Sharp or pointed object

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Esophageal location

Gastric or duodenal location

Intestinal location

Not visualized

If the patient is persistently symptomatic despite negative radiographs, or if there is concern that a non-visualized object could be high-risk, computed tomography (CT) is useful and is superior to plain films at detecting small radiolucent objects. Sensitivities for even small fish bones on CT range from 90% to 100% in most studies.$^{74.75}$ In regard to specific technique, the American Society of Gastrointestinal Endoscopy advises against oral contrast, because it adds little to the diagnostic accuracy and may potentially obscure a subsequent endoscopy.$^9$ IV contrast is usually not necessary unless evaluating for the complications of FBI, such as an abscess.

While even sharp objects can pass uneventfully through the GI tract, all sharp or pointed objects within endoscopic reach should be removed, due to the increased risk for perforation. Those in the esophagus should be removed emergently within 2 to 6 hours, and sharp objects in the stomach or duodenum within 24 hours, based on American Society for Gastrointestinal Endoscopy guidelines.$^9$ If sharp objects pass beyond endoscopic intervention, surgical management may be necessary if complications occur. Most objects, even sharp ones, that make it to the small intestines will pass spontaneously without intervention, and the literature suggests a conservative approach is appropriate if sharp objects have progressed beyond reach. Weiland and Schurr reviewed cases of sharp or pointed FBIs, many of which were multiple or recurrent ingestions in the same patient, and 23 objects were beyond endoscopic intervention and were managed conservatively with admission and observation. Of those, 22 (97%) passed spontaneously, and one patient went to the OR after developing an acute abdomen.$^{18}$ While distal sharp objects can be managed expectantly in this way, all patients should have consultation with a surgical specialist, as surgeon preference will inform management and observation strategy.

Sharp Bone Ingestion Removal

For fish or chicken bones found in the hypopharynx or proximal esophagus, ENT may be the most appropriate specialist to consult. They can often remove proximal, sharp bones by trans-nasal flexible esophagoscopy or laryngoscopy, with very little sedation. Bones found more distally should be managed as other sharp foreign bodies and removed if within endoscopic reach. The challenge comes in patients with suspected fish or chicken bone ingestion, but no findings on CT scan. Numerous case reports exist that describe perforated fishbones found on laparoscopy in patients with initially negative CTs.$^{96}$ Therefore, in cases of suspected animal bone ingestions with persistent symptoms (foreign body sensation, dysphagia, odynophagia, or abdominal pain) gastroenterology or surgery should be consulted. For a patient with suspected animal bone ingestion, negative imaging, and who remains asymptomatic, outpatient follow-up in 1 to 2 weeks is appropriate.$^{97}$