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
• 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

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

Differential Diagnosis

Tracheal/lung aspiration of foreign body

Dysphagia

• Oropharyngeal dysphagia
  • CVA
  • Parkinson's disease
  • Brain stem tumors
  • Degenerative disease - ALS, MS, Huntington's
  • Postinfectious - polio, syphilis
  • Peripheral neuropathy
  • Myasthenia gravis
  • Polymyositis, dermatomyositis
  • Muscular dystrophy
• Esophageal dysphagia
  • Achalasia
  • Diffuse esophageal spasm
  • Ingested foreign body
  • Esophageal web
  • Malignancy, mediastinal masses
  • Schatzki Ring
  • Scleroderma
  • Strictures - peptic, radiation, chemical, medication-induced
  • Vascular compression
  • Zenker's diverticulum

Diagnosis

Imaging

• May not be needed in settings such as a know food bolus
• 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
• Endoscopy
• Barium Swallow is not recommended
  • Risk of aspiration, mediastinitis, coats mucosa making endoscopy more difficult

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
• Multiple magnets (can trap bowel)

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) - may cause severe nausea/vomiting
  • Carbonated beverage (effervescents) may be effective
  • CCB/Benzos/Nitrates no longer recommended given low success and higher side effect profile

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 (high % leakage/rupture of packets)

Complications

• Airway compromise
• Aspiration pneumonia
• Esophageal perforation/necrosis
• Mediastinitis
• Aortic perforation
• Vocal cord paralysis
• Bowel perforation/necrosis, fistulas, obstruction

See Also

• Esophageal Foreign Body Removal with Foley Catheter
• Foreign body