. CT is the test of choice to radiographically diagnose fish bone impactions
[56] and is consistently accurate in revealing
the offending fish bone [38, 5761] (Fig. 10).
Unique Foreign Body
Physical Properties
Magnets
Small magnets are widely available and commonly used in toy manufacturing. Because even
small ingested magnets possess high potency
and are associated high morbidity, a high index of suspicion is required [29]. Testing with
a compass has been advocated to determine
whether swallowed objects are magnetic [62].
The bowel can become trapped between
attracted magnets or other ingested ferromagnetic objects. Magnets attached to each
other across the bowel wall are unlikely to
disengage spontaneously. Ensuing pressure

necrosis develops within several hours [62,

63]. This can lead to fistula formation, bowel
perforation, obstruction, volvulus, peritonitis, or sepsis [62].
Even though most magnets are radiopaque,
radiographic diagnosis of magnet ingestion can
be confounded by stacked magnets, which can
simulate a single object [29]. Magnifying an
ingested object on a radiograph helps to better
appreciate notches between the individual attached pieces, improving the detection of multiple magnets [64]. Fluoroscopy and low-dose
limited-field CT are potential adjunct modalities useful for problem solving [29] (Fig. 11).
Detection of a gap between magnets on
an imaging study raises the possibility of entrapment and ischemic damage to the interposed bowel wall and should trigger emergent surgical evaluation [29, 62] (Figs. 12
and 13). Failure of a magnet to move through
the lumen on sequential radiographs should
also prompt surgical or endoscopic evaluation [29]. Magnets within endoscopic reach
are a reason for urgent endoscopy [5].
Disk and Cylindric Batteries
A rising incidence of disk battery ingestion has been attributed to the increased use
of this type of power supply in portable electronic devices [65]. Most cases of battery ingestion have a relatively benign course, and
most patients have no clinical manifestations
after ingestion [1, 66, 67].
The smaller size disk batteries are ingested most frequently, with the majority of
batteries less than 15 mm in diameter [66].
The outcome is related to battery size. Button cells with diameter greater than 15 mm
were linked to a greater proportion of minor
and moderate complications. In patients with
major complications, larger-diameter batteries were ingested (20 and 23 mm) [66].
Relative to low-voltage burns and pressure
necrosis, the direct corrosive action of a leaking alkaline solution is the major mechanism
of injury produced by a disk battery [1]. The
alkaline base in these batteries is capable of
causing rapid liquefaction necrosis, leading
to esophageal mucosal damage as early as 1
hour. Perforation can result as soon as 6 hours
after ingestion, almost always in the esophagus [1, 66, 68]. In addition to perforation, major complications include tracheoesophageal
or esophageal-aortic fistula and esophageal
scarring [66].
Because the corrosive activity of a leaking disk battery is extremely damaging, imaging diagnosis of a disk battery lodged in

AJR:203, July 2014

Downloaded from www.ajronline.org by 112.215.66.70 on 08/18/14 from IP address 112.215.66.70. Copyright ARRS. For personal use only; all rights reserved

Imaging of Ingested Foreign Bodies

the esophagus requires immediate communication to the treating physician. If a foreign
body suspected to be a disk battery is noted
in the esophagus, emergent endoscopic removal is indicated [5, 68].
Once in the stomach, most disk batteries
pass without complications. The local effects
of the battery on the small-bowel mucosa
can be assumed to be similar to those on the
esophageal mucosa. Therefore, formal laparotomy with removal should be considered if
it appears that the passage of the battery has
been arrested [68].
A radiograph every 34 days is adequate
to assess the progress through the gastrointestinal tract [5, 66]. With a history of battery ingestion, radiographic confirmation of
the presence of a foreign body with posteroanterior and lateral radiographs from the nasopharynx to the anus should be performed.
Both views are necessary because the battery may be easily confused with a coin [68].
Distinguishing between the radiographic appearances of a coin and a button battery is extremely important, because management of
these entities is very different (Fig. 14).
Mercury toxicity after disk battery ingestion is infrequent [66]. Some 15.6-mm diameter batteries may contain mercuric oxide.
These devices have a greater likelihood than
others to split in the gastrointestinal tract and
release inorganic mercury. Subsequent absorption has been shown to lead to elevated
serum and urine mercury levels, although no
clinical manifestations of mercury poisoning
have been reported [66, 68, 69]. On radiographs, free mercuric oxide appears as radiopaque foci in the bowel [66].
Cylindric battery ingestions generally do
not result in major life-threatening symptoms,
and minor or moderate symptoms are infrequent [5]. Disk batteries and cylindric batteries located in the stomach of a patient without
signs of gastrointestinal injury may be observed for as long as 48 hours. Batteries remaining within the stomach longer than 48
hours should be retrieved endoscopically [5].
A battery beyond the stomach can be managed expectantly by checking the stool for the
passage of the battery with a follow-up radiograph in 1014 days [66]. Emetics should not
be used because they have been reported to
cause retrograde migration of batteries [70].
Foreign Bodies With Various
Chemical Compositions
Ingested coins are typically chemically inert, although the rare occurrence of zinc tox-

icity has been reported after the ingestion

of large quantities of pennies produced after 1981 [71]. Abdominal radiographs help to
determine the gastrointestinal burden of zinc
and guide the decision whether to continue
decontamination [72, 73].
Ingested lead-containing paint chips are seen
as flecks of radiopacities in the bowel. These
are classically sought in cases of pediatric lead
poisoning [74]. More recently, the practice of
alternative medicine has been linked to lead
poisoning. In patients with a history of alternative medicine use and abdominal pain, radiopaque spots identified on abdominal radiographs may correspond to a lead-containing
folk remedy, such as Deshi Dewa [75].
Chemical Precipitation
Chemical precipitation in the gastrointestinal tract can form masses and lead to obstruction. For example, small-bowel bacterial overgrowth can cause the decomposition of bile
salts, allowing precipitation and enterolith formation [76]. The interaction of antacids and
tube-feeding solution can create a thick substance completely occluding the esophagus
and necessitating endoscopic removal [77].
Orally ingested calcium supplement can organize in a fecalith and adhere to the large bowel wall [78], or to sediment in the esophagus,
leading to obstruction (Fig. 15).
Plastic Substances
The damage produced by plastic foreign bodies depends on their size, shape, and location in
the gastrointestinal tract. For example, small
plastic items like ballpoint pen caps and bottle
tops are completely harmless when encountered
below the diaphragm [14, 31, 79]. An ingested
plastic clip used for fastening plastic packets
can obstruct the lumen by attaching the claws
to the wall. The degree of damage depends on
the thickness of the pinched area, ranging from
mucosal ulceration to perforation and stricture
formation [50]. Plastic foreign bodies are radiolucent on routine radiographs [1, 15].
Endoscopic Capsules
Capsule endoscopy has become a method
of choice for diagnosing a variety of smallbowel diseases [80]. Capsule retention is a
major complication with an overall incidence
of 12% [8183]. The most common causes
of retention include small-bowel tumors,
strictures, or stenoses [81]. Abdominal radiographs should be obtained if the colon is not
entered during the allotted acquisition time,
if there are symptoms of obstruction, if the

patient needs to undergo MRI, or if the patient desires reassurance that the capsule has
passed [84]. If capsule retention is diagnosed,
effective removal can be achieved by endoscopic or surgical intervention [84] (Fig. 16).
Narcotic Packets
Ingestion of narcotics wrapped in plastic
or packed in latex condoms for purposes of
illegal drug trafficking can be fatal, because
rupture of even one of the packages can release a lethal dose [1, 5]. The uniform shape
of multiple oblong intraluminal objects, frequently outlined by bowel gas, and a thin
layer of air between the container wall and
its contents are radiographic features helpful in identifying the drug packets [74]. The
variable success of radiographs in the detection of intraabdominal containers is related
to the radiologic attenuation and quantity of
the containers [28]. Isoattenuation of ingested drug packets used by drug smugglers is
one of the causes for the high false-negative
results (23%) of radiography [28].
On the other hand, the accuracy of CT in
detecting the packets is well established [85]
(Fig. 17). Even though false-negative CT
scan results have been reported [86], CT is
superior to radiography for packet detection
[28, 87]. The high specificity of low-dose CT
has been outlined in a recent study [28].
The presence of broken containers, packets
susceptible to breaking, or gastrointestinal obstruction places the patient at an increased risk
of toxicity [1]. Surgical intervention is indicated when drug packets fail to progress or if there
is intestinal obstruction. Because rupture and
leakage of the contents can be fatal, endoscopic
removal should not be attempted [1, 5].
Bezoars
Bezoars are a conglomeration of material in the gastrointestinal tract, commonly
within the stomach, that is not readily digested [88]. Bezoars can fill the entire stomach,
conforming to the gastric wall [88]. Psychologically or metabolically unbalanced children may intentionally ingest various foreign
materials. Ingested hair aggregating into an
intraluminal mass, termed a trichobezoar
[31], can cause significant gastric distention
and outlet obstruction [89].
An intraluminal mass constituting a bezoar can be detected on abdominal radiography if it is outlined by gas [88]. On fluoroscopic studies, the majority of bezoars are
mobile and associated with gastric dilatation.
They are visualized as either inhomogeneous

AJR:203, July 2014 41

Downloaded from www.ajronline.org by 112.215.66.70 on 08/18/14 from IP address 112.215.66.70. Copyright ARRS. For personal use only; all rights reserved

Guelfguat et al.
or homogeneous filling defects surrounded
by contrast agent [90]. CT shows inhomogeneous, round, or ovoid masses containing areas of soft-tissue density intermixed with gas
and oral contrast material [90].
Poor mechanical breakdown of ingested
material leads to conglomerate mass formation. Accordingly, most gastric bezoars result
from gastroparesis, surgical resection, or bypass of the gastric antrum and body. For example, in a series of 19 patients with gastric
bezoars, 11 (58%) had risk for gastroparesis
and six (32%) had undergone previous gastric
surgery [90]. Radiologists should be aware of
these associations and seek evidence of bezoars in this population (Fig. 18).
Obstruction in a patient with a history of
bariatric surgery does not necessarily imply
an anastomotic stricture, adhesion, or hernia.
Bezoars should also be a consideration, and
the classic signs of a bezoar, such as intraluminal masses that have air or contrast agent
trapped in interstices, should be sought. Bezoars can form in a gastric remnant, either
proximal or distal to the jejunojejunal anastomosis [9096] (Fig. 19).
Some bezoars resolve rapidly and spontaneously or with conservative medical treatment [90, 97]. In the acute clinical setting,
endoscopic disruption and removal of the
mass can be performed, but many patients
require surgical removal [89].
Other Management Considerations
Overview of Intrinsic Gastrointestinal Causes
Impeding Passage of a Foreign Body
Preexisting narrowing of the gastrointestinal tract lumen would predispose to lodging
of an ingested object within the affected segment. Causes of the underlying conditions in
the esophagus are vast, ranging from extrinsic
compressions (dilated aortic arch or left atrium, or vascular ring), postprocedural (atresia
repair and radiation therapy), postinflammatory strictures (caustic burns and reflux esophagitis), to intrinsic and extrinsic tumors. In the
stomach and small-bowel adhesion, postoperative causes (altered anatomy from surgical
bypass and resection), strictures (ischemic
and inflammatory enteritis), and neoplasms
should be considered. Please refer to the diagram illustrating the most common points of
impedance to passage of foreign bodies in the
gastrointestinal tract (Fig. 20).
Repeated and Multiple Item Ingestion
Ingestion of multiple foreign objects and repeated episodes of ingestion are common [5].

42

For example, as many as 2533 foreign bodies

have been recorded in the stomach of a single
patient [14]. The possibility of a second foreign body should be considered when one is
known to have been ingested. Prisoners, psychiatric patients, and patients with peptic strictures have a tendency for recurrent episodes of
foreign body ingestion [1] (Fig. 21).
Radiologists should be wary of search satisfaction when a foreign body is discovered
and seek second and third foreign bodies
[15]. Thus, especially in pediatric patients,
radiographs from the base of the skull to the
anus should be made to determine whether
more than one foreign body is present [1, 31].
Conclusion
Despite the common occurrence of foreign
body ingestion, the majority of foreign objects
pass without intervention. Uneventful passage
depends on the favorable size, shape, and composition of the object, as well as an absence of
underlying structural bowel abnormality. Endoscopic removal and, less frequently, surgery
are reserved for some magnets; long, sharp,
or pointed objects; and toxic materials. Diagnostic imaging can frequently directly visualize the swallowed objects and describe their
dimensions, structure, and location in the patient. Knowledge of these parameters is crucial
in the management of ingested foreign bodies.
Timely implementation of appropriate treatment strategies depends on the radiologists familiarity with and communication of the salient radiographic and cross-sectional imaging
features of ingested foreign objects.
Acknowledgments
We thank Greg Chulsky and Noah Weg
for help with manuscript preparation and
William Robeson and Steven H. King for assistance with physics-related topics.
References
1. Webb WA. Management of foreign bodies of the
upper gastrointestinal tract: update. Gastrointest
Endosc 1995; 41:3951
2. Palta R, Sahota A, Bemarki A, Salama P, Simpson
N, Laine L. Foreign-body ingestion: characteristics and outcomes in a lower socioeconomic population with predominantly intentional ingestion.
Gastrointest Endosc 2009; 69:426433
3. Weiland ST, Schurr MJ. Conservative management of ingested foreign bodies. J Gastrointest
Surg 2002; 6:496500
4. Schwartz GF, Polsky HS. Ingested foreign bodies
of the gastrointestinal tract. Am Surg 1976;
42:236238

5. Ikenberry SO, Jue TL, Anderson MA, et al. Management of ingested foreign bodies and food impactions. Gastrointest Endosc 2011; 73:10851091
6. Yamamoto M, Mizuno H, Sugawara Y. A chopstick is removed after 60 years in the duodenum.
Gastrointest Endosc 1985; 31:51
7. Ragazzi M, Delco F, Rodoni-Cassis P, Brenna M,
Lavanchy L, Bianchetti MG. Toothpick ingestion
causing duodenal perforation. Pediatr Emerg
Care 2010; 26:506507
8. Tai AW, Sodickson A. Foreign body ingestion of
blister pill pack causing small bowel obstruction.
Emerg Radiol 2007; 14:105108
9. Wu MH, Lai WW. Aortoesophageal fistula induced by foreign bodies. Ann Thorac Surg 1992;
54:155156
10. Slamon NB, Hertzog JH, Penfil SH, Raphaely RC,
Pizarro C, Derby CD. An unusual case of button
battery-induced traumatic tracheoesophageal fistula. Pediatr Emerg Care 2008; 24:313316
11. Schwartz JT, Graham DY. Toothpick perforation
of the intestines. Ann Surg 1977; 185:6466
12. Eisen GM, Baron TH, Dominitz JA, et al. Guideline for the management of ingested foreign bodies. Gastrointest Endosc 2002; 55:802806
13. Hodge D 3rd, Tecklenburg F, Fleisher G. Coin ingestion: does every child need a radiograph? Ann
Emerg Med 1985; 14:443446
14. Pellerin D, Fortier-Beaulieu M, Gueguen J. The
fate of swallowed foreign bodies: experience of
1250 instances of sub-diaphragmatic foreign bodies in children. Progr Pediatr Radiol 1969;
2:286302
15. Hunter TB. Foreign bodies. In: Hunter TB, ed.
Radiologic guide to medical devices and foreign
bodies. St Louis, MO: MosbyYear Book,
1994:64107
16. Hunter TB, Taljanovic MS. Foreign bodies. RadioGraphics 2003; 23:731757
17. American College of Radiology. ACR-SPR practice guideline for the performance of abdominal
radiography. American College of Radiology
website. www.acr.org/~/media/79a594819bbd463
1a7e31404daa66ef6.pdf. Published 2001. Revised
2011. Accessed January 29, 2014
18. American College of Radiology. ACR-SPR practice guideline for the performance of chest radiography. American College of Radiology website.
w w w. a c r.o r g / ~ / m e d i a / B 4 0 3 0 2 E E 2 8 6 D 4120AAEDE44B409DD45E.pdf.
Published
1993. Revised 2011. Accessed January 29, 2014
19. Aras MH, Miloglu O, Barutcugil C, Kantarci M,
Ozcan E, Harorli A. Comparison of the sensitivity
for detecting foreign bodies among conventional
plain radiography, computed tomography and ultrasonography. Dentomaxillofac Radiol 2010;
39:7278
20. Oikarinen KS, Nieminen TM, Makarainen H,

AJR:203, July 2014

Downloaded from www.ajronline.org by 112.215.66.70 on 08/18/14 from IP address 112.215.66.70. Copyright ARRS. For personal use only; all rights reserved

Imaging of Ingested Foreign Bodies

Pyhtinen J. Visibility of foreign bodies in soft tissue in plain radiographs, computed tomography,
magnetic resonance imaging, and ultrasound: an
in vitro study. Int J Oral Maxillofac Surg 1993;
22:119124
21. Eliashar R, Dano I, Dangoor E, Braverman I, Sichel JY. Computed tomography diagnosis of
esophageal bone impaction: a prospective study.
Ann Otol Rhinol Laryngol 1999; 108:708710
22. Marco De Lucas E, Sadaba P, Lastra Garcia-Baron P, et al. Value of helical computed tomography
in the management of upper esophageal foreign
bodies. Acta Radiol 2004; 45:369374
23. Takada M, Kashiwagi R, Sakane M, Tabata F, Kuroda Y. 3D-CT diagnosis for ingested foreign
bodies. Am J Emerg Med 2000; 18:192193
24. Hulnick DH, Megibow AJ, Balthazar EJ, Naidich
DP, Bosniak MA. Computed tomography in the
evaluation of diverticulitis. Radiology 1984;
152:491495
25. Kim K, Kim YH, Kim SY, et al. Low-dose abdominal CT for evaluating suspected appendicitis. N Engl J Med 2012; 366:15961605
26. Mulkens TH, Daineffe S, De Wijngaert R, et al.
Urinary stone disease: comparison of standarddose and low-dose with 4D MDCT tube current
modulation. AJR 2007; 188:553562
27. Koucu P, Ahmetolu A, Koramaz I, et al. Lowdose MDCT and virtual bronchoscopy in pediatric patients with foreign body aspiration. AJR
2004; 183:17711777
28. Poletti PA, Canel L, Becker CD, et al. Screening
of illegal intracorporeal containers (body packing): is abdominal radiography sufficiently accurate? A comparative study with low-dose CT.
Radiology 2012; 265:772779
29. Otjen JP, Rohrmann CA Jr, Iyer RS. Imaging pediatric magnet ingestion with surgical-pathological correlation. Pediatr Radiol 2013; 43:851858
30. Ng KC, Mansour E, Eguare E. Retention of an ingested small blunt foreign body. JBR-BTR 2011;
94:339342
31. Alexander WJ, Kadish JA, Dunbar JS. Ingested
foreign bodies in children. Progr Pediatr Radiol
1969; 2:256285
32. Hanks PW, Brody JM. Blunt injury to mesentery
and small bowel: CT evaluation. Radiol Clin
North Am 2003; 41:11711182
33. American College of Radiology. ACR-SPR practice guideline for the performance of pediatric
computed tomography (CT). American College
of Radiology website. www.acr.org/~/media/
ACR/Documents/PGTS/guidelines/CT_Pediatric.pdf. Published 2008. Revised 2009. Accessed
January 29, 2014
34. Sreide JA, Viste A. Esophageal perforation: diagnostic work-up and clinical decision-making in
the first 24 hours. Scand J Trauma Resusc Emerg

Med 2011; 19:66

35. Vidarsdottir H, Blondal S, Alfredsson H, Geirsson A, Gudbjartsson T. Oesophageal perforations
in Iceland: a whole population study on incidence,
aetiology and surgical outcome. Thorac Cardiovasc Surg 2010; 58:476480
36. Chirica M, Champault A, Dray X, et al. Esophageal perforations. J Visc Surg 2010; 147:e117e128
37. Han SY, McElvein RB, Aldrete JS, Tishler JM.
Perforation of the esophagus: correlation of site
and cause with plain film findings. AJR 1985;
145:537540
38. Goh BK, Tan YM, Lin SE, et al. CT in the preoperative diagnosis of fish bone perforation of the
gastrointestinal tract. AJR 2006; 187:710714
39. Ma J, Kang DK, Bae JI, Park KJ, Sun JS. Value of
MDCT in diagnosis and management of esophageal
sharp or pointed foreign bodies according to level of
esophagus. AJR 2013; 201:[web]W707W711
40. Bloom J, Rapoport Y, Zikk D. Dairy products
containers as a source of unusual esophageal foreign bodies. J Otolaryngol 1988; 17:404408
41. De Lutio di Castelguidone E, Pinto A, Merola S,
Stavolo C, Romano L. Role of spiral and multislice computed tomography in the evaluation of
traumatic and spontaneous oesophageal perforation: our experience. Radiol Med (Torino) 2005;
109:252259
42. de Lutio di Castelguidone E, Merola S, Pinto A,
Raissaki M, Gagliardi N, Romano L. Esophageal
injuries: spectrum of multidetector row CT findings. Eur J Radiol 2006; 59:344348
43. Hermansson M, Johansson J, Gudbjartsson T, et
al. Esophageal perforation in South of Sweden:
results of surgical treatment in 125 consecutive
patients. BMC Surg 2010; 10:31
44. Cheng W, Tam PK. Foreign-body ingestion in
children: experience with 1,265 cases. J Pediatr
Surg 1999; 34:14721476
45. Webb WA, McDaniel L, Jones L. Foreign bodies
of the upper gastrointestinal tract: current management. South Med J 1984; 77:10831086
46. Maurice S, Mackway-Jones K. Towards evidence
based emergency medicine: best BETs from the
Manchester Royal Infirmaryingested coins and
metal detection. J Accid Emerg Med 2000;
17:282283
47. Pinto A, Muzj C, Gagliardi N, et al. Role of imaging in the assessment of impacted foreign bodies
in the hypopharynx and cervical esophagus. Semin Ultrasound CT MR 2012; 33:463470
48. Haglund S, Haverling M, Kuylenstierna R, Lind
MG. Radiographic diagnosis of foreign bodies in
the oesophagus. J Laryngol Otol 1978; 92:1117
1125
49. American College of Radiology. ACR-SPR practice guideline for the performance of computed
tomography (CT) of the abdomen and computed

tomography (CT) of the pelvis. American College

of Radiology website. www.acr.org/~/media/
ACR/Documents/PGTS/guidelines/CT_Abdomen_Pelvis.pdf. Published 1995. Revised 2011.
Accessed January 29, 2014
50. Guindi MM, Troster MM, Walley VM. Three
cases of an unusual foreign body in small bowel.
Gastrointest Radiol 1987; 12:240242
51. Johnson WE. On ingestion of razor blades. JAMA
1969; 208:2163
52. Allotey J, Duncan H, Williams H. Mediastinitis
and retropharyngeal abscess following delayed
diagnosis of glass ingestion. Emerg Med J 2006;
23:e12
53. Felman AH, Fisher MS. The radiographic detection of glass in soft tissue. Radiology 1969;
92:15291531
54. Chen C-K, Su Y-J, Lai Y-C, Cheng HK-H, Chang
W-H. Fish bone-related intra-abdominal abscess
in an elderly patient. Int J Infect Dis 2010;
14:e171e172
55. Chung SM, Kim HS, Park EH. Migrating pharyngeal foreign bodies: a series of four cases of sawtoothed fish bones. Eur Arch Otorhinolaryngol
2008; 265:11251129
56. Lue AJ, Fang WD, Manolidis S. Use of plain radiography and computed tomography to identify
fish bone foreign bodies. Otolaryngol Head Neck
Surg 2000; 123:435438
57. Abid M, Derbel R, Annabi S, et al. Intestinal perforation in a Tunisian woman: peritonitis due to a
fishbone (in French). Med Trop (Mars) 2010;
70:7779
58. Al-Abduwani JA, Bhargava D, Sawhney S, AlAbri R. Bimanual, intra-operative, fluoroscopyguided removal of nasopharyngeal migratory fish
bone from carotid space. J Laryngol Otol 2010;
124:786789

59. Guilln-Paredes MP, Lirn-Ruiz R, TorralbaMartnez JA, Martn-Lorenzo JG, Aguayo-Albasini JL. Intestinal perforation caused by incidental
ingestion of a fish bone: value of CT in the diagnosis. Rev Esp Enferm Dig 2010; 102:573574
60. Hirasaki S, Inoue A, Kubo M, Oshiro H. Esophageal large fish bone (sea bream jawbone) impaction successfully managed with endoscopy and
safely excreted through the intestinal tract. Intern
Med 2010; 49:995999
61. Hsu C-L, Chen C-W. A prolonged buried fish
bone mimicking Ludwig angina. Am J Otolaryngol 2011; 32:7576
62. Centers for Disease Control and Prevention. Gastrointestinal injuries from magnet ingestion in
children: United States, 2003-2006. MMWR
Morb Mortal Wkly Rep 2006; 55:12961300
63. McCormick S, Brennan P, Yassa J, Shawis R.
Children and mini-magnets: an almost fatal attraction. Emerg Med J 2002; 19:7173

AJR:203, July 2014 43

Downloaded from www.ajronline.org by 112.215.66.70 on 08/18/14 from IP address 112.215.66.70. Copyright ARRS. For personal use only; all rights reserved

Guelfguat et al.
64. Oestreich AE. Worldwide survey of damage from
swallowing multiple magnets. Pediatr Radiol
2009; 39:142147
65. McLarty JD, Krishnan M, Rowe MR. Disk battery aspiration in a young child: a scarcely reported phenomenon. Arch Otolaryngol Head Neck
Surg 2012; 138:680682
66. Litovitz T, Schmitz BF. Ingestion of cylindrical
and button batteries: an analysis of 2382 cases.
Pediatrics 1992; 89:747757
67. Bronstein AC, Spyker DA, Cantilena LR Jr, et al.
2007 Annual Report of the American Association
of Poison Control Centers National Poison Data
System (NPDS): 25th Annual Report. Clin Toxicol (Phila) 2008; 46:9271057
68. Maves MD, Lloyd TV, Carithers JS. Radiographic
identification of ingested disc batteries. Pediatr
Radiol 1986; 16:154156
69. Sue Y-J. Mercury. In: Nelson LS, Lewin NA,
Howland MA, Hoffman RS, Goldfrank LR, Flomenbaum NE, eds. Goldfranks toxicologic emergencies, 9th ed. Beijing, China: McGraw-Hill,
2011:12991307

70.
Church RG, Babu KM. Gastrointestinal
principles. In: Nelson LS, Lewin NA, Howland
MA, Hoffman RS, Goldfrank LR, Flomenbaum
NE, eds. Goldfranks toxicologic emergencies,
9th ed. Beijing, China: McGraw-Hill, 2011:359
366
71. Pawa S, Khalifa AJ, Ehrinpreis MN, Schiffer CA,
Siddiqui FA. Zinc toxicity from massive and prolonged coin ingestion in an adult. Am J Med Sci
2008; 336:430433
72. Dhawan SS, Ryder KM, Pritchard E. Massive
penny ingestion: the loot with local and systemic
effects. J Emerg Med 2008; 35:3337
73. Majlesi N. Zinc. In: Nelson LS, Lewin NA, Howland MA, Hoffman RS, Goldfrank LR, Flomenbaum NE, eds. Goldfranks toxicologic emergencies, 9th ed. Beijing, China: McGraw-Hill,
2011:13391344
74. Schwartz D. Diagnostic imaging. In: Nelson LS,
Lewin NA, Howland MA, Hoffman RS, Goldfrank LR, Flomenbaum NE, eds. Goldfranks
toxicologic emergencies, 9th ed. Beijing, China:
McGraw-Hill, 2011:4569

75. Kulshrestha MK. Lead poisoning diagnosed by

abdominal X-rays. J Toxicol Clin Toxicol 1996;
34:107108
76. Beal SL, Walton CB, Bodai BI. Enterolith ileus
resulting from small bowel diverticulosis. Am J
Gastroenterol 1987; 82:162164
77. Schulthess HK, Valli C, Escher F, Asper R, Hacki
WH. Esophageal obstruction in tube feeding: a
result of protein precipitation caused by antacids?
Schweiz Med Wochenschr 1986; 116:960962
78. Ginaldi S, Reisman T. Calcified rims: uncommon
radiologic finding and potential pitfall due to organization of deposits of oyster shell tablets. Dis
Colon Rectum 1986; 29:471473
79. Payne SD, Henry M. Radiolucent dentures impacted in the oesophagus. Br J Surg 1984; 71:318
80. Boivin ML, Lochs H, Voderholzer WA. Does passage of a patency capsule indicate small-bowel
patency? A prospective clinical trial. Endoscopy
2005; 37:808815
81. Karagiannis S, Faiss S, Mavrogiannis C. Capsule
retention: a feared complication of wireless capsule endoscopy. Scand J Gastroenterol 2009;
44:11581165
82. Purdy M, Heikkinen M, Juvonen P, Voutilainen
M, Eskelinen M. Characteristics of patients with a
retained wireless capsule endoscope (WCE) necessitating laparotomy for removal of the capsule.
In Vivo 2011; 25:707710
83. Van Weyenberg SJB, Van Turenhout ST, Bouma
G, et al. Double-balloon endoscopy as the primary method for small-bowel video capsule endoscope retrieval. Gastrointest Endosc 2010;
71:535541
84. Cave D, Legnani P, de Franchis R, Lewis BS.
ICCE consensus for capsule retention. Endoscopy
2005; 37:10651067
85. Schmidt S, Hugli O, Rizzo E, et al. Detection of
ingested cocaine-filled packets: diagnostic value of
unenhanced CT. Eur J Radiol 2008; 67:133138
86. Eng JG, Aks SE, Waldron R, Marcus C, Issleib S.
False-negative abdominal CT scan in a cocaine
body stuffer. Am J Emerg Med 1999; 17:702704
87. Hergan K, Kofler K, Oser W. Drug smuggling by
body packing: what radiologists should know
about it. Eur Radiol 2004; 14:736742

88. Otjen JP, Iyer RS, Phillips GS, Parisi MT. Usual
and unusual causes of pediatric gastric outlet obstruction. Pediatr Radiol 2012; 42:728737
89. Gorter RR, Kneepkens CMF, Mattens ECJL, Aronson DC, Heij HA. Management of trichobezoar: case report and literature review. Pediatr
Surg Int 2010; 26:457463
90. Hewitt AN, Levine MS, Rubesin SE, Laufer I.
Gastric bezoars: reassessment of clinical and radiographic findings in 19 patients. Br J Radiol
2009; 82:901907
91. Zapata R, Castillo F, Cordova A. Gastric food bezoar as a complication of bariatric surgery: case
report and review of the literature. Gastroenterol
Hepatol 2006; 29:7780
92. Parameswaran R, Ferrando J, Sigurdsson A. Gastric bezoar complicating laparoscopic adjustable
gastric banding with band slippage. Obes Surg
2006; 16:16831684
93. Patel C, Van Dam J, Curet M, Morton JM, Banerjee S. Use of flexible endoscopic scissors to cut
obstructing suture material in gastric bypass patients. Obes Surg 2008; 18:336339
94. Sammut SJ, Majid S, Shoab S. Phytobezoar: a rare
cause of late upper gastrointestinal perforation
following gastric bypass surgery. Ann R Coll Surg
Engl 2012; 94:e85e87
95. Sarhan M, Shyamali B, Fakulujo A, Ahmed L.
Jejunal bezoar causing obstruction after laparoscopic Roux-en-Y gastric bypass. JSLS 2010;
14:592595
96. Ripolls T, Garca-Aguayo J, Martnez MJ, Gil P.
Gastrointestinal bezoars: sonographic and CT
characteristics. AJR 2001; 177:6569
97. Martnez de Juan F, Martnez-Lapiedra C, Picazo
V. Phytobezoar dissolution with Coca-Cola (in
Spanish). Gastroenterol Hepatol 2006; 29:291293
98. Pfau PR, Gregory G. Foreign bodies and bezoars.
In: Feldman M, Friedman LS, Sleisenger MH,
eds. Sleisinger and Fordtrans gastrointestinal
and liver disease, 7th ed. Philadelphia, PA: Saunders, 2002:386398
99. Hung C-W, Hung S-C, Lee CJ, Lee W-H, Wu KH.
Risk factors for complications after a foreign body
is retained in the esophagus. J Emerg Med 2012;
43:423427
(Figures start on next page)

44

AJR:203, July 2014

Downloaded from www.ajronline.org by 112.215.66.70 on 08/18/14 from IP address 112.215.66.70. Copyright ARRS. For personal use only; all rights reserved

Imaging of Ingested Foreign Bodies

A
Fig. 1Female patient with foreign body obscured by oral contrast agent on CT.
A, CT image with bone windows shows ingested piece of glass (arrow) as linear
density.
B, CT image with soft-tissue windows shows oral contrast agent (arrow) obscuring foreign body.
C, Scout radiograph readily identifies piece of glass (arrow) in pelvis. Object is
obscured by oral contrast agent when viewed in soft-tissue windows.

Fig. 214-year-old boy who experienced dysphagia

while eating chicken. Sagittal CT multiplanar reconstruction shows intraluminal mass (arrow) isodense
to muscle in upper thoracic esophagus. Oral contrast
agent helps to outline foreign body on CT.

Fig. 333-year-old man from long-term psychiatric facility who ingested multiple foreign bodies. Ballpoint pen
perforated esophageal wall and lodged in paraesophageal soft tissues.
A, Lateral neck soft-tissue radiograph shows outline of mostly radiolucent body of plastic pen (arrows). Prevertebral soft tissues are thickened.
B, Cropped frontal chest radiograph shows radiopaque ballpoint tip (black straight arrow). Note right pneumomediastinum in abscess (curved white arrow), bulging right mediastinal contours (black arrowheads), and mild
tracheal deviation to left.
(Fig. 3 continues on next page)

AJR:203, July 2014 45

Downloaded from www.ajronline.org by 112.215.66.70 on 08/18/14 from IP address 112.215.66.70. Copyright ARRS. For personal use only; all rights reserved

Guelfguat et al.

Fig. 3 (continued)33-year-old man from long-term psychiatric facility who ingested multiple foreign bodies.
Ballpoint pen perforated esophageal wall and lodged in paraesophageal soft tissues.
C, Axial CT shows paraesophageal abscess (curved arrow) formed around ballpoint pen (straight arrow).
D, Angled multiplanar reconstruction helps to better visualize relationship of radiolucent body of pen (straight
arrows) relative to abscess (curved arrow) and air-filled esophagus (arrowhead).

A
Fig. 477-year-old man who swallowed sharp rib during meal.
A and B, Consecutive coronal CT multiplanar reconstruction images show bone fragment (arrows) obliquely
lodged in cervical esophagus. Endoscopy revealed portion of rib with attached meat, which was dislodged,
moved to stomach, broken in two pieces, and removed.

46

Fig. 5Patient who swallowed chicken bone 1 year

before presentation. Bone (black arrow) is lodged
within bowel wall. Surgical removal revealed perforation at antimesenteric border. Pericolonic soft-tissue
stranding (white arrow) and short segmental wall
thickening (black arrowheads) are evident on CT.
(Courtesy of Alterman D, Albert Einstein College of
Medicine, Bronx, NY)

AJR:203, July 2014

Downloaded from www.ajronline.org by 112.215.66.70 on 08/18/14 from IP address 112.215.66.70. Copyright ARRS. For personal use only; all rights reserved

Imaging of Ingested Foreign Bodies

Fig. 632-year-old man with history of schizophrenia and repeated toothbrush

ingestions. Thick coronal maximum-intensity-projection CT image shows 17-cmlong hypodense plastic toothbrush (arrows) lodged in gastric body. Because patient refused endoscopy, surgical removal was performed.

Fig. 72-year-old boy who swallowed quarter, which

lodged at upper esophagus.
A, On frontal radiograph, coin (arrow) is projected
en face.
B, On lateral radiograph, coin (arrow) is projected in
profile, posterior to tracheal air column.

AJR:203, July 2014 47

Downloaded from www.ajronline.org by 112.215.66.70 on 08/18/14 from IP address 112.215.66.70. Copyright ARRS. For personal use only; all rights reserved

Guelfguat et al.

Fig. 842-year-old man who swallowed razor blades.

A, A few opacities (arrows) are noted in stomach on abdominal radiograph.
B, Thick coronal maximum-intensity-projection (MIP) CT image better characterizes one foreign body (arrow) lodged in stomach. Note central apertures characteristic
of razor blade. Thick MIP helps to accentuate small dense object.

C
48

Fig. 947-year-old woman with history of drug

abuse who swallowed crack cocaine glass pipe in
two pieces to avoid police arrest.
A and B, Scout (A) and axial CT (B) images show two
glass tubular fragments (arrows) in stomach.
C, Only one piece of glass (arrows) was retrieved from
gastric body during endoscopy. Other piece was followed with radiographs until elimination.

AJR:203, July 2014

Downloaded from www.ajronline.org by 112.215.66.70 on 08/18/14 from IP address 112.215.66.70. Copyright ARRS. For personal use only; all rights reserved

Imaging of Ingested Foreign Bodies

Fig. 1039-year-old man who developed throat pain after eating fish.
A, Sagittal CT multiplanar reconstruction shows opacity (arrow) in prevertebral soft tissues.
B, Lateral neck radiograph reveals no abnormality in corresponding region (arrow).
C, Photograph shows fish bone that was removed endoscopically. Dime is provided for scale purposes. Removal was difficult because of 3-pronged shape of bone.

Fig. 119-year-old boy who admitted to swallowing

magnets after ferromagnetic material was noted in
abdomen by metal detector in MRI suite. Serial radiographic follow-up shows chain of metallic objects (arrow) that maintain spatial relationship to each other
in space and time for more than 4 days, remaining in
left hemiabdomen. Beads were removed surgically.
Enteroenteric fistula discovered intraoperatively was
likely due to pressure necrosis.

Fig. 122.5-year-old boy with history of battery ingestion who was brought to hospital with signs of complete
small-bowel obstruction. (Courtesy of Blumfield E, Albert Einstein College of Medicine, Bronx, NY)
A, Frontal abdominal radiograph reveals dilated small bowel loops consistent with obstruction. One of three
foreign bodies (curved arrow) is homogeneously dense. Other two objects have lucent rim, consistent with disk
batteries.
B, Lateral abdominal radiograph shows two disk batteries, identified by beveled edges (straight black and white
arrows) connected by another metallic object (curved white arrow). During surgery, lithium CR927 battery attached to magnet was recovered from distal ileum, and second disk battery was identified in other small-bowel
loop. Necrosis and perforation were evident in both bowel segments. Note that one disk battery (straight black
arrow) is projecting on opposite side of bowel wall relative to magnet (curved white arrow), illustrating attachment to magnet across bowel wall.

AJR:203, July 2014 49

Guelfguat et al.

Downloaded from www.ajronline.org by 112.215.66.70 on 08/18/14 from IP address 112.215.66.70. Copyright ARRS. For personal use only; all rights reserved

Fig. 137-year-old boy who had two groups of

magnets surgically removed from small bowel. Radiograph reveals central gap between two magnet conglomerates, suggesting entrapment of bowel wall.
With kind permission from Springer
Science+Business Media: Pediatric Radiology,
Imaging pediatric magnet ingestion with surgicalpathological correlation, volume 43, 2012, 851858,
Otjen JP, Rohrmann CA Jr, Iyer RS [29].

Fig. 14Cropped radiographs of four different patients highlight distinguishing features of disk battery from coin.
A, En face view of battery shows double-density shadow, or halo (arrow), due to bilaminar structure of battery.
B, Coin (arrow) does not have double density on en face projection.
C, End on view shows step-off (arrow) at junction of cathode and anode.
D, Coin (arrow) does not have step-off in this projection.

50

AJR:203, July 2014

Downloaded from www.ajronline.org by 112.215.66.70 on 08/18/14 from IP address 112.215.66.70. Copyright ARRS. For personal use only; all rights reserved

Imaging of Ingested Foreign Bodies

Fig. 1555-year-old
woman with end-stage
renal disease receiving
hemodialysis who had
been using oral calcium
acetate. She presented
with symptoms of esophageal obstruction preceded by 2-day history of
worsening dysphagia.
A, Sagittal maximumintensity-projection CT,
bone windows, shows
obstructing calcific mass
(white arrow) and food
stasis (black arrow)
above level of obstruction.
B, Bolus of crystallized
calcium obstructing
lower cervical esophagus corresponding to CT
finding was found and
removed on endoscopy.

Fig. 1669-year-old man who developed smallbowel obstruction 1 year after examination with
endoscopic capsule. Examination was negative, but
no obvious excretion of capsule was noted at that
time. Intraluminal location of foreign body (black arrow) representing capsule (Pillcam SB2, Given Imaging) was confirmed intraoperatively with fluoroscopy
by placement of metallic probe (white arrow) next to
palpable intraluminal mass.

Fig. 1727-year-old man from Central American

country with vomiting. More than 40 drug containers
were surgically removed. (Courtesy of Obedian M,
Strong Memorial Hospital, Rochester, NY)
AC, Multiple drug-containing radiopaque packets (white straight arrows, AC) are visualized on
abdominal radiograph (A), coronal CT multiplanar
reconstruction (B), and 3D volume-rendered image
(C). Note small-bowel distention (black arrow, A) due
to obstruction. Lucent line of trapped air between
container wall and content (white curved arrows, A
and B) is radiographic feature helpful in identification
of drug packets.

AJR:203, July 2014 51

Downloaded from www.ajronline.org by 112.215.66.70 on 08/18/14 from IP address 112.215.66.70. Copyright ARRS. For personal use only; all rights reserved

Guelfguat et al.

Fig. 1869-year-old woman with distant history of pyloroplasty who presented with 2 months of worsening
abdominal pain.
A, Abdominal radiograph reveals mottled left abdominal mass (arrows).
B, Coronal CT multiplanar reconstruction shows partially obstructive phytobezoar (arrows) markedly distending stomach. Diagnosis was confirmed endoscopically.

Fig. 1953-year-old woman who presented with nausea, vomiting, and abdominal pain 3.5 months after Roux-en-Y gastric bypass surgery.
A, CT scan, soft-tissue windows, revealed small-bowel obstruction (curved arrow) with dilated small-bowel loops. Transition point (straight arrow) was localized to distal
small bowel.
B, Same slice in lung windows showed substance that did not look like feces and was therefore suggestive of bezoar (arrow). Gross examination of substance revealed
minimally chewed piece of pineapple.

52

AJR:203, July 2014

Downloaded from www.ajronline.org by 112.215.66.70 on 08/18/14 from IP address 112.215.66.70. Copyright ARRS. For personal use only; all rights reserved

Imaging of Ingested Foreign Bodies

Fig. 20Diagram of most common points of impedance to passage of foreign bodies in gastrointestinal tract,
as described elsewhere [98, 99]. Each site of impedance (curved white arrows) is marked on corresponding CT
image. (Drawing by Guelfguat M)

Fig. 2133-year-old man from long-term psychiatric facility who ingested multiple foreign bodies.
A, Postoperative removal photograph revealed diverse collection ranging from plastic ballpoint pen (black arrow) to USB cable (white arrow).
B, Preoperative coronal CT multiplanar reconstruction identified numerous gastric foreign bodies. Note that plastic ballpoint pen (black
arrow) is radiolucent, whereas USB cable is radiopaque (white arrow). Multiple disposable plastic spoons (arranged to right of ballpoint pen
in A) are radiolucent and not visualized on CT.

F O R YO U R I N F O R M AT I O N

This article is available for CME and Self-Assessment (SA-CME) credit that satisfies Part II requirements for
maintenance of certification (MOC). To access the examination for this article, follow the prompts associated with
the online version of the article.

AJR:203, July 2014 53