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Foreign Bodies and Bezoars of the Stomach and Small Intestine
Foreign Body Ingestion
Foreign body ingestion is an unusual occurrence. Foreign body ingestion may be intentional or unintentional. There are several ways to classify and consider foreign body ingestion. One way is by type of object (size and shape). Foreign body ingestion may also be considered according to age groups. It is well established that 80% to 90% of ingested foreign objects will pass through the gastrointestinal (GI) tract without intervention. Endoscopic removal is required in 10% to 20% of cases and about 1% will require surgical intervention.
Foreign Body Ingestion in Children
Witnessed foreign body ingestion in small children is generally addressed rapidly. In cases where the ingestion was both unintentional and not realized, clinical presentation will depend on where the foreign object becomes lodged. For example, in the pharynx, symptoms are usually immediate and include choking and hypersalivation. In the esophagus, dysphagia or odynophagia usually occur early after ingestion. The treatment is urgent endoscopic removal of the foreign object. Detailed algorithms for endoscopic therapy in children have been published by the North America Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Foreign objects in the stomach most commonly pass into the small bowel. However, if a foreign object lodges in the stomach, it may cause nausea and/or vomiting but also may remain without presenting symptoms for a considerable time. Foreign objects in the small bowel frequently pass into the colon. Objects in the small bowel may cause injury at any point, but often become lodged in the distal ileum due to its small caliber. Injuries in the small bowel include perforation and fistula formation. These situations are discussed in detail in this chapter.
Exploratory Ingestion
Exploratory ingestion is the term used when small children ingest substances while exploring their environment. These cases are usually not witnessed. The age group most at risk is from 6 months to 3 years of age. Common objects ingested include coins, batteries, pills, and pins. Based on their size and shape, almost all coins, pebbles, and small stones pass spontaneously. Rarely, such an object will lodge in the terminal ileum causing small bowel obstruction. As mentioned, any object lodged in the esophagus should be removed urgently via endoscopy. This is because neglected foreign bodies in the esophagus may lead to esophageal perforation requiring thoracotomy and repair. Once an object enters the stomach it will likely pass spontaneously. However, sharp, long (>6 cm), or large (wider than 2.5 cm) objects in the stomach should be removed endoscopically. Once in the small bowel, even sharp objects can be watched vigilantly via imaging. These patients must be observed as inpatients because perforation occurs in 15% to 35% of cases. Signs of obstruction or perforation indicate emergency operation.
Magnets
Several foreign body ingestion types in children require special attention. Ingestion of multiple magnets is rare but dangerous. This foreign body ingestion puts a child at risk for perforation and/or fistula formation. A solitary magnet will almost always pass spontaneously. Multiple magnets seen on radiographs in the esophagus or stomach should be removed endoscopically. Multiple magnets in the small bowel in an asymptomatic child may be followed with serial plain films. Magnets in adjacent bowel loops or a single magnet with another metallic foreign object may erode the adjacent loops, resulting in perforation or fistula formation ( Fig. 64.1 ). These cases require surgical intervention.
Laundry Pods
Colorful laundry pods are new items causing problems in small children. The pods look like candy. In this patient group, 4% to 5% require hospitalization. Ingestion may cause metabolic acidosis with an increased anion gap. Symptoms may include nausea, vomiting, and somnolence. These patients may require endotracheal intubation and ventilator support. At least one death has been reported.
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