Ingested foreign body

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Background

  • 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
    • 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]

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

<6mo

>6mo

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 known 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 only be visualized <50% of time
    • Button batteries may present with "double-ring sign"
  • CT chest
    • Very high-yield for both radiopaque and non-radiopaque objects
    • Sensitivity >99% and specificity 70-92%[3] [4]
  • Endoscopy
  • 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 in a child
  • 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
  • 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

  • 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) [8]
  • 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

Narcotics Ingestion (i.e. Body Packing)

  • 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

  • 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)

Complications

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

External Links

See Also

Video

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