Introduction

Studies have shown that most foreign body (FB) pass without the need for intervention (1).
European Society of Gastrointestinal Endoscopy (ESGE) recommends urgent endoscopic retrieval of high-risk objects such as sharp, blunt (magnets, button batteries) and long objects,(2) but decision regarding endoscopic retrieval is often taken ‘case by case’ with variation in clinical practice.

Aims & Methods

We set out to evaluate and compare outcomes in cases where FB ingestion was managed conservatively versus cases where an attempt at gastroscopy (OGD) retrieval was undertaken.
This was a retrospective cohort analysis performed in a large tertiary centre reviewing FB ingestion presentations between January 2020 to December 2024. Cases were identified using an electronic coding system and adults (aged 18 and above) were included. Food impaction cases were excluded. Data analysis included demographics, early warning score (EWS) at presentation, prior FB ingestion and intervention episodes. FB type was categorised as blunt, long (5cm or more), sharp and other. Location of FB in the gastro-intestinal tract at presentation was documented where possible. For analysis, groups were categorised to those who had OGD versus those conservatively managed (no OGD).
Outcomes were categorised as eventful (defined as requiring surgical intervention for retrieval or complications such as perforation, obstruction, hemorrhage, foreign body migration through the digestive wall or death) or uneventful, defined as foreign body passing through spontaneously. Length of hospital stay (LOS) was also compared between both groups.
Chi squared, Man Whitney U and Kruskal-Wallis test were used for statistical evaluation. P value of less than 0.05 is considered significant.

Results

A total of 119 presentations were analysed (n=73 Females n=46 Males) with a median age of 38 years. Median EWS at presentation was 1. Location of FB identified at presentation were as follows; oesophagus n=11, stomach n=72, beyond n=27, radiolucent n=9.
Categories of FB, comparison between groups (OGD versus no OGD) and outcome is summarised in table 1.
Overall, 0.08% (n=7 for OGD and n=3 for no OGD respectively) of presentations had an eventful outcome. There is no significant difference observed in the number of eventful outcomes between the OGD and no OGD group (p=0.282). There is no significant difference in LOS (days) between the two groups (OGD group median = 3 days IQR 3 versus no OGD; median = 2 days IQR 4, p 0.198)
Eventful outcome occurred in all categories of FB (blunt n=3, sharp n=3, long n=3, other n=1) and location (oesophagus n=2, stomach n=7, beyond n=1).
There is a trend that those who had intervention previously for FB ingestion will have had more overall presentations (Kruskall-Wallis p=0.044).

Table 1 - Category of foreign body, OGD performed, outcomes and comparison.

Conclusion

Our study observed an overall low eventful outcome following foreign body ingestion presentation. There is no significant difference in outcomes and LOS between patients who had OGD versus those managed conservatively.

References

1. Tambakis G, Schildkraut T, Delaney I, Gilmore R, Loebenstein M, Taylor A, Holt B, Tsoi EH, Cameron G, Demediuk B, Miller A, Connell W, Wright E, Thompson A, Holmes J. Management of foreign body ingestion in adults: Time to STOP and rethink endoscopy. Endosc Int Open. 2023 Dec 12;11(12):E1161-E1167. doi: 10.1055/a-2201-6928. PMID: 38094028; PMCID: PMC10715904.
2. Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) clinical guidelines. http://dx.doi.org/ 10.1055/s-0042-100456 Published online: 0.0.2016 Endoscopy 2016; 48: 1–8 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0013-726X

Introduction

Advances in non-celiac wheat sensitivity (NCWS) have proved that it should be considered a protean condition in which several potential triggers [e.g. gluten, wheat amylase-trypsin inhibitors, etc.] might determine an intestinal mucosal damage with increased permeability and exposure of foods/microbial peptides to immune cells (1,2), resulting in both a local and systemic inflammatory activation responsible for its gastrointestinal and extraintestinal manifestations (3,4). Up to 75% of NCWS subjects complain of multiple foods hypersensitivities (MFH) (5). These patients usually have clinical, immunological and histological features similar to wheat allergy patients, although without positive gluten/wheat IgE assays, allowing to hypothesize the existence of a non-IgE mediated hypersensitivity. In addition, several studies have reported an association between atopic diseases and NCWS.

Aims & Methods

This study aimed to define the presence and features of atopic diseases and other hypersensitivities (primarily food allergies/intolerances) in NCWS compared with celiac disease (CD) and irritable bowel syndrome/functional dyspepsia (IBS/FD) and to analyze a possible correlation between these diseases and NCWS clinical manifestations. This retrospective, multicenter study included NCWS patients diagnosed by double-blind placebo-controlled challenge with wheat. Their clinical, laboratory and histology data at diagnosis (i.e. before the start of a wheat-free diet) were analyzed and compared to control subjects with CD and IBS/FD. Specific allergology data, other than clinical/laboratory features typical of NCWS, were collected and analyzed: family and personal history of atopic diseases, type of allergens responsible, positivity of skin prick tests (SPT), patch tests and total and food-specific IgE.

Results

Atopic disease prevalence was higher in NCWS (32.8%) than in CD (19.3%) and IBS/FD (21.5%) (P=.001 for both). Similarly, NCWS subjects had a higher frequency of MFH (39.8%) and self-reported milk intolerance (SRMI) (65.9%) compared to the controls (P <.001 for both). Allergic asthma, either alone (P=.03) or associated with allergic rhinitis (P=.005), was more prevalent in NCWS compared to IBS/FD, which was more often associated with allergic conjunctivitis (P=.004) or allergic rhinitis alone (P=.02). Graminaceae hypersensitivity and nickel allergic contact dermatitis (Ni-ACD) were more frequent in patients with NCWS (70.1% and 17.8%) vs both CD (48.7% and 9.4%, P=.03 and P=.01, respectively) and IBS/FD (50.8% and 6.7%, P=.01 and P<.001, respectively). On multiple logistic regression analysis, a coexistent atopic disease (OR 1.481), MFH (OR 3.882) and SRMI (OR 2.259) were associated with the NCWS diagnosis. NCWS subjects with atopy compared to those without more frequently had Ni-ACD (P<.001) and SRMI (P=.03), positive patch test (P<.001), SPT for foods (P=0.001) and both total and food-specific serum IgE (P=.02 and P=.002, respectively). On multiple logistic regression analysis, positivity to patch test (OR 2.955), SPT for foods (OR 5.799), and food-specific serum IgE (OR 3.101) were confirmed as differentiating the 2 subgroups.

Conclusion

NCWS subjects have a higher frequency of atopic disease, MFH and SRMI compared to both CD and IBS/FD ones. These conditions could be expression of an underlying hypersensitivity milieu characterizing NCWS and might be of support in the differential diagnosis between NCWS and functional gastrointestinal disorders, if inserted into a broader diagnostic panel.

References

1) Zevallos VF, Raker V, Tenzer S, Jimenez-Calvente C, Ashfaq-Khan M, Rüssel N, et al. Nutritional Wheat Amylase-Trypsin Inhibitors Promote Intestinal Inflammation via Activation of Myeloid Cells. Gastroenterology. 2017;152:1100-1113.e12.
2) Uhde M, Ajamian M, Caio G, De Giorgio R, Indart A, Green PH, et al. Intestinal cell damage and systemic immune activation in individuals reporting sensitivity to wheat in the absence of coeliac disease. Gut. 2016;65:1930–7.
3) Volta U, De Giorgio R, Caio G, Uhde M, Manfredini R, Alaedini A. Nonceliac Wheat Sensitivity. Gastroenterol Clin North Am. 2019;48:165–82.
4) Catassi C, Elli L, Bonaz B, Bouma G, Carroccio A, Castillejo G, et al. Diagnosis of Non-Celiac Gluten Sensitivity (NCGS): The Salerno Experts’ Criteria. Nutrients. 2015;7:4966–77.
5) Carroccio A, Mansueto P, Iacono G, Soresi M, D’Alcamo A, Cavataio F, et al. Non-Celiac Wheat Sensitivity Diagnosed by Double-Blind Placebo-Controlled Challenge: Exploring a New Clinical Entity. American Journal of Gastroenterology. 2012;107:1898–906.

Disclosure

This study is funded by the European Union - Next Generation EU, Mission 4, Component 1 CUP B53D23031860001, Project Code: P2022Z9RZY_001.