Ingested foreign body

(Redirected from Esophageal Foreign Body)

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 (in the US), animal bones (outside the US)
    • 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]

Foreign Body Types

Clinical Features

Adults

Children

Differential Diagnosis

Consider tracheal/lung aspiration of foreign body

Dysphagia

Upper GI Bleeding (peds)

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
Plain X-ray: an esophageal button battery foreign body. (a) Anteroposterior view (double contour), (b) Lateral view.

Imaging

  • May not be needed in settings such as a known food bolus
  • PA and lateral films necessary, should include neck, chest, and abdomen
  • Consider obtaining lateral neck films
    • 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"
    • ~60% of foreign bodies are radiopaque
  • CT chest
    • Very high-yield for both radiopaque and non-radiopaque objects
    • Sensitivity >99% and specificity 70-92%[3] [4]
  • MRI
    • Consider for radiolucent objects to avoid radiation load of CT
    • Cannot use with metallic objects (if metallic, should be radiopaque on plain films)
    • Higher cost than CT, some EDs may not be equipped to perform at certain times, may require sedating the patient due to long image capture times
  • 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. Consider pretreatment with an antiemetic
    • 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

  • If attempting to avoid endoscopy, there are non-endoscopic management options
    • Foley Catheter removal
      • Traditionally was done with fluoroscopy, but has been demonstrated to be safe without it. First described by Bigler et. al. in 1966 [8]
      • Does not require subspecialist
      • Cheap, can save 300-800% on the total Emergency Department bill by avoiding endoscopy [9] [10] [11]
      • The diameter of the foley balloon should be decided based on the diameter measured on radiograph or with twin object brought in by a family member. This procedure can be done with or without sedation depending on the patient age and clinical comfortability but has been demonstrated to be equally effective without sedation. The catheter is then inserted into the esophagus passed the foreign body, inflated with either air or normal saline, and slowly retracted [12] [13]
      • Gold standard is still endoscopy, but consider if endoscopy not available or after shared decision-making conversation with patient and family
    • Bougienage
      • The basis of this technique involves purposefully passing the object into the stomach to help facilitate spontaneous passage thereafter and ensure no esophageal impaction
      • Has also been described as safe (<1% complication rate), effective (>95% effective), and cheap (similar cost benefit as detailed above) [14] [15] [16]
      • This involves using a thin, flexible esophageal dilator and passing it from the oral cavity into the esophagus. One can measure the needed depth by measuring a Hurst dilator from the tip of the nose to the epigastrium, then a quick insertion with the child restrained can yield forced passage of the object passed the lower esophageal sphincter.[17]

Button Battery

  • Administer 10mL of honey every 10min if child is > 12 months old and ingestion < 12 hours old [18]
  • Call the National Button Battery Ingestion Hotline: 800-498-8666 (24/7) [19]
  • 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

  • 80-90% of ingested foreign bodies will pass spontaneously and do not require observation or hospitalization
  • If endoscopy performed, generally patients can still be discharged afterward and do not require hospitalization unless direct mucosal injury or other complication is identified
  • If any necrosis is present (button battery, caustic ingestion), will likely need GI follow up as strictures, fistulas can occur

Complications

External Links

See Also

Video

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. Bigler FC. The use of a Foley catheter for removal of blunt foreign bodies from the esophagus. J Thorac Cardiovasc Surg. 1966;51:759–760.
  9. Choe JY, Choe BH. Foreign Body Removal in Children Using Foley Catheter or Magnet Tube from Gastrointestinal Tract. Pediatr Gastroenterol Hepatol Nutr. 2019;22(2):132-141. doi:10.5223/pghn.2019.22.2.132
  10. Dokler ML, Bradshaw J, Mollitt DL, Tepas JJ., 3rd Selective management of pediatric esophageal foreign bodies. Am Surg. 1995;61:132–134.
  11. Little DC, Shah SR, St Peter SD, Calkins CM, Morrow SE, Murphy JP, et al. Esophageal foreign bodies in the pediatric population: our first 500 cases. J Pediatr Surg. 2006;41:914–918.
  12. Choe JY, Choe BH. Foreign Body Removal in Children Using Foley Catheter or Magnet Tube from Gastrointestinal Tract. Pediatr Gastroenterol Hepatol Nutr. 2019;22(2):132-141. doi:10.5223/pghn.2019.22.2.132
  13. Kang JH, Jung HJ, Suh JK, Park JS, Park HJ, Chu MA, et al. Feasibility of foley catheter prior to endoscopy for the removal of esophageal coin in children. Korean J Pediatr Gastroenterol Nutr. 2011;14:251–257.
  14. Burgos A, Rábago L, Triana P. Western view of the management of gastroesophageal foreign bodies. World J Gastrointest Endosc. 2016;8(9):378-384. doi:10.4253/wjge.v8.i9.378
  15. Allie EH, Blackshaw AM, Losek JD, Tuuri RE. Clinical effectiveness of bougienage for esophageal coins in a pediatric ED. Am J Emerg Med. 2014;32:1263–1269.
  16. Arms JL, Mackenberg-Mohn MD, Bowen MV, Chamberlain MC, Skrypek TM, Madhok M, Jimenez-Vega JM, Bonadio WA. Safety and efficacy of a protocol using bougienage or endoscopy for the management of coins acutely lodged in the esophagus: a large case series. Ann Emerg Med. 2008;51:367–372.
  17. Tenenbein, M. Chapter 11: Foreign Bodies. In: Schafermeyer, R ed. Strange and Schafermeyer's Pediatric Emergency Medicine. 4th Edition. McGraw Hill; 2014.
  18. https://www.poison.org/battery/guideline
  19. http://www.poison.org/battery