Video
The ingestion of foreign bodies (FBs) is a common indication for endoscopy. About 80% to 90% of cases resolve with spontaneous passage through the GI tract. In cases that do not present spontaneous resolution, endoscopy (10%-20%) or surgery (1%) may be necessary.1
The approach to endoscopic management depends on the type of FB ingested and the patient’s clinical condition. Two studies have shown that the purposeful ingestion of FBs increases the need for endoscopic (63%-73% of cases) or surgical intervention (12%-16%).2,3
Some endoscopic and radiological findings can lead to a more significant therapeutic challenge. FBs penetrating through the mucosa or even outside the GI tract are, in most cases, managed surgically. However, with the development of new techniques in specialized centers, it is possible to attempt to treat extraluminal FBs using minimally invasive techniques, such as EUS.4,5
In this case, we show the use of EUS to treat a pancreatic foreign body.
Clinical Case
A 45-year-old female presented to the emergency department with 16 days of intense epigastric pain associated with nausea, vomiting, and fever. Laboratory tests were notable for hemoglobin 12.3, leukocytes 13.4, C-reactive protein 5.2, and amylase 30. An abdominal CT scan (Video 1, available online at www.videogie.org) showed a FB located at the head/body of the pancreas, measuring 5 cm, without contact with the luminal wall (Fig. 1).
Figure 1.
Abdominal CT scan showing a foreign body located at the head/body of the pancreas, measuring 5 cm, without contact with the gastric wall or the duodenum.
Upper endoscopy showed an orifice in the lesser curvature of the antrum with drainage of purulent secretions (Fig. 2).
Figure 2.
Orifice with drainage of purulent secretion, located in the lesser curvature of the antrum.
An EUS was performed, and the FB was observed inside the pancreatic parenchyma (Fig. 3). Under ultrasound image control, FB forceps were used to remove the object through the fistulous orifice (Figs. 4 and 5).
Figure 3.
Foreign body inside the pancreatic parenchyma seen using EUS.
Figure 4.
Foreign body forceps passed through the working channel of the echoendoscope and introduced into the foreign body entry hole.
Figure 5.
Under ultrasound vision, it is possible to see forceps attached to the foreign body in the fistulous tract.
The FB follows the path of the forceps, insinuating itself into the stomach, making it possible to observe its externalized extremity under endoscopic vision (Figs. 6 and 7).
Figure 6.
Ultrasonographic image showing foreign body insinuating itself into the stomach after traction with forceps.
Figure 7.
End of the foreign body exteriorized through the fistulous orifice, visualized under endoscopic vision.
The removal was completed by traction of the externalized extremity, through the orifice using FB forceps (Fig. 8). Final appearance of the FB is shown in Figure 9.
Figure 8.
Removal of the foreign body under direct endoscopic vision by traction of the externalized extremity through the orifice.
Figure 9.
Final appearance of foreign body after its removal.
The patient received antibiotics and was discharged 9 days after the FB removal without fever or abdominal pain.
A repeat CT scan performed 2 weeks after removal of the FB was normal and revealed no abdominal collections or other signs of adverse events.
Conclusion
Accidental or deliberate ingestion of FBs is a frequent cause of indications for endoscopic examinations. Penetration of the FB through the GI tract mucosa is uncommon and requires more invasive treatment.
EUS can help locate ingested objects that have passed through the organ wall. In some cases, EUS can also be presented as an alternative to their removal, avoiding more invasive procedures and higher morbidity and mortality.
Disclosure
The authors disclosed no financial relationships relevant to this publication.
Supplementary data
SLIDE 1: “EUS-guided pancreatic foreign body removal”
SLIDE 2: [Empty]
SLIDE 3: “Keywords”
SLIDE 4:
- “Primary author: Lucio Rossini”
- “Secondary authors: Nathan Watanabe, Leonardo Saguia, Maurício Soares, and Vitor Alves”
SLIDE 5: “Author disclosures”
SLIDE 6: “Equipment”
SLIDE 7:
- “The ingestion of foreign bodies is a common indication for endoscopy.”
- “In cases that do not present spontaneous resolution, endoscopy (10%-20%) or surgery (1%) may be necessary.”
- “Foreign bodies outside the GI tract are, in most cases, surgically resolved.”
- “However, with the development of new techniques, it is possible to attempt to treat extraluminal foreign bodies using minimally invasive techniques.”
SLIDE 8:
- “A 45-year-old female presented to the emergency room with 16 days of intense epigastric pain associated with nausea, vomiting, and fever.”
- “Entry laboratory tests: hemoglobin 12.3, leukocytes 13.4, C-reactive protein 5.2, amylase 30.”
SLIDE 9:
- “An abdominal CT scan showed a foreign body located at the head/body of the pancreas, measuring 5 cm, without contact with the luminal wall.”
- “The patient was kept fasting and an upper digestive endoscopy was performed to insert a nasoenteral tube.”
- “Upper endoscopy showed an orifice in the lesser curvature of the antrum with drainage of purulent secretions.”
- “An EUS was performed, and the foreign body was observed inside the pancreatic parenchyma.”
- “A foreign body forceps is passed through the working channel of the echoendoscope and introduced into the foreign body entry hole.”
- “With forceps inserted into the fistulous tract, the transducer is advanced to the duodenal bulb.”
- “Under ultrasound vision, the forceps are opened and closed, with seizure of the end of the foreign body.”
- “At this point, we pull the foreign body, maintaining the ultrasound view.”
- “It is noted that the foreign body follows the path of the forceps, but at a certain moment, it detaches itself from the forceps.”
- “Observing the endoscopic image, it is possible to notice that one of the extremities of the seized foreign body came out through the entrance orifice, allowing its removal under direct vision.”
- “Next, the final appearance of the orifice is examined.”
- “No closure of the puncture was performed.”
SLIDE 10:
- “The patient received antibiotics and was discharged 9 days after the foreign body removal without fever or abdominal pain.”
SLIDE 11:
- “A repeat CT scan performed 2 weeks after removal of the foreign body was normal and revealed no abdominal collections or other signs of complications.”
SLIDE 12:
- “Accidental or deliberate ingestion of foreign bodies is a frequent cause of indications for endoscopic examinations.”
- “Penetration of the foreign body through the GI tract mucosa is uncommon and requires more invasive treatment.”
- “EUS can help locate ingested objects that have passed through the organ wall.”
- “With luck, EUS can also be presented as an alternative to foreign body removal, avoiding more invasive procedures with higher morbidity and mortality.”
References
- 1.Birk M., Bauerfeind P., Deprez P.H., et al. Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016;48:489–496. doi: 10.1055/s-0042-100456. [DOI] [PubMed] [Google Scholar]
- 2.Cao L., Chen N., Chen Y., et al. Foreign body embedded in the lower esophageal wall located by endoscopic ultrasonography: a case report. Medicine (Baltimore) 2018;97 doi: 10.1097/MD.0000000000011275. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.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(Pt 1):426–433. doi: 10.1016/j.gie.2008.05.072. [DOI] [PubMed] [Google Scholar]
- 4.Wang X.M., Yu S., Chen X. Successful endoscopic extraction of a proximal esophageal foreign body following accurate localization using endoscopic ultrasound: a case report. World J Clin Cases. 2019;7:1230–1233. doi: 10.12998/wjcc.v7.i10.1230. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Panchal A., Shankar U., Chun S., Budwal A.S., Anyadike N. Use of EUS for localization of an ingested needle penetrating through the stomach to the pancreas: 2091. Am J Gastroenterol. 2017;112:1157–1158. [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
SLIDE 1: “EUS-guided pancreatic foreign body removal”
SLIDE 2: [Empty]
SLIDE 3: “Keywords”
SLIDE 4:
- “Primary author: Lucio Rossini”
- “Secondary authors: Nathan Watanabe, Leonardo Saguia, Maurício Soares, and Vitor Alves”
SLIDE 5: “Author disclosures”
SLIDE 6: “Equipment”
SLIDE 7:
- “The ingestion of foreign bodies is a common indication for endoscopy.”
- “In cases that do not present spontaneous resolution, endoscopy (10%-20%) or surgery (1%) may be necessary.”
- “Foreign bodies outside the GI tract are, in most cases, surgically resolved.”
- “However, with the development of new techniques, it is possible to attempt to treat extraluminal foreign bodies using minimally invasive techniques.”
SLIDE 8:
- “A 45-year-old female presented to the emergency room with 16 days of intense epigastric pain associated with nausea, vomiting, and fever.”
- “Entry laboratory tests: hemoglobin 12.3, leukocytes 13.4, C-reactive protein 5.2, amylase 30.”
SLIDE 9:
- “An abdominal CT scan showed a foreign body located at the head/body of the pancreas, measuring 5 cm, without contact with the luminal wall.”
- “The patient was kept fasting and an upper digestive endoscopy was performed to insert a nasoenteral tube.”
- “Upper endoscopy showed an orifice in the lesser curvature of the antrum with drainage of purulent secretions.”
- “An EUS was performed, and the foreign body was observed inside the pancreatic parenchyma.”
- “A foreign body forceps is passed through the working channel of the echoendoscope and introduced into the foreign body entry hole.”
- “With forceps inserted into the fistulous tract, the transducer is advanced to the duodenal bulb.”
- “Under ultrasound vision, the forceps are opened and closed, with seizure of the end of the foreign body.”
- “At this point, we pull the foreign body, maintaining the ultrasound view.”
- “It is noted that the foreign body follows the path of the forceps, but at a certain moment, it detaches itself from the forceps.”
- “Observing the endoscopic image, it is possible to notice that one of the extremities of the seized foreign body came out through the entrance orifice, allowing its removal under direct vision.”
- “Next, the final appearance of the orifice is examined.”
- “No closure of the puncture was performed.”
SLIDE 10:
- “The patient received antibiotics and was discharged 9 days after the foreign body removal without fever or abdominal pain.”
SLIDE 11:
- “A repeat CT scan performed 2 weeks after removal of the foreign body was normal and revealed no abdominal collections or other signs of complications.”
SLIDE 12:
- “Accidental or deliberate ingestion of foreign bodies is a frequent cause of indications for endoscopic examinations.”
- “Penetration of the foreign body through the GI tract mucosa is uncommon and requires more invasive treatment.”
- “EUS can help locate ingested objects that have passed through the organ wall.”
- “With luck, EUS can also be presented as an alternative to foreign body removal, avoiding more invasive procedures with higher morbidity and mortality.”