Difference between revisions of "Ingested foreign body"

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[[File:Abdominal foreign body.png|thumb|Body-packing with multiple foreign bodies ("balls" of hashish) on [[KUB]]]]
 
[[File:Abdominal foreign body.png|thumb|Body-packing with multiple foreign bodies ("balls" of hashish) on [[KUB]]]]
 
[[File:Battery in stomach.png|thumb|Button battery in stomach on [[KUB]].]]
 
[[File:Battery in stomach.png|thumb|Button battery in stomach on [[KUB]].]]

Revision as of 20:45, 21 July 2016

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, near C6 (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 of foreign body

Dysphagia

Pediatric stridor

  • A minimal amount of edema or inflammation in the pediatric airway can result in significant obstruction
    • Can lead to rapid decompensation

<6mo

  • Laryngotracheomalacia
    • Accounts for 60%
    • Usually exacerbated by viral URI
    • Dx w/ flexible fiberoptic laryngoscopy
  • Vocal cord paralysis
    • Stridor associated w/ feeding problems, hoarse voice, weak and/or changing cry
    • May have cyanosis or apnea if bilateral (less common)
  • Subglottic stenosis
    • Congenital vs 2/2 prolonged intubation in premies
  • Airway hemangioma
    • Usually regresses by age 5
    • Associated w/ skin hemangiomas in beard distribution
  • Vascular ring/sling

>6mo

  • Croup
    • viral laryngotracheobronchitis
    • 6 mo- 3 yr, peaks at 2 yrs
    • Most severe on 3rd-4th day of illness
    • Steeple sign not reliable- diagnose clinically
  • Epiglottitis
    • H flu type B
      • Have higher suspicion in unvaccinated children
    • Rapid onset sore throat, fever, drooling
    • Difficult airway- call anesthesia/ ENT early
  • Bacterial tracheitis
    • Rare but causes life-threatening obstruction
    • Sx of croup + toxic-appearing = bacterial tracheitis
  • Foreign body (sudden onset)
    • Marked variation in quality or pattern of stridor
  • Retropharyngeal abscess
    • Fever, neck pain, dysphagia, muffled voice, drooling, neck stiffness/torticollis/extension

Evaluation

Body-packing with multiple foreign bodies ("balls" of hashish) on KUB
Button battery in stomach on KUB.
Penny in the esophagus of a 12 mo male

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 [1] [2]
  • Endoscopy
  • Barium Swallow is not recommended
    • Risk of aspiration, mediastinitis, coats mucosa making endoscopy more difficult

Management

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
    • Foley catheter removal no longer recommended[citation needed]
  • Consider Pharmacologic Therapies
    • Glucagon 1-2mg IV/IM (adults) to relax LES - may cause severe nausea/vomiting
    • Carbonated beverage (effervescents) may be effective (carbonation dilates esophagus)
    • CCB (nifedipine) / Benzos / Nitrates / papain(meat tenderizer) 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: 202-625-3333 (24/7) [3]
  • 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 with 24hr follow up

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 patient is asymptomatic document passage with daily films
    • If object is distal to duodenum and patient 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

Disposition

  • Will need GI follow up as majority of the time there is a structural abnormality that may lead to recurrence (esophageal web, stricture, tumor, etc).

External Links

See Also

Video

References

  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
  3. http://www.poison.org/battery