The type and incidence of foreign bodies ingested and reported vary by geographic region and the specialty of the authors. One of the largest reports published in the last two decades was by Nandi and Ong, who reported 2934 foreign body ingestions in China in the British Journal of Medicine. Eighty-four percent of the foreign bodies ingested in their series were fish bones, which were usually lodged in the esophagus. Three hundred and forty-three children were included in the series. Ingestions of fish bones were reported in 146 of the children, but coin ingestion was the second most common type of ingestion in children, accounting for 134 cases in the same series. In the United States, coin ingestion is the most common type of foreign body ingested during childhood. The exact incidence of foreign body ingestion in the United States is unknown, but data from the American Association of Poison Control Centers suggests that in 2004 alone there were more than 109,000 cases of foreign body ingestion by children and adolescents. Data from Sweden’s National Health Service indicate an incidence of foreign body ingestion of 122/million population per year. Approximately 1500 deaths in patients of all ages are caused annually in the United States by foreign body ingestion.

Approximately 80% of cases of foreign body ingestion occur in children, predominantly between the ages of 6 and 36 months, with coins being the objects most often ingested. In adults, the most common unintentional ingestions that become lodged are meat and fish bones. Intentional ingestions occur primarily in psychiatrically impaired individuals and prisoners. Individuals under the influence of alcohol may unintentionally swallow objects because their perception is impaired. Foreign body ingestions by gang members as part of initiation practices are becoming more frequent. A significant number of foreign body ingestions do not come to medical attention, and the objects pass without incident. It is estimated that 80% to 90% of foreign bodies ingested that come to medical attention pass spontaneously. For 10% to 20%, endoscopic removal is required, and surgery is ultimately required for 1% or fewer. Perforation of the intestinal tract, the most serious sequela of foreign body ingestion, occurs in less than 1% of cases. The higher rates reported in some series are primarily related to the subspecialty of the authors reporting the data. For example, the perforation rate would be anticipated to be higher in series reported by thoracic surgeons than in a series of all patients presenting to
an emergency room for evaluation. Sharp objects are associated with a higher perforation rate than dull objects. Approximately 75% of perforations occur at the appendix or near the ileocecal valve. Foreign body entrapment and subsequent perforation are also more likely to occur in the region of a congenital malformation, such as a Meckel diverticulum, or at a site of prior surgery.

The largest number of foreign bodies ingested by a single individual was 2533, reported by Chalk et al. in 1928. The woman, who had melancholia, was sent to a sewing room for therapy, where she ingested an assortment of pins, needles, and bobbins. Remarkably, the objects passed uneventfully, and the patient survived. In 1987, Henderson et al. reported a case of ingestion of 500 straight pins, which resulted in the patient’s death within 2 months as a consequence of multiple intestinal perforations. High number foreign body ingestions continue to be reported in the psychiatrically impaired, who may “save their treasure” by ingesting a variety of objects and who typically present with abdominal pain, distension, obstruction, and anemia, and require surgical removal of the foreign bodies, which may weigh several kilograms. One of the most remarkable reports of foreign body ingestion was by Yamamoto et al. in 1985, who reported the endoscopic removal of a chopstick from the duodenum of a 71-year-old man who had ingested the object 60 years earlier.

Most foreign bodies that reach the stomach pass uneventfully through the remainder of the gastrointestinal tract within 4 to 6 days. Patients are instructed to consume a regular diet. The use of prokinetic agents such as metoclopramide is not indicated to increase the speed of passage. Parents should monitor the stools of their children to detect passage of the foreign body. Metal detectors have been used by a few for this purpose. If a patient is asymptomatic and the foreign body has not been noted in the stool, we generally recommend waiting for 3 weeks before obtaining an x-ray film to localize a known gastric foreign body. We generally wait an additional 3 weeks after obtaining the xray film if the patient remains asymptomatic, and obtain a second film 6 weeks after the ingestion. If the object is still in the stomach, we recommend endoscopic removal at that time. We have anecdotally noted that in cases of ingestion of multiple coins, gastric passage may be delayed as the coins appear to adhere to each other and endoscopic removal may be required (Fig. 7.2). No toxicity has been reported from retention of modern zinc containing “copper” pennies following the change in composition of the penny in 1982 to a zinc-predominant coin. Toxicity studies were carried out prior to the release of the various Euro coins with regard to the potential of zinc toxicity following ingestion. These coins have a lower zinc content than the American penny, and to date no cases of zinc intoxication following ingestion have been identified.

Potential problem sites downstream for foreign bodies include the pylorus, the fixed curves of the C loop of the duodenum, and the ileocecal valve. The duodenal C loop poses a problem because of its fixed retroperitoneal location. Objects that require endoscopic removal from the stomach and proximal small intestine can be placed into two categories, those that require removal because of their size and those that require removal because of their composition and physical characteristics.

Objects in the stomach of an adult patient that are longer than 10 cm cannot negotiate the duodenal C loop and therefore should be removed endoscopically at the time of identification. Successful negotiation of the duodenum by a toothbrush has never been reported. An ovoid object with a length of more than 5 cm or a thickness of more than 2 cm is unlikely to pass the pylorus in an adult and should be removed. Appropriate size modifications are required to make recommendations in younger patients. Patients with a congenital malformation, such as a duodenal web, an annular pancreas, or a surgical anastomosis may not be able to pass objects significantly smaller than the sizes indicated above. The size of an object may be magnified on x-ray films, and therefore some estimation is required, or measurement of a similar object can be used if the identity of the ingested object is known.