Ingested foreign body: Difference between revisions
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**Perforation due to mechanical (ingested bones) or chemical corrosion (button battery)
**Perforation due to mechanical (ingested bones) or chemical corrosion (button battery)
*Esophageal irritation (e.g. from swallowed bone) can be perceived as foreign body
*Esophageal irritation (e.g. from swallowed bone) can be perceived as foreign body
*Most common site for obstruction is upper 1/3 of esophagus
*Three common sites for obstruction
**Upper 1/3 of esophagus at Cricopharyngeus muscle (most common)
**Aortic Cross Over
**Lower Esophageal Sphincter
*Once object has traversed pylorus, usually passes without issue
*Once object has traversed pylorus, usually passes without issue
**Exceptions:
**Exceptions:
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**Coins in trachea present their face on lateral view
**Coins in trachea present their face on lateral view
**Bones can be visualized <50% of time
**Bones can be visualized <50% of time
**"Double-ring sign = button battery (needs emergent removal)
**"Double-ring sign" = button battery (needs emergent removal)
*CT chest
*CT chest
**Very high-yield for both radiopaque and nonradiopaque objects
**Very high-yield for both radiopaque and nonradiopaque objects
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==Treatment==
==Treatment==
===Urgent Endscopy===
===Urgent Endscopy===
#Complete obstruction of esophagus (pooling, risk of aspiration)
*Complete obstruction of esophagus (pooling, risk of aspiration)
#Ingestion of sharp or elongated objects (toothpicks, soda can tabs)
*Ingestion of button batteries
#Ingestion of multiple foreign bodies
*Ingestion of sharp or elongated objects (toothpicks, soda can tabs)
#Ingestion of button batteries
*Ingestion of multiple foreign bodies
#Evidence of perforation
*Evidence of perforation
#Coin at the level of the cricopharyngeus muscle in a child
*Coin at the level of the cricopharyngeus muscle in a child
#Airway compromise
*Airway compromise
#Presence of foreign body for >24hr
*Presence of foreign body for >24hr
 
===Food Impaction===
===Food Impaction===
#Uncomplicated food impaction (no bones, incomplete obstruction) manage expectantly
*Uncomplicated food impaction (no bones, incomplete obstruction) can be managed expectantly
##Do not allow food bolus to remain impacted for >12-24hr
**Do not allow food bolus to remain impacted for >12-24hr
##Options
*Consider Pharmacologic Therapies
###Glucagon 1-2mg IV/IM (adults)
**Glucagon 1-2mg IV/IM (adults)
###Coca-Cola
**Nifedipine 5-10mg SL
##Obtain esophagogram after treatment to ensure passage
**Carbonated beverage
*Obtain esophagogram after treatment to ensure passage


===Coin Ingestion===
===Coin Ingestion===
*Can attempt removal with a foley catheter under fluoroscopy, though not recommended as risk for aspiration
*Can attempt removal with a foley catheter under fluoroscopy, though not recommended as risk for aspiration or perforation
*Should be admitted to ICU and removed by GI endoscopy within 24 hours
*Should be admitted to ICU and removed by GI endoscopy within 24 hours


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*Consider whole-bowel irrigation
*Consider whole-bowel irrigation
*Endoscopy contraindicated
*Endoscopy contraindicated
==Complications==
*Airway compromise
*Aspiration pneumonia
*Esophageal perforation/necrosis
*[[Mediastinitis]]
*Aortic perforation
*Vocal cord paralysis


==See Also==
==See Also==
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==References==
==References==
*Roberts: Clinical Procedures in EM, 5th


[[Category:GI]]
[[Category:GI]]
[[Category:Peds]]
[[Category:Peds]]

Revision as of 09:44, 11 June 2015

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
  • Three common sites for obstruction
    • Upper 1/3 of esophagus at Cricopharyngeus muscle (most common)
    • Aortic Cross Over
    • Lower Esophageal Sphincter
  • 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

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

  • Complete obstruction of esophagus (pooling, risk of aspiration)
  • Ingestion of button batteries
  • 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 in a child
  • Airway compromise
  • Presence of foreign body for >24hr

Food Impaction

  • Uncomplicated food impaction (no bones, incomplete obstruction) can be managed expectantly
    • Do not allow food bolus to remain impacted for >12-24hr
  • Consider Pharmacologic Therapies
    • Glucagon 1-2mg IV/IM (adults)
    • Nifedipine 5-10mg SL
    • Carbonated beverage
  • 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 or perforation
  • Should be admitted to ICU 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

Complications

  • Airway compromise
  • Aspiration pneumonia
  • Esophageal perforation/necrosis
  • Mediastinitis
  • Aortic perforation
  • Vocal cord paralysis

See Also

References

  • Roberts: Clinical Procedures in EM, 5th
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