Bread Bag Clip

Foreign body ingestion is a relatively common occurrence that may cause significant morbidity and mortality. Children under 6 years of age, edentulous adults, and the mentally ill have the highest incidence rates of these ingestions.¹ Once the diagnosis is made, the question arises whether intervention is needed. Most objects pass through the gastrointestinal tract spontaneously; however, approximately 10–20% require endoscopic removal, and, very rarely, a surgical intervention may be warranted.^2,3 The challenge to the clinician is to distinguish patients requiring endoscopic intervention from the majority of patients who require only observation.

The decision for removal is guided by the type of object ingested, the location of impaction, and the clinical presentation. Small blunt objects that have passed through the esophagus can generally be approached conservatively with radiologic imaging and observation. Objects longer than 6 cm may have difficulty traversing the duodenal sweep and therefore should be removed endoscopically prior to the onset of symptoms. Sharp pointed objects should always be removed if it is possible to do so in a safe manner. Toothpicks and stiff wires are associated with a high likelihood of intestinal perforation and should be removed before damage occurs.^4,5 An overtube may be used to protect the mucosa during withdrawal of these types of objects.⁶ Single- and double-balloon enteroscopy offers the endoscopist the opportunity to remove foreign bodies that in the past were too far downstream.⁷ Disk batteries are particularly problematic when lodged in the esophagus⁸; this scenario represents a true endoscopic emergency, as there is potential for the development of liquefactive necrosis. If the patient is asymptomatic and a small (<2 cm) battery passes into the stomach, conservative management is appropriate. Ingested bags of narcotics should not be removed endoscopically except under unusual circumstances, as there is a high risk of accidental perforation of the bag with ensuing absorption of large quantities of the drug.⁹

Ingested bread bag clips are another type of foreign body associated with a high risk of complications. The approach to these clips is problematic, as the diagnosis is often not apparent until a complication has occurred and surgery is necessary. The patient is usually unaware of the ingestion, and imaging such as computed tomography does not help, as the clips are radiolucent.¹⁰ The mechanism of damage stems from the design of the clips. Gastrointestinal mucosa, generally in the small bowel, becomes trapped within the opening of the clip, leading to perforation, obstruction, and/or bleeding.¹¹ Recommendations for redesign or elimination of these clips have been made by a number of experts.¹²

Endoscopic removal of foreign bodies can be accomplished in a number of methods. To aid endoscopists in the removal of these objects, a variety of tools are now available including snares, foreign body forceps, retrieval nets, and overtubes. When a bread bag clip is knowingly ingested, prompt endoscopic removal should be attempted, as the risk of serious impending complication is high.¹³ We successfully removed a bread bag clip from the stomach of a patient who accidentally ingested it. The patient was aware of a foreign body sensation when swallowing and suspected that he had ingested the clip. Subsequent endoscopy revealed the bread bag clip in the stomach. The gastrointestinal mucosa had not been cinched within the jaws of the bread bag clip, therefore making removal with a standard biopsy forceps quite simple.¹⁴ Although there have been many reports of symptomatic ingestion of bread bag clips, there have been few reports of successful endoscopic retrievals, which demonstrates the need for additional foreign body removal equipment. In addition, objects such as bread clips may be found in the small bowel, which cannot be reached with standard endoscopes. Balloon enteroscopy now gives endoscopists the ability to reach these areas, though there are no specialized foreign body forceps available for use with these longer instruments.

In the case study reported by Morrissey and colleagues, a patient presented with gastrointestinal bleeding secondary to ingestion of a bread bag clip.¹⁵ The clip was not visualized on computed tomography, emphasizing the fact that negative radiographs do not rule out a foreign body. On repeat endoscopy, the foreign body was identified, but surgical removal was required. A tool that would give the endoscopist the ability to cut a bread bag clip in half once it becomes firmly imbedded into the mucosa may have allowed for successful endoscopic removal of the clip in this case.

In groups susceptible to foreign body ingestion, such as children and elderly adults with dentures or impaired vision, foreign bodies should always be considered when gastrointestinal symptoms are unexplained. The case report by Morrissey and associates is an important reminder of an uncommon but dangerous foreign body ingestion.