Gastrointestinal foreign bodies and foreign body intestinal obstruction in children

　　1. Etiology

　　Foreign bodies entering the gastrointestinal tract are called gastrointestinal foreign bodies. About 95% of foreign bodies that can pass through the esophageal stricture can be excreted from the body. Among them, esophageal foreign bodies are the most common, followed by the stomach and intestines. Gastrointestinal foreign bodies are divided into 3 categories:

　　1. Exogenous foreign bodies are often due to children playing with foreign objects in their mouths and accidentally swallowing them into the digestive tract. There are also cases where children swallow them due to mental abnormalities, but these are rare in children. There are many types of foreign bodies, which can be divided into metallic and non-metallic categories. The metallic ones include: coins, safety pins, screws, jewelry, nails, knives, needles, tacks, keys, badges, etc.; even more so, there are toy cars, toy planes, and so on. The non-metallic ones include: fruit seeds, bone fragments, buttons, building blocks, glass, meat balls, fish bones, hard plastic, etc. Someone summarized that among the 62 upper gastrointestinal foreign bodies removed by gastroscopy, there were 23 metal items, 13 glass items, 6 hard plastic items, 9 fruit seeds, and 11 meat balls, which shows the diversity of exogenous foreign bodies.

　　2. Endogenous foreign bodies are rare in children and are produced outside the digestive tract. For example, gallstones can enter the stomach through a gallbladder-duodenal fistula, or enter the intestines. There are reports of intestinal obstruction caused by gallstones. Roundworms entering the stomach or esophagus through the pylorus are also endogenous foreign bodies.

　　3. The formation of foreign bodies in the digestive tract is often due to the intake of a large amount of fibrous foods, fruits, or swallowing hair and other substances within a short period of time, which form clumps in the stomach or intestines after the action of the digestive tract and digestive juices. Those in the stomach are called 'gastric stones', and those in the intestines are called 'fecal stones'. The clinical manifestations and treatment methods of gastrointestinal foreign bodies are closely related to the nature of the foreign bodies and the site of impaction. Most foreign bodies can be excreted smoothly, and those that are difficult can be tried to be removed with a gastroscopy. Only a few individual cases require surgical treatment.

　　Second, Pathogenesis

　　Pediatric gastrointestinal foreign bodies are most commonly exogenous, followed by gastric stones and fecal stones, with rare endogenous cases. The entry of foreign bodies into the gastrointestinal tract is considered gastrointestinal foreign bodies. Larger foreign bodies can cause gastrointestinal obstruction, while sharp foreign bodies can cause bleeding due to damage to the gastrointestinal mucosa and perineal abrasions. Sharp foreign bodies can also stick to the walls of the stomach or intestines, even causing perforation and entering the abdominal cavity. After perforation, they often adhere to surrounding organs, hence the rarity of severe peritonitis. Foreign bodies that are too long to pass through the duodenum curve can cause serious complications. Toxic or corrosive foreign bodies can cause serious complications. Endogenous foreign bodies, such as gallstones, have been reported to cause intestinal obstruction in adults, but are very rare in children. Gastric stones and fecal stones will be discussed in this section.

　　There is an uncomfortable feeling in the abdomen, followed by periumbilical pain, and the abdominal pain gradually intensifies. When the obstruction is more complete, frequent vomiting occurs. Gastric stones that remain in the stomach can cause indigestion, nausea, vomiting, loss of appetite, discomfort in the stomach, and mild abdominal pain. Larger or sharp foreign bodies can cause abdominal colic, bleeding, intestinal perforation, and peritonitis, and can also lead to gastric or intestinal obstruction.

　　Circular, ovoid, or cuboid gastrointestinal foreign bodies without sharp corners can generally be quickly excreted from the rectum, so children often have no symptoms. Individual sharp, elongated objects, such as needles, nails, and open safety pins, are also rarely pierced through the intestinal or gastric walls. Even if pierced, as they gradually pass through the digestive tract, they are often surrounded by fibers and do not cause acute perforative peritonitis. Most of these foreign bodies can turn their blunt ends forward and be excreted from the body on their own, without causing harm to the child. X-rays can be used to track the non-X-ray penetrable foreign bodies. If the foreign body penetrates X-rays, barium can be swallowed to observe for any filling defects. If the foreign body remains in one place for too long, it is often not excreted from the body on its own. If fecal stones cause intestinal obstruction, it generally presents with symptoms of simple intestinal obstruction, with a delayed onset. Early symptoms include discomfort in the abdomen, followed by periumbilical pain, which gradually intensifies. When the obstruction is more complete, frequent vomiting occurs. Gastric stones that remain in the stomach can cause indigestion, nausea, vomiting, loss of appetite, discomfort in the stomach, and mild abdominal pain. When examining the upper abdomen, a large, movable hard mass can often be felt. Small intestinal fecal stones are difficult to feel, and those in the rectum can be felt during rectal examination as a large, hard fecal mass.

　　Gastrointestinal foreign bodies are completely preventable, and education should be widely provided to parents and caregivers, mainly strengthening the supervision of infants and young children:

　　1. Children under 3 years of age who have not yet erupted their molars should not be given peanuts, walnuts, beans, and other foods with seeds.

　　2. Do not choose 'dangerous' toys for children, and items that young children may swallow should not be used as toys.

　　3. Do not allow children to run and jump around while eating to prevent swallowing foreign bodies when they fall.

　　4. Do not frighten, amuse, or scold while eating to avoid crying or laughing and accidentally swallowing.

　　5. Educate children to get rid of bad habits such as biting pen caps, whistles, and small toys.

　　6. Pay special attention to feeding critically ill and unconscious patients to prevent accidental swallowing.

　　7. Good defecation habits are important to prevent fecal stone obstruction, which is often caused by children having poor defecation habits or ingesting a large amount of inedible foods with seeds, which accumulate in the small intestine or colon and cannot be excreted, causing intestinal obstruction.

　　First, X-ray examination

　　Photograph the posterior-anterior and lateral views of light-blocking foreign bodies to determine their location and shape. For non-light-blocking foreign bodies, swallow barium or swallow barium mixed with cotton fibers during filming, so that the barium fibers adhere to the foreign body and become visible, and can track its path, but attention should be paid to the following points:

　　1. A negative X-ray examination cannot exclude a foreign body.

　　2. The residual barium after swallowing affects the observation and grasping of the endoscope.

　　3. In case of perforation, the barium can spread to the surrounding tissues, causing serious consequences.

　　Second, fiberoptic gastroscopy

　　It is possible to directly observe the shape, nature, and location of the foreign body, and it is generally believed that using a gastroscopy for the treatment of children with esophageal foreign bodies is safe and reliable, and can use foreign body forceps to remove the foreign body.

　　1. Eat foods rich in protein and iron, such as lean meat, fish and shrimp, animal blood, animal liver and kidney, egg yolk, soy products, and jujube, green leafy vegetables, sesame paste, etc.

　　2. Use vegetable oils, and cook mainly by boiling, steaming, cold dish, frying, roasting, pickling, and stewing; avoid foods high in cholesterol such as fatty meat, internal organs, fish eggs, and butter.

　　3. Avoid foods that produce gas, such as milk, soy milk, and foods rich in rough fiber, such as celery, soybean sprouts, and onions.

　　4. Abstain from foods high in dietary fiber and gas-producing foods before surgery, such as celery, cabbage, rapeseed, radish, potato, sweet potato, soybean, broad bean, etc. Avoid greasy, rough, fishy, and greasy foods after surgery, such as fatty meat, animal internal organs, brown rice, dog meat, mutton, beef, smoked fish, etc.

　　I. Treatment

　　Generally, gastrointestinal foreign bodies, except for esophageal foreign bodies that require immediate removal through esophagoscopy, do not require treatment. In terms of diet, general diet should be maintained, and the diet should not be changed. Some high-fiber foods can be taken to increase the amount of stool to facilitate the excretion of foreign bodies. It is禁忌 to use laxatives to prevent intestinal motility disorders and injury to the intestinal wall. Gastrointestinal foreign bodies usually do not cause abdominal distension. If the abdomen is soft and the foreign body mass can be felt, such as gastric stones formed by black jujube or fecal stones in the colon, they can be pressed through the abdominal wall under anesthesia or examined by digital rectal examination, and the large pieces can be捏成小块, combined with the administration of traditional Chinese medicine for the treatment of accumulation and knotting, which can often be excreted spontaneously and cured. If the foreign body remains fixed in one place for a long time, and symptoms such as complete intestinal obstruction, intestinal perforation, peritonitis, and intestinal bleeding occur, surgical treatment is required. Foreign bodies containing harmful chemical substances (such as lead and mercury) should not remain in the intestines for too long and should be removed early and actively.

　　1. Generally, only observation and waiting for the foreign body to pass spontaneously is recommended, and it is not advisable to use laxatives or change the diet, as this may increase gastrointestinal motility, making the foreign body more likely to become lodged or cause gastric or intestinal perforation.

　　2. High-fiber foods can help sharp foreign bodies pass. There is a report of a case where a small knife was accidentally swallowed and remained in the stomach in an open position. It was advised to eat high-fiber foods, such as stir-fried chives that are not cut, and the next day the small knife was safely excreted wrapped in the plant fibers of the chive, without any injury to the gastrointestinal tract. In the aforementioned report by Li Shuanwei on the failure of 3 cases of upper gastrointestinal foreign bodies treated with gastroscopy, 2 cases were sharp metal pieces embedded in the middle segment of the esophagus, and there was a risk of perforation when forcibly removed. They were advised to consume high-fiber diets, and the next day the foreign body was excreted outside the body without complications. This shows that high-fiber diets have a certain protective effect on sharp foreign bodies. In cases where there are no other treatment conditions available, or parents refuse gastroscopy or surgical treatment, high-fiber diets can be tried under strict monitoring.

　　3. Medication Some believe that according to the treatment principle that should make the foreign body easy to pass, paraffin oil, inert powders such as kaolin, bismuth preparations, and others can be given to help the foreign body pass smoothly.

　　4. Other cases with secondary infection should be given anti-infection treatment in a timely manner. In cases of dehydration, bleeding, and others, appropriate treatments such as intravenous fluid therapy, blood transfusion, and hemostasis should be provided.

　　II. Prognosis

　　After the removal or extraction of gastrointestinal foreign bodies, the prognosis is good. However, if perforation occurs, abdominal peritonitis can lead to adhesion sequelae.