Ingested foreign body: Difference between revisions

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==Background==
==Background==
*Esophageal impaction can result in airway obstruction, stricture, or perforation
*Esophageal impaction can result in airway obstruction, stricture, or perforation. Perforation can be due to multiple mechanisms but is generally either mechanical (e.g. ingested bones) or via chemical corrosion (e.g. button battery)<ref>Arugula R, Dorofaeff T. Oesophageal button battery injuries: think again. Emerg Med Australas. 2011 Apr;23(2):220-3.</ref>
**Perforation due to mechanical (ingested bones) or chemical corrosion (button battery)
*Esophageal irritation can be perceived as foreign body (globus sensation)
*Esophageal irritation (e.g. from swallowed bone) can be perceived as foreign body
*Once the object has traversed the pylorus, it usually passes without issue
*Three common sites for obstruction
**Exceptions: Irregular or sharp edges, particularly wide (>2.5cm) or long (>6cm) objects
**Upper 1/3 of esophagus at Cricopharyngeus muscle, near C6 (most common)
*Common foreign bodies:
**Aortic Cross Over
**Most common in children: coins
**Lower Esophageal Sphincter
**Most common in adults: food bolus
*Once object has traversed pylorus, usually passes without issue
*Site of obstruction:
**Exceptions:
**Cricopharyngeus (near C6) muscle is the most common (about 75%)<ref name="systematic review">Leopard D et al. The management of oesophageal soft food bolus obstruction: a systematic review. Ann R Coll Surg Engl 2011;93:441–4. PMID: 21929913</ref>
***Irregular or sharp edges
**Aortic cross over the esophagus<ref name="systematic review"></ref>
***Particularly wide (>2.5cm) or long (>6cm)
**Lower Esophageal Sphincter<ref name="systematic review"></ref>


==Clinical Features==
==Clinical Features==
===Adults===
===Adults===
*Retrosternal pain
*[[chest pain|Retrosternal pain]]
*[[Dysphagia]]
*[[Dysphagia]]
*[[Vomiting]]
*[[Vomiting]]
*Choking
*Choking
*Coughing/aspiration (if secretions pool proximal to the obstruction)
*[[Cough]]ing/aspiration (if secretions pool proximal to the obstruction)
===Children===
===Children===
*Refusal or inability to eat
*Refusal or inability to eat
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*Gagging and choking
*Gagging and choking
*[[Stridor]]
*[[Stridor]]
*[[Neck pain|Neck]] or throat pain
*[[Neck pain|Neck]] or [[sore throat|throat]] pain
*Drooling
*Drooling


==Differential Diagnosis==
==Differential Diagnosis==
''Tracheal/lung aspiration of foreign body''
''Consider [[Foreign body aspiration|tracheal/lung aspiration ]] of foreign body''
 
{{Dysphagia DDX}}
{{Dysphagia DDX}}


{{Pediatric stridor DDX}}
==Evaluation==
 
==Diagnosis==
[[File:Abdominal foreign body.png|thumb|Body-packing with multiple foreign bodies ("balls" of hashish) on [[KUB]]]]
[[File:Abdominal foreign body.png|thumb|Body-packing with multiple foreign bodies ("balls" of hashish) on [[KUB]]]]
[[File:Battery in stomach.png|thumb|Button battery in stomach on [[KUB]].]]
[[File:Battery in stomach.png|thumb|Button battery in stomach on [[KUB]].]]
[[File: Esophageal_fb.JPG |thumb|Penny in the esophagus of a 12 mo male]]
[[File: Esophageal_fb.JPG |thumb|Penny in the esophagus of a 12 mo male]]
===Imaging===
===Imaging===
*May not be needed in settings such as a know food bolus
*May not be needed in settings such as a known food bolus
*[[CXR]] PA and lateral
*[[CXR]] PA and lateral
**Coins in esophagus present their face on AP view
**Coins in esophagus present their face on AP view
**Coins in trachea present their face on lateral view
**Coins in trachea present their face on lateral view
**Bones can be visualized <50% of time
**Bones can only be visualized <50% of time
**"Double-ring sign" = button battery (needs emergent removal)
**Button batteries may present with "double-ring sign"
*CT chest
*CT chest
**Very high-yield for both radiopaque and nonradiopaque objects
**Very high-yield for both radiopaque and non-radiopaque objects
**CT with >99% sensitivity and 70-92% specificity for esophageal foreign body <ref>Loh WS, Eu DK, Loh SR, Chao SS. Efficacy of computed tomography scans in the evaluation of patients with esophageal foeign bodies. Ann Otol Rhino Laryngol. Oct 2012; 121 (10) 678- 681</ref> <ref> Liu YC, Zhou SH, Ling L. Value of helial computed tomography in the early diagnosis of esophageal foreign bodies in adults. Am J Emerg Med. Sep 2013; 31 (9), 1328-32 </ref>
**Sensitivity >99% and specificity 70-92%<ref>Loh WS, Eu DK, Loh SR, Chao SS. Efficacy of computed tomography scans in the evaluation of patients with esophageal foeign bodies. Ann Otol Rhino Laryngol. Oct 2012; 121 (10) 678- 681</ref> <ref> Liu YC, Zhou SH, Ling L. Value of helial computed tomography in the early diagnosis of esophageal foreign bodies in adults. Am J Emerg Med. Sep 2013;31(9),1328-32</ref>
*Endoscopy
*Endoscopy
*Barium Swallow is '''not recommended'''
*Barium Swallow is '''not recommended''' due to risk of aspiration, mediastinitis, and barrium coating mucosa (makes endoscopy more difficult)
**Risk of aspiration, mediastinitis, coats mucosa making endoscopy more difficult


==Management==
==Management==
===Urgent Endscopy===
===Indications for Urgent Endscopy===
*Complete obstruction of esophagus (pooling, risk of aspiration)
*Complete obstruction of esophagus (pooling, risk of aspiration)<ref>Ikenberry SO et al. Management of ingested foreign bodies and food impactions. Gastrointest ends 2011; 73(6): 1085-91. PMID: 21628009</ref>
*Ingestion of button batteries
*Ingestion of button batteries<ref>Panella NJ et al. Disk battery ingestion: case series with assessment of clinical and financial impact of a preventable disease. Pediatr Emerg Care 2013; 29(2): 165-9. PMID: 23364381</ref>
*Ingestion of sharp or elongated objects (toothpicks, soda can tabs)
*Ingestion of sharp or elongated objects (toothpicks, soda can tabs)
*Ingestion of multiple foreign bodies
*Ingestion of multiple foreign bodies
*Evidence of perforation
*Evidence of [[esophageal perforation|perforation]]
*Coin at the level of the cricopharyngeus muscle in a child
*Coin at the level of the cricopharyngeus muscle (C6)in a child (Lodged esophageal foreign bodies can cause esophageal necrosis and lead to perforation)
*Airway compromise
*Airway compromise
*Presence of foreign body for >24hr
*Presence of foreign body for >24hr
*Multiple magnets (can trap bowel)
*Multiple magnets (can trap bowel)
*Objects >6cm in length


===Food Impaction===
===Food Impaction===
*Uncomplicated food impaction (no bones, incomplete obstruction) can be managed expectantly
Uncomplicated food impaction (no bones, incomplete obstruction) can be managed expectantly but do not allow food bolus to remain impacted for >12-24hr.  It is reasonable to consider therapies such as [[glucagon]] or a carbonated beverage
**Do not allow food bolus to remain impacted for >12-24hr
*Glucagon 1-2mg IV/IM (adults) to relax LES - may cause severe nausea/vomiting
**Foley catheter removal no longer recommended{{Citation needed|reason=Reliable source needed|date=February 2016}}
**Only one RCT of glucagon with 24 patients compared glucagon to diazepam and found no difference in the need for endoscopy<ref>Tibbling L et al. Effect of spasmolytic drugs on esophageal foreign bodies. Dysphagia 1995; 10(2): 126-7. PMID: 7600855</ref>
*Consider Pharmacologic Therapies
**The major side effect of glucagon is vomiting and can increase the risk for esophageal perforation or aspiration
**Glucagon 1-2mg IV/IM (adults) to relax LES - may cause severe nausea/vomiting
**Rate of success increases with soft foods and lack of anatomic pathology, though in majority of presentations this information, particularly anatomic defects, is unknown
**Carbonated beverage (effervescents) may be effective (carbonation dilates esophagus)
*Carbonated beverage (effervescents) may be effective for small impactions (carbonation dilates esophagus)<ref name="systematic review"></ref>
**CCB (nifedipine) / Benzos / Nitrates / papain(meat tenderizer) no longer recommended given low success and higher side effect profile
*Calcium channel blockers (nifedipine) / Benzos / Nitrates / papain (meat tenderizer) no longer recommended given low success and higher side effect profile<ref name="systematic review"></ref>


===Coin Ingestion===
===Coin Ingestion===
*Can attempt removal with a foley catheter under fluoroscopy, though not recommended as risk for aspiration or perforation
*Can attempt removal with a foley catheter under fluoroscopy, though not recommended as risk for aspiration or perforation
*Should be admitted to ICU and removed by GI endoscopy within 24 hours


===Button Battery===
===Button Battery===
*Administer 10mL of honey every 10min if child is > 12 months old and ingestion < 12 hours old <ref>https://www.poison.org/battery/guideline</ref>
*Call the National Button Battery Ingestion Hotline: 202-625-3333 (24/7) <ref>http://www.poison.org/battery</ref>
*Call the National Button Battery Ingestion Hotline: 202-625-3333 (24/7) <ref>http://www.poison.org/battery</ref>
*True emergency if located in esophagus
*True emergency if located in esophagus
**Perforation can occur within 6hr of ingestion
**Perforation can occur within 6hr of ingestion
**Obtain urgent endoscopic removal
***via direct pressure or electrical conduction leading to liquefactive necrosis
***If endoscopy unavailable AND <2hr since ingestion Foley balloon technique can be tried
**[[Mercury toxicity]]
*Batteries past the esophagus can be managed expectantly w/ 24hr f/u
**Obtain urgent endoscopic removal  
*Batteries past the esophagus can be managed expectantly with 24hr follow up


===Sharp Objects===
===Sharp Objects===
*Intestinal perforation from objects distal to stomach is common (up to 35%)
*Intestinal perforation from objects distal to stomach is common (up to 35%)
*Require immediate removal (even if located in stomach or duodenum)
*Require immediate removal (even if located in stomach or duodenum)
**If object is distal to duodenum and pt is asymptomatic document passage w/ daily films
**If object is distal to duodenum and patient is asymptomatic document passage with daily films
**If object is distal to duodenum and pt symptomatic obtain immediate surgery consult
**If object is distal to duodenum and patient symptomatic obtain immediate surgery consult
===Narcotics Ingestion===
''*plastic bread clips are invisible on radiographs and CT''
*Consider whole-bowel irrigation
 
===[[Body packing]] (with Narcotics)===
*Multiple packets inserted in latex bags, ingested to cross borders
**Each packet potentially toxic if bag bursts
*Consider [[whole-bowel irrigation]]
*Endoscopy contraindicated (high % leakage/rupture of packets)
*Endoscopy contraindicated (high % leakage/rupture of packets)
*Surgical removal indicated if evidence of systemic toxicity
*Do not discharge until all packets removed or 3 packet-free stools
==Disposition==
*Will need GI follow up as majority of the time there is a structural abnormality that may lead to recurrence (esophageal web, stricture, tumor, etc)


==Complications==
==Complications==
*Airway compromise
*Airway compromise
*Aspiration pneumonia
*[[aspiration Pneumonia|Aspiration pneumonia]]
*Esophageal perforation/necrosis
*[[Esophageal perforation]]/necrosis
*[[Mediastinitis]]
*[[Mediastinitis]]
*Aortic perforation
*Aortic perforation
*Vocal cord paralysis
*Vocal cord paralysis
*Bowel perforation/necrosis, fistulas, obstruction
*Bowel perforation/[[bowel ischemia|necrosis]], fistulas, [[SBO|obstruction]]
*Stricture
*Infection


==External Links==
==External Links==
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==See Also==
==See Also==
*[[Esophageal Foreign Body Removal with Foley Catheter]]
*[[Foreign bodies]]
*[[Foreign body]]
*[[Esophageal foreign body removal with foley catheter]]
*[[Bezoar]]
*[[Esophageal perforation]]


==Video==
==Video==
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[[Category:GI]]
[[Category:GI]]
[[Category:Pediatrics]]
[[Category:Pediatrics]]
[[Category:Symptoms]]

Revision as of 15:06, 20 October 2019

Background

  • Esophageal impaction can result in airway obstruction, stricture, or perforation. Perforation can be due to multiple mechanisms but is generally either mechanical (e.g. ingested bones) or via chemical corrosion (e.g. button battery)[1]
  • Esophageal irritation can be perceived as foreign body (globus sensation)
  • Once the object has traversed the pylorus, it usually passes without issue
    • Exceptions: Irregular or sharp edges, particularly wide (>2.5cm) or long (>6cm) objects
  • Common foreign bodies:
    • Most common in children: coins
    • Most common in adults: food bolus
  • Site of obstruction:
    • Cricopharyngeus (near C6) muscle is the most common (about 75%)[2]
    • Aortic cross over the esophagus[2]
    • Lower Esophageal Sphincter[2]

Clinical Features

Adults

Children

Differential Diagnosis

Consider tracheal/lung aspiration of foreign body

Dysphagia

Evaluation

Body-packing with multiple foreign bodies ("balls" of hashish) on KUB
Button battery in stomach on KUB.
Penny in the esophagus of a 12 mo male

Imaging

  • May not be needed in settings such as a known food bolus
  • CXR PA and lateral
    • Coins in esophagus present their face on AP view
    • Coins in trachea present their face on lateral view
    • Bones can only be visualized <50% of time
    • Button batteries may present with "double-ring sign"
  • CT chest
    • Very high-yield for both radiopaque and non-radiopaque objects
    • Sensitivity >99% and specificity 70-92%[3] [4]
  • Endoscopy
  • Barium Swallow is not recommended due to risk of aspiration, mediastinitis, and barrium coating mucosa (makes endoscopy more difficult)

Management

Indications for Urgent Endscopy

  • Complete obstruction of esophagus (pooling, risk of aspiration)[5]
  • Ingestion of button batteries[6]
  • Ingestion of sharp or elongated objects (toothpicks, soda can tabs)
  • Ingestion of multiple foreign bodies
  • Evidence of perforation
  • Coin at the level of the cricopharyngeus muscle (C6)in a child (Lodged esophageal foreign bodies can cause esophageal necrosis and lead to perforation)
  • Airway compromise
  • Presence of foreign body for >24hr
  • Multiple magnets (can trap bowel)
  • Objects >6cm in length

Food Impaction

Uncomplicated food impaction (no bones, incomplete obstruction) can be managed expectantly but do not allow food bolus to remain impacted for >12-24hr. It is reasonable to consider therapies such as glucagon or a carbonated beverage

  • Glucagon 1-2mg IV/IM (adults) to relax LES - may cause severe nausea/vomiting
    • Only one RCT of glucagon with 24 patients compared glucagon to diazepam and found no difference in the need for endoscopy[7]
    • The major side effect of glucagon is vomiting and can increase the risk for esophageal perforation or aspiration
    • Rate of success increases with soft foods and lack of anatomic pathology, though in majority of presentations this information, particularly anatomic defects, is unknown
  • Carbonated beverage (effervescents) may be effective for small impactions (carbonation dilates esophagus)[2]
  • Calcium channel blockers (nifedipine) / Benzos / Nitrates / papain (meat tenderizer) no longer recommended given low success and higher side effect profile[2]

Coin Ingestion

  • Can attempt removal with a foley catheter under fluoroscopy, though not recommended as risk for aspiration or perforation

Button Battery

  • Administer 10mL of honey every 10min if child is > 12 months old and ingestion < 12 hours old [8]
  • Call the National Button Battery Ingestion Hotline: 202-625-3333 (24/7) [9]
  • True emergency if located in esophagus
    • Perforation can occur within 6hr of ingestion
      • via direct pressure or electrical conduction leading to liquefactive necrosis
    • Mercury toxicity
    • Obtain urgent endoscopic removal
  • Batteries past the esophagus can be managed expectantly with 24hr follow up

Sharp Objects

  • Intestinal perforation from objects distal to stomach is common (up to 35%)
  • Require immediate removal (even if located in stomach or duodenum)
    • If object is distal to duodenum and patient is asymptomatic document passage with daily films
    • If object is distal to duodenum and patient symptomatic obtain immediate surgery consult

*plastic bread clips are invisible on radiographs and CT

Body packing (with Narcotics)

  • Multiple packets inserted in latex bags, ingested to cross borders
    • Each packet potentially toxic if bag bursts
  • Consider whole-bowel irrigation
  • Endoscopy contraindicated (high % leakage/rupture of packets)
  • Surgical removal indicated if evidence of systemic toxicity
  • Do not discharge until all packets removed or 3 packet-free stools

Disposition

  • Will need GI follow up as majority of the time there is a structural abnormality that may lead to recurrence (esophageal web, stricture, tumor, etc)

Complications

External Links

See Also

Video

{{#widget:YouTube|id=gKj13Mq2FC8}}

References

  1. Arugula R, Dorofaeff T. Oesophageal button battery injuries: think again. Emerg Med Australas. 2011 Apr;23(2):220-3.
  2. 2.0 2.1 2.2 2.3 2.4 Leopard D et al. The management of oesophageal soft food bolus obstruction: a systematic review. Ann R Coll Surg Engl 2011;93:441–4. PMID: 21929913
  3. Loh WS, Eu DK, Loh SR, Chao SS. Efficacy of computed tomography scans in the evaluation of patients with esophageal foeign bodies. Ann Otol Rhino Laryngol. Oct 2012; 121 (10) 678- 681
  4. Liu YC, Zhou SH, Ling L. Value of helial computed tomography in the early diagnosis of esophageal foreign bodies in adults. Am J Emerg Med. Sep 2013;31(9),1328-32
  5. Ikenberry SO et al. Management of ingested foreign bodies and food impactions. Gastrointest ends 2011; 73(6): 1085-91. PMID: 21628009
  6. Panella NJ et al. Disk battery ingestion: case series with assessment of clinical and financial impact of a preventable disease. Pediatr Emerg Care 2013; 29(2): 165-9. PMID: 23364381
  7. Tibbling L et al. Effect of spasmolytic drugs on esophageal foreign bodies. Dysphagia 1995; 10(2): 126-7. PMID: 7600855
  8. https://www.poison.org/battery/guideline
  9. http://www.poison.org/battery