Esophageal Foreign Body (Peds): Difference between revisions

Revision as of 01:19, 1 August 2011

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)

Diagnosis

History=

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

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
CT chest
- Very high-yield for both radiopaque and nonradiopaque objects
Endoscopy

DDx

Tracheal/lung aspiration

Treatment

Urgent Endscopy

Complete obstruction of esophagus (pooling, risk of aspiration)
Ingestion of sharp or elongated objects (toothpicks, soda can tabs)
Ingestion of multiple foreign bodies
Ingestion of button batteries
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) manage expectantly
1. Do not allow food bolus to remain impacted for >12-24hr
2. Options
  1. Glucagon 1-2mg IV (adults)
  2. Coca-Cola
3. Obtain esophagogram after treatment to ensure passage

Coin Ingestion

Can attempt removal with a foley catheter under fluoroscopy

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 that have passed 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

Source

Tintinalli

Authors:

@@ Line 1: / Line 1: @@
 ==Background==
-*Most common site is upper 1/3 of esophagous
+*Esophageal impaction can result in airway obstruction, stricture, or perforation
-*5% of FB are more than one FB
+**Perforation due to mechanical (ingested bones) or chemical corrosion (button battery)
-*Disc batteries can cause esophageal burns w/in 4hr and perforation w/in 6hr
+*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)
 ==Diagnosis==
-Clinical
+===History====
+====Adults====
-*Consider CXR and/or soft tissue lateral x-ray
+*Retrosternal pain
-**(soft tissue lateral of neck, cxr, kub), if no FB on xr (radiolucent, ie plastic, button), but child w/ sx or strong hx of recent FB ingestion, then endoscopy is indicated.
+*Dysphagia
-**Coins in the esoph are in coronal plane & coins in trachea in the sagital plane
+*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
+===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
+*CT chest
+**Very high-yield for both radiopaque and nonradiopaque objects
+*Endoscopy
 ==DDx==
@@ Line 15: / Line 37: @@
 ==Treatment==
-===Stable===
+===Urgent Endscopy===
-# Food bolus (soft; ie. no bones)
+#Complete obstruction of esophagus (pooling, risk of aspiration)
-##glucagon (caution causes vomiting)
+#Ingestion of sharp or elongated objects (toothpicks, soda can tabs)
-##fails --> endosopic removal
+#Ingestion of multiple foreign bodies
-# Coin (or similar round/smooth FB)
+#Ingestion of button batteries
-## Below diaphram
+#Evidence of perforation
-### asymptomatic
+#Coin at the level of the cricopharyngeus muscle in a child
-####d/c home, check stool x 1 wk, repeak KUB if not passed as outpt
+#Airway compromise
-### sx obstruction or perf
+#Presence of foreign body for >24hr
-####surgery
+===Food Impaction===
-## Above diaphram
+#Uncomplicated food impaction (no bones, incomplete obstruction) manage expectantly
-### asymptomatic
+##Do not allow food bolus to remain impacted for >12-24hr
-####Obs + repeat XR x 6hrs
+##Options
-####Consider "Foley manuver" if fails Obs
+###Glucagon 1-2mg IV (adults)
-#Disc or button battery
+###Coca-Cola
-##Esophagus --> immediate removal (endoscopy)
+##Obtain esophagogram after treatment to ensure passage
-##Below diaphram
+===Coin Ingestion===
-###Asymptomatic
+#Can attempt removal with a foley catheter under fluoroscopy
-####Outpt obs with close f/u
+===Button Battery===
-####Needs to be removed if still in stomach after 24-48hr
+*Call the National Button Battery Ingestion Hotline: 202-325-3333 (24/7)
-###Sypmtomatic
+*True emergency if located in esophagus
-####Immediate removal (endoscopy)
+**Perforation can occur within 6hr of ingestion
-# Sharp (ie bone, pin, etc) or long (>3-6cm)
+**Obtain urgent endoscopic removal
-##Esophagous, stomach, and/or symptomatic
+***If endoscopy unavailable AND <2hr since ingestion Foley balloon technique can be tried
-###Immediate removal (endoscopy)
+*Batteries that have passed esophagus can be managed expectantly w/ 24hr f/u
-###Below stomach and asymptomatic
+===Sharp Objects===
-####Outpt obs with close F/U
+*Intestinal perforation from objects distal to stomach is common (up to 35%)
-####Perf rare (<1-2%)
+*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
-==See Also==
+**If object is distal to duodenum and pt symptomatic obtain immediate surgery consult
-GI: Esophageal Foreign Body
+===Narcotics Ingestion===
+*Consider whole-bowel irrigation
+*Endoscopy contraindicated
 ==Source==
-/04 EM Reports- By Lampe
+Tintinalli
 [[Category:Peds]]
 [[Category:GI]]