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)
- Exceptions:
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
- Oropharyngeal dysphagia
- CVA
- Parkinson's disease
- Brain stem tumors
- Degenerative disease - ALS, MS, Huntington's
- Postinfectious - polio, syphilis
- Peripheral neuropathy
- Myasthenia gravis
- Polymyositis, dermatomyositis
- Muscular dystrophy
- Esophageal dysphagia
- Achalasia
- Diffuse esophageal spasm
- Ingested foreign body
- Esophageal web
- Malignancy, mediastinal masses
- Schatzki Ring
- Scleroderma
- Strictures - peptic, radiation, chemical, medication-induced
- Vascular compression
- Zenker's diverticulum
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
- H flu type B
- 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
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
- 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
- ↑ 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
- ↑ 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
- ↑ http://www.poison.org/battery