Ingested foreign body

Background

  • Esophageal impaction can result in airway obstruction, stricture, or perforation
    • Perforation due to mechanical (ingested bones) or chemical corrosion (button battery)
  • Esophageal irritation (e.g. from swallowed bone) can be perceived as foreign body
  • Three common sites for obstruction
    • Upper 1/3 of esophagus at Cricopharyngeus muscle, near C6 (most common)
    • Aortic Cross Over
    • Lower Esophageal Sphincter
  • Once object has traversed pylorus, usually passes without issue
    • Exceptions:
      • Irregular or sharp edges
      • Particularly wide (>2.5cm) or long (>6cm)

Clinical Features

Adults

  • Retrosternal pain
  • Dysphagia
  • Vomiting
  • Choking
  • Coughing/aspiration (if secretions pool proximal to the obstruction)

Children

Differential Diagnosis

Tracheal/lung aspiration of foreign body

Dysphagia

Pediatric stridor

<6 Months Old

  • Laryngotracheomalacia
    • Accounts for 60%
    • Usually exacerbated by viral URI
    • Diagnosed with flexible fiberoptic laryngoscopy
  • Vocal cord paralysis
    • Stridor associated with feeding problems, hoarse voice, weak and/or changing cry
    • May have cyanosis or apnea if bilateral (less common)
  • Subglottic stenosis
    • Congenital vs secondary to prolonged intubation in premies
  • Airway hemangioma
    • Usually regresses by age 5
    • Associated with skin hemangiomas in beard distribution
  • Vascular ring/sling

>6 Months Old

  • Croup
    • viral laryngotracheobronchitis
    • 6 mo - 3 yr, peaks at 2 yrs
    • Most severe on 3rd-4th day of illness
    • Steeple sign not reliable- diagnose clinically
  • Epiglottitis
    • H flu type B
      • Have higher suspicion in unvaccinated children
    • Rapid onset sore throat, fever, drooling
    • Difficult airway- call anesthesia/ ENT early
  • Bacterial tracheitis
    • Rare but causes life-threatening obstruction
    • Symptoms of croup + toxic-appearing = bacterial tracheitis
  • Foreign body (sudden onset)
    • Marked variation in quality or pattern of stridor
  • Retropharyngeal abscess
    • Fever, neck pain, dysphagia, muffled voice, drooling, neck stiffness/torticollis/extension

Diagnosis

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 know 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 be visualized <50% of time
    • "Double-ring sign" = button battery (needs emergent removal)
  • CT chest
    • Very high-yield for both radiopaque and nonradiopaque objects
    • CT with >99% sensitivity and 70-92% specificity for esophageal foreign body [1] [2]
  • Endoscopy
  • Barium Swallow is not recommended
    • Risk of aspiration, mediastinitis, coats mucosa making endoscopy more difficult

Management

Urgent Endscopy

  • Complete obstruction of esophagus (pooling, risk of aspiration)
  • Ingestion of button batteries
  • 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 in a child
  • Airway compromise
  • Presence of foreign body for >24hr
  • Multiple magnets (can trap bowel)

Food Impaction

  • Uncomplicated food impaction (no bones, incomplete obstruction) can be managed expectantly
    • Do not allow food bolus to remain impacted for >12-24hr
    • Foley catheter removal no longer recommended[citation needed]
  • Consider Pharmacologic Therapies
    • Glucagon 1-2mg IV/IM (adults) to relax LES - may cause severe nausea/vomiting
    • Carbonated beverage (effervescents) may be effective (carbonation dilates esophagus)
    • CCB (nifedipine) / Benzos / Nitrates / papain(meat tenderizer) no longer recommended given low success and higher side effect profile

Coin Ingestion

  • 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

  • Call the National Button Battery Ingestion Hotline: 202-625-3333 (24/7) [3]
  • True emergency if located in esophagus
    • Perforation can occur within 6hr of ingestion
    • Obtain urgent endoscopic removal
      • If endoscopy unavailable AND <2hr since ingestion Foley balloon technique can be tried
  • 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

Narcotics Ingestion

  • Consider whole-bowel irrigation
  • Endoscopy contraindicated (high % leakage/rupture of packets)

Complications

  • Airway compromise
  • Aspiration pneumonia
  • Esophageal perforation/necrosis
  • Mediastinitis
  • Aortic perforation
  • Vocal cord paralysis
  • Bowel perforation/necrosis, fistulas, obstruction

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).

External Links

See Also

Video

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References

  1. 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
  2. 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
  3. http://www.poison.org/battery