Ingestions

Foreign Bodies in the Esophagus

Seema Khan

The majority (80%) of accidental foreign-body ingestions occur in children, most of whom are 5 yr of age or younger. Older children and adolescents with developmental delays and those with psychiatric disorders are also at increased risk. The presentation of a foreign body lodged in the esophagus constitutes an emergency and is associated with significant morbidity and mortality because of the potential for perforation and sepsis. Coins are by far the most commonly ingested foreign body, followed by small toy items. Food impactions are less common in children than in adults and usually occur in children in association with eosinophilic esophagitis (diagnosed in 92% of those presenting with food impactions and dysphagia), repair of esophageal atresia, and Nissen fundoplication. Most esophageal foreign bodies lodge at the level of the cricopharyngeus (upper esophageal sphincter), the aortic arch, or just superior to the diaphragm at the gastroesophageal junction (lower esophageal sphincter).

At least 30% of children with esophageal foreign bodies may be totally asymptomatic, so any history of foreign body ingestion should be taken seriously and investigated. An initial bout of choking, gagging, and coughing may be followed by excessive salivation, dysphagia, food refusal, emesis, or pain in the neck, throat, or sternal notch regions. Respiratory symptoms such as stridor, wheezing, cyanosis, or dyspnea may be encountered if the esophageal foreign body impinges on the larynx or membranous posterior tracheal wall. Cervical swelling, erythema, or subcutaneous crepitations suggest perforation of the oropharynx or proximal esophagus.

Evaluation of the child with a history of foreign body ingestion starts with plain anteroposterior radiographs of the neck, chest, and abdomen, along with lateral views of the neck and chest. The flat surface of a coin in the esophagus is seen on the anteroposterior view and the edge on the lateral view ( Fig. 353.1 ). The reverse is true for coins lodged in the trachea; here, the edge is seen anteroposteriorly and the flat side is seen laterally. Disk-shaped button batteries can look like coins and be differentiated by the double halo and step-off on anteroposterior and lateral views, respectively ( Fig. 353.2 ). The use of button batteries has been increasingly popular, leading to a sharp rise in accidental ingestions, and critical in the increase in morbidity and mortality. The latter is thought to be due to both an increase in diameter and a change to lithium cells. Children younger than 5 yr of age with ingestion of batteries ≥20 mm are considered to have the highest risk for catastrophic events such as necrosis, tracheoesophageal fistula, perforation, stricture, vocal cord paralysis, mediastinitis, and aortoenteric fistula ( Fig. 353.3 ). Materials such as plastic, wood, glass, aluminum, and bones may be radiolucent; failure to visualize the object with plain films in a symptomatic patient warrants urgent endoscopy. Computed tomography (CT) scan with 3-dimensional reconstruction may increase the sensitivity of imaging a foreign body. Although barium contrast studies may be helpful in the occasional asymptomatic patient with negative plain films, their use is to be discouraged because of the potential of aspiration, as well as making subsequent visualization and object removal more difficult.

In managing the child with an esophageal foreign body, it is important to assess risk for airway compromise and to obtain a chest CT scan and surgical consultation in cases of suspected airway perforation. Treatment of esophageal foreign bodies usually merits endoscopic visualization of the object and underlying mucosa and removal of the object using an appropriately designed foreign body–retrieving accessory instrument through the endoscope and with an endotracheal tube protecting the airway. Sharp objects in the esophagus, multiple magnets or single magnet with a metallic object, or foreign bodies associated with respiratory symptoms mandate urgent removal within 12 hr of presentation. Button batteries, in particular, must be emergently removed within 2 hr of presentation regardless of the timing of patient's last oral intake because they can induce mucosal injury in as little as 1 hr of contact time and involve all esophageal layers within 4 hr (see Figs. 353.3 and 353.4 ). Asymptomatic blunt objects and coins lodged in the esophagus can be observed for up to 24 hr in anticipation of passage into the stomach. If there are no problems in handling secretions, meat impactions can be observed for up to 24 hr. In patients without prior esophageal surgeries, glucagon (0.05 mg/kg intravenously [IV]) can sometimes be useful in facilitating passage of distal esophageal food boluses by decreasing the lower esophageal sphincter pressure. The use of meat tenderizers or gas-forming agents can lead to perforation and are not recommended. An alternative technique for removing esophageal coins impacted for <24 hr, performed most safely by experienced radiology personnel, consists of passage of a Foley catheter beyond the coin at fluoroscopy, inflating the balloon, and then pulling the catheter and coin back simultaneously with the patient in a prone oblique position. Concerns about the lack of direct mucosal visualization and, when tracheal intubation is not used, the lack of airway protection prompt caution in the use of this technique. Bougienage of esophageal coins toward the stomach in selected uncomplicated pediatric cases has been suggested to be an effective, safe, and economical modality where endoscopy might not be routinely available.