Ingested foreign body: Difference between revisions

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*CT chest
*CT chest
**Very high-yield for both radiopaque and nonradiopaque objects
**Very high-yield for both radiopaque and nonradiopaque objects
**CT with >99% sensitivity and 70-92% specificity for esophageal foreign body <ref>Loh WS, Eu DK, Loh SR, Chao SS. Efficacy of computed tomography scans in the evaluation of patients with esophageal foeign bodies. Ann Otol Rhino Laryngol. Oct 2012; 121 (10) 678- 681</ref> <ref> Liu YC, Zhou SH, Ling L. Value of helial computed tomography in the early diagnosis of esophageal foreign bodies in adults. Am J Emerg Med. Sep 2013; 31 (9), 1328-32 </ref>
*Endoscopy
*Endoscopy


Revision as of 20:05, 1 September 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
    • CT with >99% sensitivity and 70-92% specificity for esophageal foreign body [1] [2]
  • 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
  1. ↑ Loh WS, Eu DK, Loh SR, Chao SS. Efficacy of computed tomography scans in the evaluation of patients with esophageal foeign bodies. Ann Otol Rhino Laryngol. Oct 2012; 121 (10) 678- 681
  2. ↑ Liu YC, Zhou SH, Ling L. Value of helial computed tomography in the early diagnosis of esophageal foreign bodies in adults. Am J Emerg Med. Sep 2013; 31 (9), 1328-32
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