• endoscopic procedures
• endoscopy

We read with interest the paper by Yadollahi et al reporting on their experience of intentional foreign body ingestion (iFoBI).1 We would like to highlight the risks of conservative management, an approach with which we are in general agreement and which has been reported elsewhere.2 A patient presented to the emergency department (ED) stating that he had swallowed two button batteries, a razor blade and a quantity of small change. A chest radiograph demonstrated several round opacities in the stomach, consistent with both coins and batteries. The patient was referred to the duty endoscopist, who arranged urgent endoscopy under general anaesthetic (the patient having refused conscious sedation). An exploratory laparotomy on another patient was delayed to make capacity in the emergency operating theatre schedule. Only coins were identified in the stomach lumen. The patient discharged himself from the recovery ward.

In discussion with colleagues and on review of previous notes, the endoscopist learnt that the patient had presented to ED with a similar history on numerous occasions over 2 years, and that no batteries or sharp objects had ever been retrieved. Psychiatric support had been offered on each occasion but the patient refused to accept this.

The department developed an individual management plan based on the patient’s history of repeated non-dangerous iFoBI combined with European society of Gastrointestinal Endoscopy (ESGE) guidance,3 in order to balance safety of the patient against pressure on endoscopy team and wider impacts on the hospitals acute care services.

We ensured appropriate psychiatric referral and communicated a memo to endoscopists describing the background, clarifying the absolute indications for emergent endoscopy and empowering staff to elect a ‘soon but non-emergent’ approach if the radiograph did not show an object in the oesophagus. Moreover, based on the history, the patient’s report that he had swallowed batteries could justifiably be challenged. At the next presentation, the patient was not taken for urgent endoscopy, but instead discharged and came to no harm. Following this change in approach, the number of presentations was reduced substantially.

Four months later, they attended again and repeated the history of having ingested button batteries. This time, there was a round opacity in the mid-oesophagus on X-ray. The on-call endoscopist was called and debated whether to proceed. Although highly doubtful that batteries had been ingested, the decision was made to perform emergency endoscopy under general anaesthetic. It occurred approximately 8 hours after ingestion. A button battery was found in the mid-upper oesophagus lying within an area of severe ulceration. The battery was removed and the patient recovered. In-patient psychiatric review led to more intense community follow-up.

This case illustrates the real challenges in managing iFoBI, specifically the balance between patient safety and a reflexive, uncritical emergent response (with its wider effects on the acute hospital service). Here, a potentially life-threatening incidence of iFoBI was treated expeditiously despite the endoscopist’s concern that the patient was ‘crying wolf’ again.