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
• Most common site for obstruction is upper 1/3 of esophagus
• Once object has traversed pylorus, usually passes without issue
  • Exceptions:
    • Irregular or sharp edges
    • Particularly wide (>2.5cm) or long (>6cm)

Clinical Features

Adults

• Retrosternal pain
• Dysphagia
• Vomiting
• Choking
• Coughing/aspiration (if secretions pool proximal to the obstruction)

Children

• Refusal or inability to eat
• Vomiting
• Gagging and choking
• Stridor
• neck or throat pain
• Drooling

Differential Diagnosis

• Tracheal/lung aspiration

Diagnosis

Imaging

• 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
  • Very high-yield for both radiopaque and nonradiopaque objects
• Endoscopy

Treatment

Urgent Endscopy

1. Complete obstruction of esophagus (pooling, risk of aspiration)
2. Ingestion of sharp or elongated objects (toothpicks, soda can tabs)
3. Ingestion of multiple foreign bodies
4. Ingestion of button batteries
5. Evidence of perforation
6. Coin at the level of the cricopharyngeus muscle in a child
7. Airway compromise
8. Presence of foreign body for >24hr

Food Impaction

1. Uncomplicated food impaction (no bones, incomplete obstruction) manage expectantly
   1. Do not allow food bolus to remain impacted for >12-24hr
   2. Options
      1. Glucagon 1-2mg IV/IM (adults)
      2. Coca-Cola
   3. Obtain esophagogram after treatment to ensure passage

Coin Ingestion

• Can attempt removal with a foley catheter under fluoroscopy, though not recommended as risk for aspiration
• Should be admitted to PICU and removed by GI endoscopy within 24 hours

Button Battery

• Call the National Button Battery Ingestion Hotline: 202-325-3333 (24/7)
• 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 w/ 24hr f/u

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 pt is asymptomatic document passage w/ daily films
  • If object is distal to duodenum and pt symptomatic obtain immediate surgery consult

Narcotics Ingestion

• Consider whole-bowel irrigation
• Endoscopy contraindicated

See Also

• Esophageal Foreign Body Removal with Foley Catheter
• Foreign body