54 | My top 4 considerations for nursing GI foreign bodies

PodcastGastroenterologyEmergency + Critical Care
Written By Laura Jones

Would we be talking about GI disease if we weren’t talking about intestinal foreign bodies?!

 

From strings to balls to bones to toys and pretty much everything in between, we’ve seen it all - and whilst most of these patients are pretty well on presentation, we know that foreign body patients aren’t always smooth sailing.

In this episode, we’ll get stuck into the common complications we see with GI foreign bodies, and I’ll share my top 4 tips for giving them great nursing care

What happens when our patients get a gastrointestinal foreign body?

Unsurprisingly, our patients end up with varying degrees of gastrointestinal obstruction. The severity of their presenting signs depends on a few things, including:

  • The type of foreign body they have,

  • Where the foreign body is

  • How long it has been present,

  • Whether gastrointestinal perforation is present.

Let’s start by looking at the foreign bodies we see.

We can divide our foreign bodies into two types - discrete and linear.

Discrete foreign bodies are separate, shorter, or smaller foreign bodies. These tend to be one-off objects in only one location within the GI tract (though our patient can have several simultaneously, affecting multiple areas in the GI tract).

Examples of discrete foreign bodies include:

  • Balls

  • Toys

  • Hairballs

  • Stones

  • Food objects

And then we have linear foreign bodies. 

These include things like ribbon, string, fishing line, tights or stockings, and sewing thread, and they are usually more challenging to remove since they are longer items that tend to extend throughout larger areas of the GI tract. Because of this and the potential for cheese-wiring and perforation of the GI tract, these foreign bodies carry a worse prognosis than discrete foreign bodies.

What happens when that foreign body causes an obstruction?

When an intestinal obstruction occurs, the GI tract proximal to the foreign body becomes distended with fluid and gas. 

Because of that obstruction, the guts can’t continue to move, so our patients can’t eat without vomiting or effectively absorb nutrition.

This obstruction leads to impaired blood flow to the area, GI venous congestion and devitalisation of that intestinal tissue. 

If this continues, gastrointestinal necrosis and perforation follow, causing leakage of the contaminated intestinal contents into the abdomen. The result is septic peritonitis - carrying significant morbidity and mortality risk for our patients.

Which patients tend to get foreign bodies?

Young cats and young-to-middle-aged dogs, mainly medium and large-breed dogs, are most likely to present with a foreign body.

There are a few breed associations, and I’m sure it will surprise no one to hear that Labradors, Golden Retrievers, and Terrier breeds are at the top of that list.

Shifting our focus to cats, purebred cats are more likely to ingest foreign bodies than other cats, and there is some evidence that Siamese and related breeds are at a particularly high risk. Indoor cats may be more likely to present with a foreign body than outdoor or mixed-access cats due to the potential lack of environmental stimulation and boredom.

Patients with pica are also at a higher risk of presenting with foreign bodies. Pica is a behavioural or medical condition that causes patients to ingest abnormal or non-food items. It is most common in cats, particularly with medical disorders like chronic anaemia.

So that’s what our foreign bodies are and the patients we commonly see with them - but what signs do we see?

Common clinical signs seen in these patients vary depending on the duration, degree and location of the foreign body.

The most commonly reported signs are vomiting and anorexia, though vomiting is less likely in patients with distal small intestinal obstruction. Diarrhoea, lethargy and weight loss are less common, as are signs of septic shock, though we can, of course, see them in some cases.

In cats, signs such as hairballs, coughing and hiding away, and altered urination (presumably through pain and stress) are also reported, though rarely.

Gastric foreign bodies may be present for a long time (months to years even in some cases) without causing significant clinical signs if they have not caused an obstruction. We can also see waxing and waning clinical signs in these patients, as gastric foreign bodies can move in and out of the pylorus, causing intermittent obstruction.

Physical examination of the foreign body patient may not show any significant abnormality, or reveal abdominal pain, signs of dehydration +/- hypovolaemia +/- septic shock. In some cases, an intestinal mass/thickening may be palpated.

One final tip from me when examining these patients - include an oral examination, particularly in cats. Often, linear foreign bodies are anchored to the base of the tongue, especially things like thread or fishing line. If you do see an anchored linear foreign body, do not pull it - instead, cut it immediately.

Ok, so you think your patient has a foreign body. How do we confirm this?

We perform several diagnostic tests in suspected foreign body patients, including:

  • Haematology and biochemistry

  • Venous blood gas

  • Abdominal imaging

  • Fluid analysis (if peritoneal effusion is present)

Let’s look at each of these in a bit more detail.

Starting with bloodwork

Biochemistry and haematology may reveal increased haematocrit/PCV due to haemoconcentration, and an increased total protein level due to dehydration.

Other common changes include increased white blood cells, and a stress leukogram or neutrophilia with a left-shift, especially if the patient has septic peritonitis.

On biochemistry, we typically see increases in BUN, hypoalbuminaemia and hyperlactataemia, though not always.

Hypokalaemia may also be seen due to anorexia, and changes to sodium, chloride and pH may also be seen secondary to vomiting.

However, the main way we diagnose these patients is through imaging.

You’ll likely perform abdominal radiography, abdominal ultrasound, or both in your foreign body patients.

Radiographs are less sensitive, particularly if the foreign body is radiolucent, though definitive results are reported in up to 89% of foreign body cases.

If we can’t see the foreign body itself, we may be able to see the consequences of it, such as dilated intestinal loops.

If the patient has a linear foreign body, we may see bowel plication or bunching of the small intestine.

Ultrasonography is a superior method of detecting foreign bodies than radiography, though it does depend on operator experience. Alongside detecting the foreign body, ultrasound also reveals the presence of abdominal effusion and can detect intestinal perforation, where we can see things like free gas in the abdominal cavity.

Ultrasonographic findings consistent with foreign bodies include distal acoustic shadowing and surface reflection.

So that’s how we diagnose these patients - but what about treatment and nursing care?

So treatment for these guys is pretty straightforward - we must get that foreign body out. There are a few ways we can do this, including

  • Surgically, which is effective for both gastric and intestinal foreign bodies

  • Endoscopically, which works for gastric foreign bodies, depending on the size and shape of the object.

In some cases, we may opt to monitor the patient whilst the foreign body passes. This is only an option in patients without marked clinical signs and who have small foreign bodies (ideally in the distal GI tract) where the veterinary surgeons feels it is safe to leave in place and monitor carefully.

These patients should have regular radiographic or ultrasonographic monitoring to track the foreign body’s movements. If it hasn’t moved in 8 hours or passed within 36 hours, or if the patient has ongoing or progressive clinical signs, surgical removal is required.

But it’s not just surgery…

Yes, of course, we need to remove that foreign body. However, there’s a lot more to think about in these patients, including

  • Stabilising fluid, acid-base and electrolyte balance

  • Administering analgesia

  • Administering pre and perioperative antibiotics (+/- continuing them postoperatively if indicated)

  • Treating nausea and ongoing vomiting

  • Treating postoperative ileus (if present) with prokinetics, provided that the foreign body has been removed first

  • Treating complications such as septic peritonitis - with things like fluid therapy, antibiotics, analgesia, vasopressors to control blood pressure where needed, and supportive treatment.

And that’s where we come in.

Veterinary nurses and technicians are heavily involved in caring for these patients - be that on admission during triage and initial stabilisation, through anaesthetic monitoring and perioperative care, or in recovery.

There’s a lot to think about when caring for these patients, and I’m finishing this episode with my top 4 for you:

#1: Early enteral nutrition is essential.

We’ve all heard the old adage, “If the gut works, use it!” and that couldn’t be more true for FB patients. Avoid prolonged periods of starvation or holding back on offering food whilst the gut heals - we NEED to get nutrition to that GI tract!

Our enterocytes receive their nutrition from the food they come into contact with. The last thing we want to do in a patient with existing GI compromise is deprive those enterocytes of nourishment, compromise them further, and reduce the GI tract’s barrier ability.

In episode 53, we chatted quite a bit about bacterial translocation in GI patients - and foreign body cases are no exception. In fact, studies looking at the impact of early nutrition in septic peritonitis patients have found shorter hospitalisation times in patients fed via the GI tract within 24 hours of surgery.

Get a feeding tube in if you think your patient won’t eat (bonus points if you place one at the time of surgery), and start refeeding them carefully using a highly digestible, good-quality diet.

#2: To feed the gut, we need to keep it moving.

Ileus is a common complication in these patients - these foreign bodies and the surgery to remove them often interfere with GI motility.

Where this happens, it can be a challenge to get the guts moving, meaning that food and fluid build up in the stomach, and we then can’t feed our patients without them regurgitating (or getting uncomfortable gastric distension).

Prokinetics are your best friend in ileus cases - as is a nasogastric tube, which you can use for feeding AND gastric drainage.

#3: Monitoring is one of the most underrated (and essential) nursing skills.

Our job as vet nurses is to be the eyes and ears for our patients, picking up on subtle changes early.

One such change is gastrointestinal dehiscence and sepsis - a common complication in foreign body surgeries, especially in patients with areas of very devitalised gut or hypoalbuminaemia.

Where patients do suffer from this, it is usually seen around 3-5 days postoperatively - so our monitoring arguably needs to increase as time goes on!

And it’s not just sepsis we’re monitoring for - it’s everything, including:

  • Nausea

  • Pain

  • Vomiting and regurgitation

  • Diarrhoea

  • Fluid overload or underhydration

  • Nutritional status

  • Cleanliness

  • Stress

  • IV catheter site complications

  • And much more.

#4: Fluids, fluids, fluids.

Ongoing gastrointestinal losses are common in these patients - vomiting is common both before and after surgery, and anorexia and diarrhoea are also seen.

The result of all of this? Significant dehydration (and with that, acid-base and electrolyte changes).

This means that monitoring fluid balance is absolutely essential in these patients.

Assess their hydration status (skin tenting, MM dryness and acute weight loss) and perfusion status (heart rate, pulses, blood pressure, MM colour and CRT) and administer fluid therapy appropriately.

Remember, fluid balance is dynamic, and a patient’s fluid requirements change regularly throughout hospitalisation. Repeat these assessments frequently, and tailor your patient’s fluid therapy plan (alongside your veterinary surgeon) accordingly.

So there you have it. 

Here are my top tips for providing great care to your foreign body patients! These patients can easily go very wrong, very quickly, and whilst this can make them challenging to care for, we can use LOTS of skills in the process.



I’d love to know more about the foreign bodies you’ve seen and how you’ve cared for them. If you’ve made it this far in the episode, drop me a DM on Instagram and let me know what the weirdest thing you’ve removed from a patient is! Mine is a my little pony toy, which we removed whole from a patient’s stomach - it is still, to this day, one of the best X-rays I’ve ever seen!

Thanks so much for learning with me this week, and I’ll see you next time!

References and Further Reading

Laura Jones
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