Foreign Body IngestionAPPROACH

ABDOMINAL AND GASTROINTESTINAL · 19 SECTIONS

⚲

623 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Abdominal Distension Abdominal Pain, Undifferentiated Acute Abdominal Pain (general)Suspected Incarcerated Or Strangulated Hernia Pancreatitis Concern Biliary Colic And Cholecystitis Concern Appendicitis Concern Diverticulitis Concern Rectal Pain And Anorectal Complaints Dysphagia And Food Bolus Impaction Foreign Body Ingestion Refractory Vomiting And Recurrent Vomiting Syndromes Cannabis Associated Hyperemesis Upper Gastrointestinal Bleeding Symptoms (melena)Lower Gastrointestinal Bleeding And Hematochezia Constipation And Obstipation Diarrhea Acute Hepatitis And Jaundice Concern Right Upper Quadrant Pain Epigastric Pain Left Upper Quadrant Pain Right Lower Quadrant Pain Left Lower Quadrant Pain Suprapubic Pain

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx94

Presentation and context

›Presentation features

›Time of ingestion or suspected ingestion

›Witnessed ingestion

›Object description

›Type

›Size

›Shape

›Material

›Estimated number of objects

›Intent

›Accidental

›Intentional

›Self harm concern

›Location symptoms

›Oropharyngeal

›Esophageal

›Gastric

›Intestinal

›High risk object categories

›Button battery

›Multiple magnets

›Sharp object

›Long object

›Drug packets

›Prior ED or outside facility evaluation and results

Onset

›Onset

›Sudden onset after ingestion

›Gradual onset with evolving symptoms

›Time since ingestion categories

›Less than 2 hours

›2 to 24 hours

›More than 24 hours

Provocation/Palliation

›Provocation and palliation

›Worse with swallowing

›Worse with solids

›Worse with liquids

›Relief with regurgitation or vomiting

›Relief with position change

›Prior attempts to dislodge object

›Bread bolus

›Carbonated beverage

›Manual removal

Quality

›Quality

›Dysphagia

›Odynophagia

›Globus sensation

›Chest discomfort

›Abdominal pain

›Drooling or inability to handle secretions

Region/Radiation

›Region and radiation

›Throat pain

›Retrosternal pain

›Epigastric pain

›Periumbilical pain

›Radiation to back

›Radiation to neck

Severity

›Severity

›Complete inability to swallow saliva

›Partial dysphagia with liquids tolerated

›Pain severity trend

›Improving

›Stable

›Worsening

Timing

›Timing

›Persistent symptoms

›Intermittent symptoms

›Progressive symptoms

›Symptom free interval after ingestion

Associated symptoms

›Associated symptoms

›Choking episode

›Stridor

›Wheeze

›Cough

›Voice change

›Vomiting

›Hematemesis

›Fever

›Dyspnea

›Abdominal distension

›Melena

›Hematochezia

High risk situation details

›High risk situation details

›Esophageal disease history

›Eosinophilic esophagitis

›Stricture

›Achalasia

›Dentures

›Neurologic impairment

›Prior GI surgery

›Prison or custody setting

›Psychiatric illness

›Pica

›Substance use

›Pregnancy status when relevant

02Alarm Features/alarm44

Airway and breathing

›Airway and breathing red flags

›Stridor

›Severe respiratory distress

›Cyanosis

›Drooling with inability to handle secretions

›Voice change with distress

›Suspected aspiration with hypoxemia

Esophageal perforation and mediastinitis

›Perforation red flags

›Severe chest pain

›Subcutaneous emphysema

›Neck crepitus

›Fever

›Tachycardia out of proportion

›Hypotension

›Pain with neck movement

›Odynophagia with rapid progression

GI perforation and obstruction

›Abdominal catastrophe red flags

›Peritonitis

›Persistent vomiting with dehydration

›Abdominal distension with obstipation

›GI bleeding

›Severe localized pain

›Sepsis physiology

High risk objects

›High risk object triggers

›Button battery ingestion

›Any symptoms

›Unknown location

›Esophageal location on imaging

›Multiple magnets or magnet plus metal

›Any symptoms

›Unknown number ingested

›Sharp or pointed object

›Pain

›Bleeding

›Drug packets

›Altered mental status

›Sympathomimetic toxidrome

›Opioid toxidrome

Vital sign danger thresholds

›Vital sign danger thresholds

›SpO2 less than 92 percent on room air

›RR greater than 30 per minute

›SBP less than 90 mmHg or shock index greater than 1

›HR greater than 120 per minute with concerning symptoms

›Temperature 38.5 C or higher with suspected perforation or aspiration

03Medications/meds27

Current and recent exposures

›Medication profile

›Prescription medications

›OTC medications

›Supplements and herbals

›Recent medication changes

›Adherence concerns

Bleeding and procedural risk

›Antithrombotic exposure

›Anticoagulants

›DOAC

›Warfarin

›Heparin products

›Antiplatelets

›Aspirin

›P2Y12 inhibitors

›NSAIDs

›Known coagulopathy or liver disease

Sedation and airway risk

›Sedation risk medications

›Opioids

›Benzodiazepines

›Alcohol co ingestion

›Other sedatives

Medication contraindications relevant to management

›Contraindications and interactions

›Allergy history

›Contrast allergy

›Antibiotic allergy

›QT prolonging medications when antiemetics considered

›Pregnancy and lactation considerations when imaging or meds needed

04Diet/diet10

Intake and fasting status

›Intake pattern

›Last oral intake timing

›Solids tolerance

›Liquids tolerance

›Inability to swallow saliva

›Vomiting after intake

Trigger foods and bolus impaction context

›Bolus impaction context

›Meat or dry food bolus

›Prior similar episodes

›Known esophageal narrowing symptoms with meals

05Review of Systems/ros28

Airway and pulmonary

›Respiratory symptoms

›Choking

›Cough

›Wheeze

›Stridor

›Dyspnea

›Pleuritic pain

GI and constitutional

›GI and systemic symptoms

›Dysphagia

›Odynophagia

›Drooling

›Chest pain

›Abdominal pain

›Nausea

›Vomiting

›Hematemesis

›Melena

›Hematochezia

›Fever

›Weight loss

Neuro and tox

›Neuro and tox symptoms

›Altered mental status

›Agitation

›Seizure

›Diaphoresis

›Mydriasis

›Bradycardia

›Hypoventilation

06Collateral History and Family History/chafh11

Collateral source and reliability

›Collateral and supervision

›Witness report

›Caregiver reliability

›Timeline reliability

›Packaging or missing objects at scene

›Photo of object if available

Family history and inherited conditions

›Family history

›Atopy and eosinophilic disease

›Inherited connective tissue disorder

›Early cardiovascular disease if chest pain differential

›Bleeding disorders

07Risk Factors/rf27

Patient factors

›Patient level risks

›Pediatric age group

›Developmental delay

›Psychiatric illness

›Dementia

›Intoxication

›Poor dentition or dentures

›Prior esophageal disease

›Prior GI surgery

›Pregnancy

Object and exposure factors

›Object related risks

›Button battery

›Lithium cell risk

›Larger diameter risk

›Multiple magnets

›Sharp or pointed object

›Long object

›Caustic material attached

›Glass

›Drug packet ingestion

›Body stuffing vs body packing context

Procedure related risks

›Procedure and sedation risks

›Anticoagulation

›Significant cardiopulmonary disease

›Obstructive sleep apnea

›Aspiration risk

›Difficult airway history

08Differential Diagnosis/ddx61

Life threatening

›Life threatening causes

›Airway foreign body aspiration (T17)

›Sudden cough or choking

›Unilateral wheeze

›Esophageal obstruction with inability to handle secretions

›Drooling

›Complete dysphagia

›Esophageal perforation (K22.3)

›Severe chest pain

›Crepitus

›Fever

›Mediastinitis (J98.6)

›Toxic appearance

›Sepsis physiology

›GI perforation (K63.1)

›Peritonitis

›Free air on imaging

›Magnet related bowel fistula or necrosis

›Severe abdominal pain

›Obstruction signs

›Button battery esophageal injury

›Any esophageal battery location

›Hematemesis

›Packet rupture with toxidrome

›Sympathomimetic syndrome

›Opioid syndrome

Common

›Common causes

›Food bolus impaction (T18.1)

›Meat bolus

›Known dysphagia history

›Esophagitis (K20.9)

›Odynophagia

›Reflux symptoms

›Eosinophilic esophagitis (K20.0)

›Recurrent impactions

›Atopy history

›Esophageal stricture (K22.2)

›Progressive solid food dysphagia

›Weight loss or chronic symptoms

›Globus sensation (R09.89)

›Normal swallowing

›Anxiety association

Less common

›Less common causes

›Esophageal malignancy (C15.9)

›Progressive dysphagia

›Weight loss

›Achalasia (K22.0)

›Dysphagia to solids and liquids

›Regurgitation

›Oropharyngeal dysphagia neurologic

›Stroke history

›Aspiration events

›Esophageal spasm (K22.4)

›Intermittent chest pain

›Triggered by temperature of liquids

Key distinguishing clues

›Distinguishing clues

›Inability to handle secretions favors esophageal obstruction needing urgent endoscopy

›Respiratory distress favors aspiration or proximal obstruction

›Fever and crepitus favors perforation and mediastinitis pathway

›Multiple magnets favor urgent surgical consultation even if initially well

›Drug packets favor tox pathway and avoid endoscopic manipulation unless indicated by instability

09Past Medical History/pmh16

Relevant conditions and procedures

›Relevant history

›Prior foreign body ingestion episodes

›Known esophageal disease

›Eosinophilic esophagitis

›GERD

›Stricture

›Prior dilation

›Prior GI surgery

›Bariatric surgery

›Esophagectomy

›Gastric outlet surgery

›Neurologic disease affecting swallow

›Psychiatric illness

›Substance use disorder

›Bleeding disorder

›Chronic cardiopulmonary disease affecting sedation tolerance

10Physical Exam/exam39

General and vitals

›General and vitals

›Toxic appearance

›Hydration status

›Work of breathing

›Ability to speak full sentences

›Handling secretions

›Pain behavior

Airway and ENT

›Airway and ENT

›Stridor

›Voice change

›Drooling

›Oropharyngeal foreign body visible

›Trismus

›Neck tenderness

›Neck crepitus

Pulmonary

›Pulmonary

›Unilateral wheeze

›Decreased breath sounds

›Rales suggesting aspiration

›Hypoxemia pattern

Cardiovascular

›Cardiovascular

›Tachycardia

›Hypotension

›Perfusion markers

›Cool extremities

›Delayed cap refill

Abdomen

›Abdomen

›Focal tenderness

›Guarding

›Rebound

›Distension

›Bowel sounds changes

›Peritoneal signs

Skin and neuro

›Skin and neuro

›Diaphoresis

›Rash suggesting allergic reaction

›Mental status level

›Agitation or somnolence

›Focal neurologic deficit

11Lab Studies/labs31

Core labs by scenario

›Laboratory testing framework

›No routine labs if asymptomatic low risk object and expectant management

›CBC

›Fever

›Suspected perforation

›GI bleeding

›Electrolytes and renal function

›Dehydration from vomiting

›Contrast planning

›Venous blood gas

›Significant respiratory distress

›Toxidrome with hypoventilation

›Lactate

›Sepsis physiology

›Suspected bowel ischemia from magnets

›Coagulation studies

›Anticoagulation

›Planned urgent procedure with bleeding risk

›Pregnancy test

›Pregnancy possible and imaging planned

Toxicology and packet ingestion

›Tox focused labs

›Glucose

›Altered mental status

›Creatine kinase

›Severe agitation

›Hyperthermia

›Troponin

›Chest pain with stimulant toxidrome

›Targeted tox testing local protocol dependent

›Not a rule out for packet rupture

›Clinical toxidrome prioritized

12Imaging/img45

Scoring Systems

›Imaging decision framework

›Symptom based urgency categories

›Airway compromise immediate airway pathway

›Inability to handle secretions urgent endoscopy pathway

›Object risk categories drive imaging and consult

›Button battery

›Multiple magnets

›Sharp object

›Pediatric button battery risk tools local protocol dependent

›Diameter and age risk stratification

›Symptom based escalation

MRI

›MRI considerations

›Generally avoided for acute localization

›Contraindications

›Unknown metallic foreign body

›Suspected magnet ingestion

›Possible niche indications

›Complication evaluation when CT contraindicated

›Specialist directed protocols

›CT strategy

›Indications

›Suspected perforation or abscess

›Complicated magnet ingestion

›Non radiopaque object with concerning symptoms

›Packet ingestion complications

›Protocol considerations

›IV contrast for complication evaluation

›Oral contrast rarely needed in acute setting

›Radiation minimization in pediatrics

›Interpretation pearls

›Pneumomediastinum

›Free intraperitoneal air

›Localized fat stranding and fluid

›Magnet adjacency across bowel loops

›Limitations

›Some materials radiolucent

›Motion artifact in distressed patient

Ultrasound

›Ultrasound and POCUS

›Limited role for object localization

›POCUS for complications

›Free fluid with peritonitis concern

›Bowel obstruction signs

›Pediatric considerations

›Adjunct for radiolucent objects when expertise available

›Operator dependent limitations

13Special Tests/spec24

Plain radiography

›Radiography approach

›Neck chest abdomen radiographs for radiopaque objects

›Two view technique when needed

›AP view

›Lateral view for esophageal location

›Button battery identification

›Double rim sign on AP

›Step off sign on lateral

›Magnet identification

›Multiple identical dense objects

›Clustering pattern

Endoscopy and procedural evaluation

›Endoscopic evaluation

›Diagnostic and therapeutic for esophageal foreign body

›Urgent timing triggers

›Inability to handle secretions

›Esophageal button battery

›Key limitations

›Do not delay for unnecessary imaging if high risk and clear history

›Avoid endoscopy for stable packet ingestion without indication

Airway evaluation adjuncts

›Airway adjunct tests

›Flexible nasopharyngoscopy for suspected supraglottic foreign body when stable and expertise available

›Bronchoscopy pathway for suspected aspiration

›Persistent unilateral wheeze

›Focal atelectasis on imaging

14ECG/ecg9

When ECG matters

›ECG indications

›Toxidrome with stimulant features

›Chest pain not clearly esophageal

›Significant electrolyte disturbance concern from vomiting

›Pre sedation assessment in higher risk patients

High risk patterns to recognize

›High risk ECG findings

›QT prolongation

›Wide QRS with suspected sodium channel blockade tox

›Ischemic changes in stimulant toxidrome

15Assessment/ax34

Problem representation and severity

›Severity assessment

›Airway compromise

›Stridor

›Severe respiratory distress

›Esophageal obstruction severity

›Unable to handle secretions

›Complete dysphagia

›Complication concern

›Perforation features

›Sepsis physiology

›Peritonitis

›High risk object category

›Button battery

›Multiple magnets

›Sharp object

›Drug packets

Working diagnosis examples

›Working diagnosis options

›Foreign body in esophagus (T18.1)

›Dysphagia

›Drooling

›Foreign body in stomach or small intestine (T18.2)

›Abdominal pain

›Vomiting

›Food bolus obstruction (T18.1)

›Meat bolus

›Prior dysphagia history

›Airway foreign body aspiration (T17)

›Sudden cough

›Unilateral wheeze

Diagnostic uncertainty and alternatives

›Uncertainty framework

›Radiolucent object possibility despite negative radiograph

›Esophageal pathology driving symptoms without retained object

›Aspiration plus ingestion dual pathway

›Non GI mimics of chest pain when indicated

16Plan/plan85

First 5 minutes

›Immediate stabilization workflow

›Airway assessment

›Stridor or impending obstruction immediate airway team activation

›Suction available for secretions

›Monitoring

›Continuous pulse oximetry if symptomatic

›Cardiac monitor if unstable or tox concern

›IV access criteria

›Hemodynamic instability

›Perforation concern

›Anticipated procedural sedation

›NPO status if endoscopy likely

›Analgesia and antiemetic as needed

›Avoid oversedation if airway risk

Object specific pathways

›Object based management

›Button battery

›Esophageal battery immediate endoscopic removal

›Pre removal mitigation local protocol dependent

›After removal monitoring for delayed bleeding and fistula

›Magnets

›Multiple magnets or magnet plus metal urgent surgical and GI consultation

›Serial imaging if non operative pathway chosen by specialists

›Sharp or pointed object

›Esophageal location urgent removal

›Gastric or proximal location specialist guided removal vs close follow up

›Warning signs for perforation

›Long object

›Endoscopic removal if length exceeds passage likelihood

›Obstruction monitoring

›Drug packets

›Avoid endoscopic manipulation unless instability or obstruction

›Whole bowel irrigation specialist and tox guided local protocol dependent

›ICU planning if toxidrome

Symptom driven pathways

›Symptom based management

›Inability to handle secretions urgent endoscopy pathway

›Suspected aspiration bronchoscopy pathway

›Perforation concern

›Broad spectrum antibiotics

›NPO

›CT for complication mapping

›Thoracic surgery or general surgery consult

›Uncomplicated distal object asymptomatic

›Expectant management with return precautions

›Follow up imaging plan when indicated

Medications and dosing examples

›Medication options

›Analgesia

›Acetaminophen PO 1000 mg once

›Morphine IV 0.05 mg per kg once

›Antiemetic

›Ondansetron ODT 4 mg once

›Ondansetron IV 4 mg once

›Antibiotics for suspected perforation

›Piperacillin tazobactam IV 4.5 g every 6 hours

›Ceftriaxone IV 2 g daily plus metronidazole IV 500 mg every 8 hours

›Tetanus prophylaxis when mucosal injury and status uncertain local protocol dependent

Consultation plan

›Consult triggers

›GI

›Esophageal foreign body

›Food bolus with complete obstruction

›Button battery in esophagus

›ENT

›Oropharyngeal object not easily removed

›Suspected hypopharyngeal injury

›Thoracic surgery

›Suspected esophageal perforation

›Mediastinitis concern

›General surgery

›Peritonitis

›Complicated magnets

›Obstruction

›Toxicology

›Packet ingestion

›Unexplained toxidrome

Reassessment loop

›Reassessment loop

›Interval reassessment timing

›Every 30 to 60 minutes if symptomatic

›After any intervention or imaging result

›Repeat focused exams

›Airway and secretion handling

›Chest and abdominal exam for evolving peritonitis

›Escalation triggers

›New fever

›Worsening pain

›New tachycardia or hypotension

›New GI bleeding

17Disposition/dispo26

Level of care criteria

›Level of care

›ICU criteria

›Airway intervention required

›Hemodynamic instability

›Severe toxidrome

›Post endoscopic removal with high risk complications concern

›Inpatient admission criteria

›Perforation or mediastinitis concern

›Complicated magnet ingestion

›Significant dehydration

›Persistent inability to tolerate oral intake

›Need for serial imaging and observation

›Observation pathway criteria

›Symptomatic but stable awaiting endoscopy

›Post procedure monitoring without complications

›Discharge criteria

›Asymptomatic

›Tolerating oral intake

›Low risk object beyond esophagus or not retained by specialist assessment

›Reliable supervision and return ability

Follow up timing

›Follow up plan

›GI follow up for suspected underlying esophageal pathology

›Recurrent food impactions

›Dysphagia history

›Pediatric follow up coordination when child ingestion

›Mental health follow up if intentional ingestion

18Discharge Instructions/di7

Copy discharge instructions

›Patient instructions

›You swallowed an object and it does not currently show signs of emergency complications

›Return to the emergency department now for any trouble breathing, drooling, inability to swallow, chest pain, severe belly pain, vomiting that will not stop, fever, black stools, or blood in vomit or stool

›Do not try to push the object down with food or drinks unless told by your specialist team

›Eat and drink as tolerated if you were told it is safe to do so

›Follow up as instructed for repeat imaging or specialist review

›If magnets or a button battery were involved, follow your specialist instructions exactly and return immediately for any new symptoms

19References/r5

Guidelines and key sources

›Key references

›ASGE guideline Management of ingested foreign bodies and food impactions 2011

›ESGE guideline Removal of foreign bodies in the upper gastrointestinal tract in adults 2016

›NASPGHAN guideline Management of ingested foreign bodies in children 2015

›National Button Battery Task Force and National Capital Poison Center guidance updated regularly local protocol dependent

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Foreign Body IngestionAPPROACH

ABDOMINAL AND GASTROINTESTINAL · 19 SECTIONS

⚲

623 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx94

Presentation and context

›Presentation features

›Time of ingestion or suspected ingestion

›Witnessed ingestion

›Object description

›Type

›Size

›Shape

›Material

›Estimated number of objects

›Intent

›Accidental

›Intentional

›Self harm concern

›Location symptoms

›Oropharyngeal

›Esophageal

›Gastric

›Intestinal

›High risk object categories

›Button battery

›Multiple magnets

›Sharp object

›Long object

›Drug packets

›Prior ED or outside facility evaluation and results

Onset

›Onset

›Sudden onset after ingestion

›Gradual onset with evolving symptoms

›Time since ingestion categories

›Less than 2 hours

›2 to 24 hours

›More than 24 hours

Provocation/Palliation

›Provocation and palliation

›Worse with swallowing

›Worse with solids

›Worse with liquids

›Relief with regurgitation or vomiting

›Relief with position change

›Prior attempts to dislodge object

›Bread bolus

›Carbonated beverage

›Manual removal

Quality

›Quality

›Dysphagia

›Odynophagia

›Globus sensation

›Chest discomfort

›Abdominal pain

›Drooling or inability to handle secretions

Region/Radiation

›Region and radiation

›Throat pain

›Retrosternal pain

›Epigastric pain

›Periumbilical pain

›Radiation to back

›Radiation to neck

Severity

›Severity

›Complete inability to swallow saliva

›Partial dysphagia with liquids tolerated

›Pain severity trend

›Improving

›Stable

›Worsening

Timing

›Timing

›Persistent symptoms

›Intermittent symptoms

›Progressive symptoms

›Symptom free interval after ingestion

Associated symptoms

›Associated symptoms

›Choking episode

›Stridor

›Wheeze

›Cough

›Voice change

›Vomiting

›Hematemesis

›Fever

›Dyspnea

›Abdominal distension

›Melena

›Hematochezia

High risk situation details

›High risk situation details

›Esophageal disease history

›Eosinophilic esophagitis

›Stricture

›Achalasia

›Dentures

›Neurologic impairment

›Prior GI surgery

›Prison or custody setting

›Psychiatric illness

›Pica

›Substance use

›Pregnancy status when relevant

02Alarm Features/alarm44

Airway and breathing

›Airway and breathing red flags

›Stridor

›Severe respiratory distress

›Cyanosis

›Drooling with inability to handle secretions

›Voice change with distress

›Suspected aspiration with hypoxemia

Esophageal perforation and mediastinitis

›Perforation red flags

›Severe chest pain

›Subcutaneous emphysema

›Neck crepitus

›Fever

›Tachycardia out of proportion

›Hypotension

›Pain with neck movement

›Odynophagia with rapid progression

GI perforation and obstruction

›Abdominal catastrophe red flags

›Peritonitis

›Persistent vomiting with dehydration

›Abdominal distension with obstipation

›GI bleeding

›Severe localized pain

›Sepsis physiology

High risk objects

›High risk object triggers

›Button battery ingestion

›Any symptoms

›Unknown location

›Esophageal location on imaging

›Multiple magnets or magnet plus metal

›Any symptoms

›Unknown number ingested

›Sharp or pointed object

›Pain

›Bleeding

›Drug packets

›Altered mental status

›Sympathomimetic toxidrome

›Opioid toxidrome

Vital sign danger thresholds

›Vital sign danger thresholds

›SpO2 less than 92 percent on room air

›RR greater than 30 per minute

›SBP less than 90 mmHg or shock index greater than 1

›HR greater than 120 per minute with concerning symptoms

›Temperature 38.5 C or higher with suspected perforation or aspiration

03Medications/meds27

Current and recent exposures

›Medication profile

›Prescription medications

›OTC medications

›Supplements and herbals

›Recent medication changes

›Adherence concerns

Bleeding and procedural risk

›Antithrombotic exposure

›Anticoagulants

›DOAC

›Warfarin

›Heparin products

›Antiplatelets

›Aspirin

›P2Y12 inhibitors

›NSAIDs

›Known coagulopathy or liver disease

Sedation and airway risk

›Sedation risk medications

›Opioids

›Benzodiazepines

›Alcohol co ingestion

›Other sedatives

Medication contraindications relevant to management

›Contraindications and interactions

›Allergy history

›Contrast allergy

›Antibiotic allergy

›QT prolonging medications when antiemetics considered

›Pregnancy and lactation considerations when imaging or meds needed

04Diet/diet10

Intake and fasting status

›Intake pattern

›Last oral intake timing

›Solids tolerance

›Liquids tolerance

›Inability to swallow saliva

›Vomiting after intake

Trigger foods and bolus impaction context

›Bolus impaction context

›Meat or dry food bolus

›Prior similar episodes

›Known esophageal narrowing symptoms with meals

05Review of Systems/ros28

Airway and pulmonary

›Respiratory symptoms

›Choking

›Cough

›Wheeze

›Stridor

›Dyspnea

›Pleuritic pain

GI and constitutional

›GI and systemic symptoms

›Dysphagia

›Odynophagia

›Drooling

›Chest pain

›Abdominal pain

›Nausea

›Vomiting

›Hematemesis

›Melena

›Hematochezia

›Fever

›Weight loss

Neuro and tox

›Neuro and tox symptoms

›Altered mental status

›Agitation

›Seizure

›Diaphoresis

›Mydriasis

›Bradycardia

›Hypoventilation

06Collateral History and Family History/chafh11

Collateral source and reliability

›Collateral and supervision

›Witness report

›Caregiver reliability

›Timeline reliability

›Packaging or missing objects at scene

›Photo of object if available

Family history and inherited conditions

›Family history

›Atopy and eosinophilic disease

›Inherited connective tissue disorder

›Early cardiovascular disease if chest pain differential

›Bleeding disorders

07Risk Factors/rf27

Patient factors

›Patient level risks

›Pediatric age group

›Developmental delay

›Psychiatric illness

›Dementia

›Intoxication

›Poor dentition or dentures

›Prior esophageal disease

›Prior GI surgery

›Pregnancy

Object and exposure factors

›Object related risks

›Button battery

›Lithium cell risk

›Larger diameter risk

›Multiple magnets

›Sharp or pointed object

›Long object

›Caustic material attached

›Glass

›Drug packet ingestion

›Body stuffing vs body packing context

Procedure related risks

›Procedure and sedation risks

›Anticoagulation

›Significant cardiopulmonary disease

›Obstructive sleep apnea

›Aspiration risk

›Difficult airway history

08Differential Diagnosis/ddx61

Life threatening

›Life threatening causes

›Airway foreign body aspiration (T17)

›Sudden cough or choking

›Unilateral wheeze

›Esophageal obstruction with inability to handle secretions

›Drooling

›Complete dysphagia

›Esophageal perforation (K22.3)

›Severe chest pain

›Crepitus

›Fever

›Mediastinitis (J98.6)

›Toxic appearance

›Sepsis physiology

›GI perforation (K63.1)

›Peritonitis

›Free air on imaging

›Magnet related bowel fistula or necrosis

›Severe abdominal pain

›Obstruction signs

›Button battery esophageal injury

›Any esophageal battery location

›Hematemesis

›Packet rupture with toxidrome

›Sympathomimetic syndrome

›Opioid syndrome

Common

›Common causes

›Food bolus impaction (T18.1)

›Meat bolus

›Known dysphagia history

›Esophagitis (K20.9)

›Odynophagia

›Reflux symptoms

›Eosinophilic esophagitis (K20.0)

›Recurrent impactions

›Atopy history

›Esophageal stricture (K22.2)

›Progressive solid food dysphagia

›Weight loss or chronic symptoms

›Globus sensation (R09.89)

›Normal swallowing

›Anxiety association

Less common

›Less common causes

›Esophageal malignancy (C15.9)

›Progressive dysphagia

›Weight loss

›Achalasia (K22.0)

›Dysphagia to solids and liquids

›Regurgitation

›Oropharyngeal dysphagia neurologic

›Stroke history

›Aspiration events

›Esophageal spasm (K22.4)

›Intermittent chest pain

›Triggered by temperature of liquids

Key distinguishing clues

›Distinguishing clues

›Inability to handle secretions favors esophageal obstruction needing urgent endoscopy

›Respiratory distress favors aspiration or proximal obstruction

›Fever and crepitus favors perforation and mediastinitis pathway

›Multiple magnets favor urgent surgical consultation even if initially well

›Drug packets favor tox pathway and avoid endoscopic manipulation unless indicated by instability

09Past Medical History/pmh16

Relevant conditions and procedures

›Relevant history

›Prior foreign body ingestion episodes

›Known esophageal disease

›Eosinophilic esophagitis

›GERD

›Stricture

›Prior dilation

›Prior GI surgery

›Bariatric surgery

›Esophagectomy

›Gastric outlet surgery

›Neurologic disease affecting swallow

›Psychiatric illness

›Substance use disorder

›Bleeding disorder

›Chronic cardiopulmonary disease affecting sedation tolerance

10Physical Exam/exam39

General and vitals

›General and vitals

›Toxic appearance

›Hydration status

›Work of breathing

›Ability to speak full sentences

›Handling secretions

›Pain behavior

Airway and ENT

›Airway and ENT

›Stridor

›Voice change

›Drooling

›Oropharyngeal foreign body visible

›Trismus

›Neck tenderness

›Neck crepitus

Pulmonary

›Pulmonary

›Unilateral wheeze

›Decreased breath sounds

›Rales suggesting aspiration

›Hypoxemia pattern

Cardiovascular

›Cardiovascular

›Tachycardia

›Hypotension

›Perfusion markers

›Cool extremities

›Delayed cap refill

Abdomen

›Abdomen

›Focal tenderness

›Guarding

›Rebound

›Distension

›Bowel sounds changes

›Peritoneal signs

Skin and neuro

›Skin and neuro

›Diaphoresis

›Rash suggesting allergic reaction

›Mental status level

›Agitation or somnolence

›Focal neurologic deficit

11Lab Studies/labs31

Core labs by scenario

›Laboratory testing framework

›No routine labs if asymptomatic low risk object and expectant management

›CBC

›Fever

›Suspected perforation

›GI bleeding

›Electrolytes and renal function

›Dehydration from vomiting

›Contrast planning

›Venous blood gas

›Significant respiratory distress

›Toxidrome with hypoventilation

›Lactate

›Sepsis physiology

›Suspected bowel ischemia from magnets

›Coagulation studies

›Anticoagulation

›Planned urgent procedure with bleeding risk

›Pregnancy test

›Pregnancy possible and imaging planned

Toxicology and packet ingestion

›Tox focused labs

›Glucose

›Altered mental status

›Creatine kinase

›Severe agitation

›Hyperthermia

›Troponin

›Chest pain with stimulant toxidrome

›Targeted tox testing local protocol dependent

›Not a rule out for packet rupture

›Clinical toxidrome prioritized

12Imaging/img45

Scoring Systems

›Imaging decision framework

›Symptom based urgency categories

›Airway compromise immediate airway pathway

›Inability to handle secretions urgent endoscopy pathway

›Object risk categories drive imaging and consult

›Button battery

›Multiple magnets

›Sharp object

›Pediatric button battery risk tools local protocol dependent

›Diameter and age risk stratification

›Symptom based escalation

MRI

›MRI considerations

›Generally avoided for acute localization

›Contraindications

›Unknown metallic foreign body

›Suspected magnet ingestion

›Possible niche indications

›Complication evaluation when CT contraindicated

›Specialist directed protocols

›CT strategy

›Indications

›Suspected perforation or abscess

›Complicated magnet ingestion

›Non radiopaque object with concerning symptoms

›Packet ingestion complications

›Protocol considerations

›IV contrast for complication evaluation

›Oral contrast rarely needed in acute setting

›Radiation minimization in pediatrics

›Interpretation pearls

›Pneumomediastinum

›Free intraperitoneal air

›Localized fat stranding and fluid

›Magnet adjacency across bowel loops

›Limitations

›Some materials radiolucent

›Motion artifact in distressed patient

Ultrasound

›Ultrasound and POCUS

›Limited role for object localization

›POCUS for complications

›Free fluid with peritonitis concern

›Bowel obstruction signs

›Pediatric considerations

›Adjunct for radiolucent objects when expertise available

›Operator dependent limitations

13Special Tests/spec24

Plain radiography

›Radiography approach

›Neck chest abdomen radiographs for radiopaque objects

›Two view technique when needed

›AP view

›Lateral view for esophageal location

›Button battery identification

›Double rim sign on AP

›Step off sign on lateral

›Magnet identification

›Multiple identical dense objects

›Clustering pattern

Endoscopy and procedural evaluation

›Endoscopic evaluation

›Diagnostic and therapeutic for esophageal foreign body

›Urgent timing triggers

›Inability to handle secretions

›Esophageal button battery

›Key limitations

›Do not delay for unnecessary imaging if high risk and clear history

›Avoid endoscopy for stable packet ingestion without indication

Airway evaluation adjuncts

›Airway adjunct tests

›Flexible nasopharyngoscopy for suspected supraglottic foreign body when stable and expertise available

›Bronchoscopy pathway for suspected aspiration

›Persistent unilateral wheeze

›Focal atelectasis on imaging

14ECG/ecg9

When ECG matters

›ECG indications

›Toxidrome with stimulant features

›Chest pain not clearly esophageal

›Significant electrolyte disturbance concern from vomiting

›Pre sedation assessment in higher risk patients

High risk patterns to recognize

›High risk ECG findings

›QT prolongation

›Wide QRS with suspected sodium channel blockade tox

›Ischemic changes in stimulant toxidrome

15Assessment/ax34

Problem representation and severity

›Severity assessment

›Airway compromise

›Stridor

›Severe respiratory distress

›Esophageal obstruction severity

›Unable to handle secretions

›Complete dysphagia

›Complication concern

›Perforation features

›Sepsis physiology

›Peritonitis

›High risk object category

›Button battery

›Multiple magnets

›Sharp object

›Drug packets

Working diagnosis examples

›Working diagnosis options

›Foreign body in esophagus (T18.1)

›Dysphagia

›Drooling

›Foreign body in stomach or small intestine (T18.2)

›Abdominal pain

›Vomiting

›Food bolus obstruction (T18.1)

›Meat bolus

›Prior dysphagia history

›Airway foreign body aspiration (T17)

›Sudden cough

›Unilateral wheeze

Diagnostic uncertainty and alternatives

›Uncertainty framework

›Radiolucent object possibility despite negative radiograph

›Esophageal pathology driving symptoms without retained object

›Aspiration plus ingestion dual pathway

›Non GI mimics of chest pain when indicated

16Plan/plan85

First 5 minutes

›Immediate stabilization workflow

›Airway assessment

›Stridor or impending obstruction immediate airway team activation

›Suction available for secretions

›Monitoring

›Continuous pulse oximetry if symptomatic

›Cardiac monitor if unstable or tox concern

›IV access criteria

›Hemodynamic instability

›Perforation concern

›Anticipated procedural sedation

›NPO status if endoscopy likely

›Analgesia and antiemetic as needed

›Avoid oversedation if airway risk

Object specific pathways

›Object based management

›Button battery

›Esophageal battery immediate endoscopic removal

›Pre removal mitigation local protocol dependent

›After removal monitoring for delayed bleeding and fistula

›Magnets

›Multiple magnets or magnet plus metal urgent surgical and GI consultation

›Serial imaging if non operative pathway chosen by specialists

›Sharp or pointed object

›Esophageal location urgent removal

›Gastric or proximal location specialist guided removal vs close follow up

›Warning signs for perforation

›Long object

›Endoscopic removal if length exceeds passage likelihood

›Obstruction monitoring

›Drug packets

›Avoid endoscopic manipulation unless instability or obstruction

›Whole bowel irrigation specialist and tox guided local protocol dependent

›ICU planning if toxidrome

Symptom driven pathways

›Symptom based management

›Inability to handle secretions urgent endoscopy pathway

›Suspected aspiration bronchoscopy pathway

›Perforation concern

›Broad spectrum antibiotics

›NPO

›CT for complication mapping

›Thoracic surgery or general surgery consult

›Uncomplicated distal object asymptomatic

›Expectant management with return precautions

›Follow up imaging plan when indicated

Medications and dosing examples

›Medication options

›Analgesia

›Acetaminophen PO 1000 mg once

›Morphine IV 0.05 mg per kg once

›Antiemetic

›Ondansetron ODT 4 mg once

›Ondansetron IV 4 mg once

›Antibiotics for suspected perforation

›Piperacillin tazobactam IV 4.5 g every 6 hours

›Ceftriaxone IV 2 g daily plus metronidazole IV 500 mg every 8 hours

›Tetanus prophylaxis when mucosal injury and status uncertain local protocol dependent

Consultation plan

›Consult triggers

›GI

›Esophageal foreign body

›Food bolus with complete obstruction

›Button battery in esophagus

›ENT

›Oropharyngeal object not easily removed

›Suspected hypopharyngeal injury

›Thoracic surgery

›Suspected esophageal perforation

›Mediastinitis concern

›General surgery

›Peritonitis

›Complicated magnets

›Obstruction

›Toxicology

›Packet ingestion

›Unexplained toxidrome

Reassessment loop

›Reassessment loop

›Interval reassessment timing

›Every 30 to 60 minutes if symptomatic

›After any intervention or imaging result

›Repeat focused exams

›Airway and secretion handling

›Chest and abdominal exam for evolving peritonitis

›Escalation triggers

›New fever

›Worsening pain

›New tachycardia or hypotension

›New GI bleeding

17Disposition/dispo26

Level of care criteria

›Level of care

›ICU criteria

›Airway intervention required

›Hemodynamic instability

›Severe toxidrome

›Post endoscopic removal with high risk complications concern

›Inpatient admission criteria

›Perforation or mediastinitis concern

›Complicated magnet ingestion

›Significant dehydration

›Persistent inability to tolerate oral intake

›Need for serial imaging and observation

›Observation pathway criteria

›Symptomatic but stable awaiting endoscopy

›Post procedure monitoring without complications

›Discharge criteria

›Asymptomatic

›Tolerating oral intake

›Low risk object beyond esophagus or not retained by specialist assessment

›Reliable supervision and return ability

Follow up timing

›Follow up plan

›GI follow up for suspected underlying esophageal pathology

›Recurrent food impactions

›Dysphagia history

›Pediatric follow up coordination when child ingestion

›Mental health follow up if intentional ingestion

18Discharge Instructions/di7

Copy discharge instructions

›Patient instructions

›You swallowed an object and it does not currently show signs of emergency complications

›Do not try to push the object down with food or drinks unless told by your specialist team

›Eat and drink as tolerated if you were told it is safe to do so

›Follow up as instructed for repeat imaging or specialist review

›If magnets or a button battery were involved, follow your specialist instructions exactly and return immediately for any new symptoms

19References/r5

Guidelines and key sources

›Key references

›ASGE guideline Management of ingested foreign bodies and food impactions 2011

›ESGE guideline Removal of foreign bodies in the upper gastrointestinal tract in adults 2016

›NASPGHAN guideline Management of ingested foreign bodies in children 2015

›National Button Battery Task Force and National Capital Poison Center guidance updated regularly local protocol dependent

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.