Ingested foreign body: Difference between revisions

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==Background==
==Background==
*Esophageal impaction can result in airway obstruction, stricture, or perforation
[[File:Gray1032.png|thumb|Posterior view of the position and relation of the esophagus in the cervical region and in the posterior mediastinum.]]
**Perforation due to mechanical (ingested bones) or chemical corrosion (button battery)
[[File:Layers of the GI Tract english.svg|thumb|Layers of the GI track: the mucosa, submucosa, muscularis, and serosa.]]
*Esophageal irritation (e.g. from swallowed bone) can be perceived as foreign body
[[File:Illu esophagus.jpg|thumb|Esophagus anatomy and nomenclature based on two systems.]]
*Three common sites for obstruction
*Esophageal impaction can result in airway obstruction, stricture, or perforation. Perforation can be due to multiple mechanisms but is generally either mechanical (e.g. ingested bones) or via chemical corrosion (e.g. button battery)<ref>Arugula R, Dorofaeff T. Oesophageal button battery injuries: think again. Emerg Med Australas. 2011 Apr;23(2):220-3.</ref>
**Upper 1/3 of esophagus at Cricopharyngeus muscle, near C6 (most common)
*Esophageal irritation can be perceived as foreign body (globus sensation)
**Aortic Cross Over
*Once the object has traversed the pylorus, it usually passes without issue
**Lower Esophageal Sphincter
**Exceptions: Irregular or sharp edges, particularly wide (>2.5cm) or long (>6cm) objects
*Once object has traversed pylorus, usually passes without issue
*Common foreign bodies:
**Exceptions:
**Most common in children: coins (in the US), animal bones (outside the US)
***Irregular or sharp edges
**Most common in adults: food bolus
***Particularly wide (>2.5cm) or long (>6cm)
*Site of obstruction:
**Cricopharyngeus (near C6) muscle is the most common (about 75%)<ref name="systematic review">Leopard D et al. The management of oesophageal soft food bolus obstruction: a systematic review. Ann R Coll Surg Engl 2011;93:441–4. PMID: 21929913</ref>
**Aortic cross over the esophagus<ref name="systematic review"></ref>
**Lower Esophageal Sphincter<ref name="systematic review"></ref>
 
{{FB types}}


==Clinical Features==
==Clinical Features==
===Adults===
===Adults===
*Retrosternal pain
*[[chest pain|Retrosternal pain]]
*[[Dysphagia]]
*[[Dysphagia]]
*[[Vomiting]]
*[[Vomiting]]
*Choking
*Choking
*Coughing/aspiration (if secretions pool proximal to the obstruction)
*[[Cough]]ing/aspiration (if secretions pool proximal to the obstruction)
===Children===
===Children===
*Refusal or inability to eat
*Refusal or inability to eat
Line 24: Line 29:
*Gagging and choking
*Gagging and choking
*[[Stridor]]
*[[Stridor]]
*[[Neck pain|Neck]] or throat pain
*[[Neck pain|Neck]] or [[sore throat|throat]] pain
*Drooling
*Drooling


==Differential Diagnosis==
==Differential Diagnosis==
''Tracheal/lung aspiration of foreign body''
''Consider [[Foreign body aspiration|tracheal/lung aspiration ]] of foreign body''
 
{{Dysphagia DDX}}
{{Dysphagia DDX}}
{{Upper GI bleeding peds DDX}}


{{Pediatric stridor DDX}}
==Evaluation==
 
[[File:Abdominal foreign body.png|thumb|[[Body packing]] with multiple foreign bodies ("balls" of hashish) on [[KUB]]]]
==Diagnosis==
[[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]].]]
[[File: Esophageal_fb.JPG |thumb|Penny in the esophagus of a 12 mo male]]
[[File: Esophageal_fb.JPG |thumb|Penny in the esophagus of a 12 mo male]]
[[File:PMC3725977 BMRI2013-846091.002.png|thumb|Plain X-ray: an esophageal button battery foreign body. (a) Anteroposterior view (double contour), (b) Lateral view.]]
===Imaging===
===Imaging===
*May not be needed in settings such as a know food bolus
*May not be needed in settings such as a known food bolus
*[[CXR]] PA and lateral
*PA and lateral films necessary, should include neck, chest, and abdomen
*Consider obtaining lateral neck films
**Coins in esophagus present their face on AP view
**Coins in esophagus present their face on AP view
**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 only be visualized <50% of time
**"Double-ring sign" = button battery (needs emergent removal)
**Button batteries may present with "double-ring sign"
**~60% of foreign bodies are radiopaque
*CT chest
*CT chest
**Very high-yield for both radiopaque and nonradiopaque objects
**Very high-yield for both radiopaque and non-radiopaque 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>
**Sensitivity >99% and specificity 70-92%<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
*MRI
*Barium Swallow is '''not recommended'''
**Consider for radiolucent objects to avoid radiation load of CT
**Risk of aspiration, mediastinitis, coats mucosa making endoscopy more difficult
**Cannot use with metallic objects (if metallic, should be radiopaque on plain films)
**Higher cost than CT, some EDs may not be equipped to perform at certain times, may require sedating the patient due to long image capture times
*Barium Swallow is '''not recommended''' due to risk of aspiration, mediastinitis, and barrium coating mucosa (makes endoscopy more difficult)


==Treatment==
==Management==
===Urgent Endscopy===
===Indications for Urgent Endscopy===
*Complete obstruction of esophagus (pooling, risk of aspiration)
*Complete obstruction of esophagus (pooling, risk of aspiration)<ref>Ikenberry SO et al. Management of ingested foreign bodies and food impactions. Gastrointest ends 2011; 73(6): 1085-91. PMID: 21628009</ref>
*Ingestion of button batteries
*Ingestion of button batteries<ref>Panella NJ et al. Disk battery ingestion: case series with assessment of clinical and financial impact of a preventable disease. Pediatr Emerg Care 2013; 29(2): 165-9. PMID: 23364381</ref>
*Ingestion of sharp or elongated objects (toothpicks, soda can tabs)
*Ingestion of sharp or elongated objects (toothpicks, soda can tabs)
*Ingestion of multiple foreign bodies
*Ingestion of multiple foreign bodies
*Evidence of perforation
*Evidence of [[esophageal perforation|perforation]]
*Coin at the level of the cricopharyngeus muscle in a child
*Coin at the level of the cricopharyngeus muscle (C6)in a child (Lodged esophageal foreign bodies can cause esophageal necrosis and lead to perforation)
*Airway compromise
*Airway compromise
*Presence of foreign body for >24hr
*Presence of foreign body for >24hr
*Multiple magnets (can trap bowel)
*Multiple magnets (can trap bowel)
*Objects >6cm in length


===Food Impaction===
===Food Impaction===
*Uncomplicated food impaction (no bones, incomplete obstruction) can be managed expectantly
Uncomplicated food impaction (no bones, incomplete obstruction) can be managed expectantly but do not allow food bolus to remain impacted for >12-24hr.  It is reasonable to consider therapies such as [[glucagon]] or a carbonated beverage
**Do not allow food bolus to remain impacted for >12-24hr
*Glucagon 1-2mg IV/IM (adults) to relax LES - may cause severe nausea/vomiting
*Consider Pharmacologic Therapies
**Only one RCT of glucagon with 24 patients compared glucagon to diazepam and found no difference in the need for endoscopy<ref>Tibbling L et al. Effect of spasmolytic drugs on esophageal foreign bodies. Dysphagia 1995; 10(2): 126-7. PMID: 7600855</ref>
**Glucagon 1-2mg IV/IM (adults) - may cause severe nausea/vomiting
**The major side effect of glucagon is vomiting and can increase the risk for esophageal perforation or aspiration. Consider pretreatment with an antiemetic
**Carbonated beverage (effervescents) may be effective  
**Rate of success increases with soft foods and lack of anatomic pathology, though in majority of presentations this information, particularly anatomic defects, is unknown
**CCB/Benzos/Nitrates no longer recommended given low success and higher side effect profile
*Carbonated beverage (effervescents) may be effective for small impactions (carbonation dilates esophagus)<ref name="systematic review"></ref>
*Calcium channel blockers (nifedipine) / Benzos / Nitrates / papain (meat tenderizer) no longer recommended given low success and higher side effect profile<ref name="systematic review"></ref>


===Coin Ingestion===
===Coin Ingestion===
*Can attempt removal with a foley catheter under fluoroscopy, though not recommended as risk for aspiration or perforation
*If attempting to avoid endoscopy, there are non-endoscopic management options
*Should be admitted to ICU and removed by GI endoscopy within 24 hours
**Foley Catheter removal
***Traditionally was done with fluoroscopy, but has been demonstrated to be safe without it. First described by Bigler et. al. in 1966 <ref>Bigler FC. The use of a Foley catheter for removal of blunt foreign bodies from the esophagus. J Thorac Cardiovasc Surg. 1966;51:759–760.</ref>
***Does not require subspecialist
***Cheap, can save 300-800% on the total Emergency Department bill by avoiding endoscopy <ref>Choe JY, Choe BH. Foreign Body Removal in Children Using Foley Catheter or Magnet Tube from Gastrointestinal Tract. Pediatr Gastroenterol Hepatol Nutr. 2019;22(2):132-141. doi:10.5223/pghn.2019.22.2.132</ref> <ref>Dokler ML, Bradshaw J, Mollitt DL, Tepas JJ., 3rd Selective management of pediatric esophageal foreign bodies. Am Surg. 1995;61:132–134.</ref> <ref>Little DC, Shah SR, St Peter SD, Calkins CM, Morrow SE, Murphy JP, et al. Esophageal foreign bodies in the pediatric population: our first 500 cases. J Pediatr Surg. 2006;41:914–918.</ref>
***The diameter of the foley balloon should be decided based on the diameter measured on radiograph or with twin object brought in by a family member. This procedure can be done with or without sedation depending on the patient age and clinical comfortability but has been demonstrated to be equally effective without sedation. The catheter is then inserted into the esophagus passed the foreign body, inflated with either air or normal saline, and slowly retracted <ref>Choe JY, Choe BH. Foreign Body Removal in Children Using Foley Catheter or Magnet Tube from Gastrointestinal Tract. Pediatr Gastroenterol Hepatol Nutr. 2019;22(2):132-141. doi:10.5223/pghn.2019.22.2.132</ref> <ref>Kang JH, Jung HJ, Suh JK, Park JS, Park HJ, Chu MA, et al. Feasibility of foley catheter prior to endoscopy for the removal of esophageal coin in children. Korean J Pediatr Gastroenterol Nutr. 2011;14:251–257.</ref>
***Gold standard is still endoscopy, but consider if endoscopy not available or after shared decision-making conversation with patient and family
 
**Bougienage
***The basis of this technique involves purposefully passing the object into the stomach to help facilitate spontaneous passage thereafter and ensure no esophageal impaction
***Has also been described as safe (<1% complication rate), effective (>95% effective), and cheap (similar cost benefit as detailed above) <ref>Burgos A, Rábago L, Triana P. Western view of the management of gastroesophageal foreign bodies. World J Gastrointest Endosc. 2016;8(9):378-384. doi:10.4253/wjge.v8.i9.378</ref> <ref>Allie EH, Blackshaw AM, Losek JD, Tuuri RE. Clinical effectiveness of bougienage for esophageal coins in a pediatric ED. Am J Emerg Med. 2014;32:1263–1269.</ref> <ref>Arms JL, Mackenberg-Mohn MD, Bowen MV, Chamberlain MC, Skrypek TM, Madhok M, Jimenez-Vega JM, Bonadio WA. Safety and efficacy of a protocol using bougienage or endoscopy for the management of coins acutely lodged in the esophagus: a large case series. Ann Emerg Med. 2008;51:367–372.</ref>
***This involves using a thin, flexible esophageal dilator and passing it from the oral cavity into the esophagus. One can measure the needed depth by measuring a Hurst dilator from the tip of the nose to the epigastrium, then a quick insertion with the child restrained can yield forced passage of the object passed the lower esophageal sphincter.<ref>Tenenbein, M. Chapter 11: Foreign Bodies. In: Schafermeyer, R ed. Strange and Schafermeyer's Pediatric Emergency Medicine. 4th Edition. McGraw Hill; 2014.</ref>


===Button Battery===
===Button Battery===
*Call the National Button Battery Ingestion Hotline: 202-625-3333 (24/7) <ref>http://www.poison.org/battery</ref>
*Administer 10mL of honey every 10min if child is > 12 months old and ingestion < 12 hours old <ref>https://www.poison.org/battery/guideline</ref>
*Call the National Button Battery Ingestion Hotline: 800-498-8666 (24/7) <ref>http://www.poison.org/battery</ref>
*True emergency if located in esophagus
*True emergency if located in esophagus
**Perforation can occur within 6hr of ingestion
**Perforation can occur within 6hr of ingestion
**Obtain urgent endoscopic removal
***via direct pressure or electrical conduction leading to liquefactive necrosis
***If endoscopy unavailable AND <2hr since ingestion Foley balloon technique can be tried
**[[Mercury toxicity]]
*Batteries past the esophagus can be managed expectantly w/ 24hr f/u
**Obtain urgent endoscopic removal  
*Batteries past the esophagus can be managed expectantly with 24hr follow up


===Sharp Objects===
===Sharp Objects===
*Intestinal perforation from objects distal to stomach is common (up to 35%)
*Intestinal perforation from objects distal to stomach is common (up to 35%)
*Require immediate removal (even if located in stomach or duodenum)
*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 patient is asymptomatic document passage with daily films
**If object is distal to duodenum and pt symptomatic obtain immediate surgery consult
**If object is distal to duodenum and patient symptomatic obtain immediate surgery consult
===Narcotics Ingestion===
''*plastic bread clips are invisible on radiographs and CT''
*Consider whole-bowel irrigation
 
===[[Body packing]] (with Narcotics)===
*Multiple packets inserted in latex bags, ingested to cross borders
**Each packet potentially toxic if bag bursts
*Consider [[whole-bowel irrigation]]
*Endoscopy contraindicated (high % leakage/rupture of packets)
*Endoscopy contraindicated (high % leakage/rupture of packets)
*Surgical removal indicated if evidence of systemic toxicity
*Do not discharge until all packets removed or 3 packet-free stools
==Disposition==
*80-90% of ingested foreign bodies will pass spontaneously and do not require observation or hospitalization
*If endoscopy performed, generally patients can still be discharged afterward and do not require hospitalization unless direct mucosal injury or other complication is identified
*If any necrosis is present (button battery, caustic ingestion), will likely need GI follow up as strictures, fistulas can occur


==Complications==
==Complications==
*Airway compromise
*Airway compromise
*Aspiration pneumonia
*[[aspiration Pneumonia|Aspiration pneumonia]]
*Esophageal perforation/necrosis
*[[Esophageal perforation]]/necrosis
*[[Mediastinitis]]
*[[Mediastinitis]]
*Aortic perforation
*Aortic perforation
*Vocal cord paralysis
*Vocal cord paralysis
*Bowel perforation/necrosis, fistulas, obstruction
*Bowel perforation/[[bowel ischemia|necrosis]], fistulas, [[SBO|obstruction]]
*Stricture
*Infection


==External Links==
==External Links==
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==See Also==
==See Also==
*[[Esophageal Foreign Body Removal with Foley Catheter]]
*[[Foreign bodies]]
*[[Foreign body]]
*[[Esophageal foreign body removal with foley catheter]]
*[[Bezoar]]
*[[Esophageal perforation]]


==Video==
==Video==
Line 116: Line 153:


[[Category:GI]]
[[Category:GI]]
[[Category:Peds]]
[[Category:Pediatrics]]
[[Category:Symptoms]]

Latest revision as of 21:07, 1 November 2023

Background

Posterior view of the position and relation of the esophagus in the cervical region and in the posterior mediastinum.
Layers of the GI track: the mucosa, submucosa, muscularis, and serosa.
Esophagus anatomy and nomenclature based on two systems.
  • Esophageal impaction can result in airway obstruction, stricture, or perforation. Perforation can be due to multiple mechanisms but is generally either mechanical (e.g. ingested bones) or via chemical corrosion (e.g. button battery)[1]
  • Esophageal irritation can be perceived as foreign body (globus sensation)
  • Once the object has traversed the pylorus, it usually passes without issue
    • Exceptions: Irregular or sharp edges, particularly wide (>2.5cm) or long (>6cm) objects
  • Common foreign bodies:
    • Most common in children: coins (in the US), animal bones (outside the US)
    • Most common in adults: food bolus
  • Site of obstruction:
    • Cricopharyngeus (near C6) muscle is the most common (about 75%)[2]
    • Aortic cross over the esophagus[2]
    • Lower Esophageal Sphincter[2]

Foreign Body Types

Clinical Features

Adults

Children

Differential Diagnosis

Consider tracheal/lung aspiration of foreign body

Dysphagia

Upper GI Bleeding (peds)

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
Plain X-ray: an esophageal button battery foreign body. (a) Anteroposterior view (double contour), (b) Lateral view.

Imaging

  • May not be needed in settings such as a known food bolus
  • PA and lateral films necessary, should include neck, chest, and abdomen
  • Consider obtaining lateral neck films
    • Coins in esophagus present their face on AP view
    • Coins in trachea present their face on lateral view
    • Bones can only be visualized <50% of time
    • Button batteries may present with "double-ring sign"
    • ~60% of foreign bodies are radiopaque
  • CT chest
    • Very high-yield for both radiopaque and non-radiopaque objects
    • Sensitivity >99% and specificity 70-92%[3] [4]
  • MRI
    • Consider for radiolucent objects to avoid radiation load of CT
    • Cannot use with metallic objects (if metallic, should be radiopaque on plain films)
    • Higher cost than CT, some EDs may not be equipped to perform at certain times, may require sedating the patient due to long image capture times
  • Barium Swallow is not recommended due to risk of aspiration, mediastinitis, and barrium coating mucosa (makes endoscopy more difficult)

Management

Indications for Urgent Endscopy

  • Complete obstruction of esophagus (pooling, risk of aspiration)[5]
  • Ingestion of button batteries[6]
  • 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 (C6)in a child (Lodged esophageal foreign bodies can cause esophageal necrosis and lead to perforation)
  • Airway compromise
  • Presence of foreign body for >24hr
  • Multiple magnets (can trap bowel)
  • Objects >6cm in length

Food Impaction

Uncomplicated food impaction (no bones, incomplete obstruction) can be managed expectantly but do not allow food bolus to remain impacted for >12-24hr. It is reasonable to consider therapies such as glucagon or a carbonated beverage

  • Glucagon 1-2mg IV/IM (adults) to relax LES - may cause severe nausea/vomiting
    • Only one RCT of glucagon with 24 patients compared glucagon to diazepam and found no difference in the need for endoscopy[7]
    • The major side effect of glucagon is vomiting and can increase the risk for esophageal perforation or aspiration. Consider pretreatment with an antiemetic
    • Rate of success increases with soft foods and lack of anatomic pathology, though in majority of presentations this information, particularly anatomic defects, is unknown
  • Carbonated beverage (effervescents) may be effective for small impactions (carbonation dilates esophagus)[2]
  • Calcium channel blockers (nifedipine) / Benzos / Nitrates / papain (meat tenderizer) no longer recommended given low success and higher side effect profile[2]

Coin Ingestion

  • If attempting to avoid endoscopy, there are non-endoscopic management options
    • Foley Catheter removal
      • Traditionally was done with fluoroscopy, but has been demonstrated to be safe without it. First described by Bigler et. al. in 1966 [8]
      • Does not require subspecialist
      • Cheap, can save 300-800% on the total Emergency Department bill by avoiding endoscopy [9] [10] [11]
      • The diameter of the foley balloon should be decided based on the diameter measured on radiograph or with twin object brought in by a family member. This procedure can be done with or without sedation depending on the patient age and clinical comfortability but has been demonstrated to be equally effective without sedation. The catheter is then inserted into the esophagus passed the foreign body, inflated with either air or normal saline, and slowly retracted [12] [13]
      • Gold standard is still endoscopy, but consider if endoscopy not available or after shared decision-making conversation with patient and family
    • Bougienage
      • The basis of this technique involves purposefully passing the object into the stomach to help facilitate spontaneous passage thereafter and ensure no esophageal impaction
      • Has also been described as safe (<1% complication rate), effective (>95% effective), and cheap (similar cost benefit as detailed above) [14] [15] [16]
      • This involves using a thin, flexible esophageal dilator and passing it from the oral cavity into the esophagus. One can measure the needed depth by measuring a Hurst dilator from the tip of the nose to the epigastrium, then a quick insertion with the child restrained can yield forced passage of the object passed the lower esophageal sphincter.[17]

Button Battery

  • Administer 10mL of honey every 10min if child is > 12 months old and ingestion < 12 hours old [18]
  • Call the National Button Battery Ingestion Hotline: 800-498-8666 (24/7) [19]
  • True emergency if located in esophagus
    • Perforation can occur within 6hr of ingestion
      • via direct pressure or electrical conduction leading to liquefactive necrosis
    • Mercury toxicity
    • Obtain urgent endoscopic removal
  • 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

*plastic bread clips are invisible on radiographs and CT

Body packing (with Narcotics)

  • Multiple packets inserted in latex bags, ingested to cross borders
    • Each packet potentially toxic if bag bursts
  • Consider whole-bowel irrigation
  • Endoscopy contraindicated (high % leakage/rupture of packets)
  • Surgical removal indicated if evidence of systemic toxicity
  • Do not discharge until all packets removed or 3 packet-free stools

Disposition

  • 80-90% of ingested foreign bodies will pass spontaneously and do not require observation or hospitalization
  • If endoscopy performed, generally patients can still be discharged afterward and do not require hospitalization unless direct mucosal injury or other complication is identified
  • If any necrosis is present (button battery, caustic ingestion), will likely need GI follow up as strictures, fistulas can occur

Complications

External Links

See Also

Video

{{#widget:YouTube|id=gKj13Mq2FC8}}

References

  1. ↑ Arugula R, Dorofaeff T. Oesophageal button battery injuries: think again. Emerg Med Australas. 2011 Apr;23(2):220-3.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 Leopard D et al. The management of oesophageal soft food bolus obstruction: a systematic review. Ann R Coll Surg Engl 2011;93:441–4. PMID: 21929913
  3. ↑ 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
  4. ↑ 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
  5. ↑ Ikenberry SO et al. Management of ingested foreign bodies and food impactions. Gastrointest ends 2011; 73(6): 1085-91. PMID: 21628009
  6. ↑ Panella NJ et al. Disk battery ingestion: case series with assessment of clinical and financial impact of a preventable disease. Pediatr Emerg Care 2013; 29(2): 165-9. PMID: 23364381
  7. ↑ Tibbling L et al. Effect of spasmolytic drugs on esophageal foreign bodies. Dysphagia 1995; 10(2): 126-7. PMID: 7600855
  8. ↑ Bigler FC. The use of a Foley catheter for removal of blunt foreign bodies from the esophagus. J Thorac Cardiovasc Surg. 1966;51:759–760.
  9. ↑ Choe JY, Choe BH. Foreign Body Removal in Children Using Foley Catheter or Magnet Tube from Gastrointestinal Tract. Pediatr Gastroenterol Hepatol Nutr. 2019;22(2):132-141. doi:10.5223/pghn.2019.22.2.132
  10. ↑ Dokler ML, Bradshaw J, Mollitt DL, Tepas JJ., 3rd Selective management of pediatric esophageal foreign bodies. Am Surg. 1995;61:132–134.
  11. ↑ Little DC, Shah SR, St Peter SD, Calkins CM, Morrow SE, Murphy JP, et al. Esophageal foreign bodies in the pediatric population: our first 500 cases. J Pediatr Surg. 2006;41:914–918.
  12. ↑ Choe JY, Choe BH. Foreign Body Removal in Children Using Foley Catheter or Magnet Tube from Gastrointestinal Tract. Pediatr Gastroenterol Hepatol Nutr. 2019;22(2):132-141. doi:10.5223/pghn.2019.22.2.132
  13. ↑ Kang JH, Jung HJ, Suh JK, Park JS, Park HJ, Chu MA, et al. Feasibility of foley catheter prior to endoscopy for the removal of esophageal coin in children. Korean J Pediatr Gastroenterol Nutr. 2011;14:251–257.
  14. ↑ Burgos A, Rábago L, Triana P. Western view of the management of gastroesophageal foreign bodies. World J Gastrointest Endosc. 2016;8(9):378-384. doi:10.4253/wjge.v8.i9.378
  15. ↑ Allie EH, Blackshaw AM, Losek JD, Tuuri RE. Clinical effectiveness of bougienage for esophageal coins in a pediatric ED. Am J Emerg Med. 2014;32:1263–1269.
  16. ↑ Arms JL, Mackenberg-Mohn MD, Bowen MV, Chamberlain MC, Skrypek TM, Madhok M, Jimenez-Vega JM, Bonadio WA. Safety and efficacy of a protocol using bougienage or endoscopy for the management of coins acutely lodged in the esophagus: a large case series. Ann Emerg Med. 2008;51:367–372.
  17. ↑ Tenenbein, M. Chapter 11: Foreign Bodies. In: Schafermeyer, R ed. Strange and Schafermeyer's Pediatric Emergency Medicine. 4th Edition. McGraw Hill; 2014.
  18. ↑ https://www.poison.org/battery/guideline
  19. ↑ http://www.poison.org/battery
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