Ingestion of Foreign Bodies

Esophageal Foreign Bodies

Foreign body (FB) ingestions are a common occurrence in infants and young children. The exact incidence is unknown because many cases are not reported. In 2015, the Annual Report of the American Association of Poison Control Centers noted more than 94,000 cases of FB ingestion. More than 68,000 occurred in children ≤5 years of age. Of note, magnet ingestions have increased 8.5-fold over the past 10 years with a 75% average annual increase per year. Recently, the Susy Safe project has been formed to provide a pan-European surveillance registry for injuries due to FB ingestion and aspiration. This international consortium provides a risk-analysis profile for each product causing harm, evaluates socioeconomic disparities among these patients, and uses data collection to interact with consumer associations.

The vast majority of ingestions in children are accidental. The most common type of ingested FB varies by geographic region. In the United States and Europe, coins are the most common. Other commonly ingested objects include toys, batteries, needles, straight pins, safety pins ( Fig. 11.1 ), screws, earrings, pencils, erasers, glass, fish and chicken bones, and meat. However, in areas of the world where fish contribute a significant portion of the diet, such as in Asia, a fish bone is the most common FB ingested by children.

FB ingestions usually present after a witnessed event or disappearance of an object. Also, there may be heightened suspicion for ingestion by a caregiver based on the child’s description. The initial presentation can vary from the child being completely asymptomatic to a variety of symptoms including drooling, neck and throat pain, dysphagia, emesis, wheezing, respiratory distress, or abdominal pain/distention. The majority of patients will have a normal physical exam; however, the child should be evaluated for signs of complications. Physical exam findings that raise suspicion of potential complications include oropharyngeal abrasions, crepitus, or signs of peritonitis.

The esophagus is the narrowest portion of the alimentary tract and is thus a common site for FB impaction. Within the esophagus itself, there are three areas of anatomical narrowing that are potential areas of impaction: the cricopharyngeus sling (70%), the level of the aortic arch in the mid esophagus (15%), and the lower esophageal sphincter at the gastroesophageal junction (15%). Other areas of potential impaction may be found in the esophagus of children who have underlying esophageal pathology (i.e., strictures or eosinophilic esophagitis) or prior esophageal surgery (i.e., esophageal atresia). Although usually asymptomatic, sharp foreign bodies may penetrate the mucosa at any level and cause mediastinitis, aortoenteric fistula, or peritonitis.

Symptoms of esophageal FB impaction are nonspecific and include drooling, poor feeding, neck and throat pain, vomiting, or wheezing. Radiopaque objects can be detected on anteroposterior (AP) and lateral neck and chest radiographs ( Fig. 11.2 ), while radiolucent objects may require further workup with a gastrografin esophagram or esophagoscopy depending on the symptoms and provider’s level of suspicion ( Fig. 11.3 ).

The most common round, smooth object ingested that is amenable to extraction or advancement is a coin. The majority of esophageal coins will appear en face in the AP view, and from the side on the lateral radiograph (see Fig. 11.2 ). On occasion, more than one coin will have been ingested ( Fig. 11.4 ), and thus completion esophagoscopy is generally recommended following removal of the first coin.

The location of the object on the radiograph is important in determining the treatment options. Most FB impactions are located in the proximal esophagus at the level of the upper esophageal sphincter or thoracic inlet. The majority of FB impactions found in the upper or mid esophagus will remain entrapped and require retrieval. Options for retrieval include nonemergent endoscopy (rigid or flexible) ( Fig. 11.5 ) and Foley balloon extraction with fluoroscopy ( Fig. 11.6 ). The Foley balloon extraction technique should be limited to round, smooth objects that have been impacted for <1 week in appropriately selected children without any evidence of complications. This technique was found to have a success rate of 80% while significantly lowering costs. More recent fiscal analysis continues to show advantages for this approach. In a recent study, median total cost (including the emergency department [ED], operating room [OR], transport, admission, etc.) was $1231 for balloon retrieval versus $3615 for primary endoscopy. Objects that are impacted in the lower esophagus often spontaneously pass into the stomach. For this reason, certain lower esophageal impactions can be observed for a brief duration of time, or attempted to be advanced into the stomach with bougienage or a nasogastric tube in the ED without anesthesia. Recently, transnasal esophagoscopy has emerged as a new option. Advantages include shortened procedure time and the need for only a local anesthetic. Rarely, a chronic esophageal coin can cause esophageal perforation, but this will usually be contained ( Fig. 11.7 ).

Gastrointestinal Foreign Bodies

FB ingestions that are found to be distal to the esophagus are usually asymptomatic when discovered. Signs and symptoms including significant abdominal pain, nausea, vomiting, fevers, abdominal distention, or peritonitis should alert the provider to potential complications including obstruction and/or perforation. The majority of FBs that pass into the stomach will usually pass through the remainder of the gastrointestinal (GI) tract uneventfully. These patients can be managed as an outpatient. Occasionally, a FB will remain present in the bowel after a period of observation and serial radiographs ( Fig. 11.8 ). Prokinetic agents and cathartics have not been found to improve gut transit time and passage of the FB. Often parents are instructed to strain the child’s stool; however, in up to 50% of cases, the FB is not identified even with successful passage. If the child remains asymptomatic and the FB has not been identified, a repeat abdominal radiograph can be performed at 2- to 3-week intervals. Subsequent endoscopy is usually deferred for 4–6 weeks.

Special Topic Ingestions