GI

Ingestion of Foreign Bodies

180px-CoinAP.jpg
A coin seen on AP CXR in the esophagus https://en.wikipedia.org/wiki/Foreign_body

 

177px-CoinL (1).jpg
A coin seen on lateral CXR in the esophagus
https://en.wikipedia.org/wiki/Foreign_body 

 

9mmbatteryintestines.png
AP X ray showing a 9mm battery in the intestines
https://en.wikipedia.org/wiki/Foreign_body 

 

9mmbatteryintestineslt.png
Lateral X ray showing a 9mm battery in the intestines
https://en.wikipedia.org/wiki/Foreign_body

 

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Multiple button batteries in the stomach
https://en.wikipedia.org/wiki/Foreign_body

 

Foreign Body Ingestion

The placing of foreign materials in the mouth is very common in children. The most common ingested foreign bodies are coins. Typically occurs when children are less than 4 years of age. Most small objects will pass into the stomach and through the gastrointestinal tract without much difficulty, however there are several places in which the foreign body can lodge and many types of foreign body which can prove especially dangerous. 

Areas of esophagus that foreign bodies may get caught

  1. Thoracic inlet- this will be evident by the presence of foreign body at the level of the clavicle on an xray examination.
  2. Mid-esophagus. This will be at the level of the carina and aortic arch
  3. Esophageal-stomach junction.
  4. Any area of the esophagus where there is a stricture secondary to previous surgery or caustic burn.

Presenting Symptoms

  1. Child may be asymptomatic
  2. Choking, dysphagia, discomfort, drooling and/or vomiting if the foreign body is compressing the larynx or trachea.
  3. If the foreign body perforates the esophagus, signs of pain and infection

Evaluation

  1. The ingestion of foreign objects is often very alarming to families and if the child is asymptomatic, the family should try to find out what the child ingested and the quantity.
    1. After reassuring the family, a chest xray should be taken that includes the stomach. This does not have to be on an emergency basis if the child is asymptomatic.
  2. The radiograph will identify the nature of the foreign body, the size, number, and location. Coins will be in the transverse position on a PA film of the chest.
  3. If the history suggests the ingestion of a foreign object and  plain radiograph does not reveal any foreign body or abnormalities, further evaluation depends on the characteristics of the patient and the suspected foreign body (e.g., CT, MRI, ultrasound) and endocscopy should be performed when warning signs (e.g., airway compromise, esophageal obstruction) is present. 
  4. Foreign bodies should be removed within 24 hours to prevent erosive changes.  In general, sharp, long, superabsorbent polymers, disk batteries, high power magnets should be removed.
  5. The majority of objects that have passed into the stomach will go through the GI tract. Possible areas of getting caught are the duodenal sweep, ligament of Treitz, Meckel's diverticulum, and the appendix. 
  6. It is recommended to repeat xray of chest prior to performing removal procedure to insure that object has not passed into the stomach by itself.

Removal Techniques

  1. Esophagoscopy- rigid (requires general anesthesia, but most effective for removing object) and flexible (sedation) 
  2. Balloon catheter - the balloon may be inflated past the object and used to pull the object out.
  3. Bougienage- pushing the object into the stomach
  4. Waiting- repeat examination in 24 hours to see if object has passed into the stomach

Batteries and Sharp Objects

  1. Any sharp object or battery in the esophagus must be removed immediately. Sharp objects are best removed by esophagoscopy. Once in the stomach, most objects will pass into the feces, but xrays every few days should be performed to make sure that the objects aren't stationary. Cathartics maybe helpful in speeding transit time. 
  2. Going through stools not recommended.

References

  1. McGahren E. Esophageal Foreign Bodies. Pediatrics in Review. 1999; 20L129-133. 
  2. Fisher, Jeremy, et al. Yield of Chest Radiography After Removal of Esophageal Foreign Bodies. Pediatrics 131.5 (2013): e1497-e1501.
  3. Byrne, William J., and Arthur R. Euler. Foreign bodies: Is removal necessary? AAP News 29.11 (2008): 21-21.
  4. Rovin JD and Rodgers BM. Pediatric Foreign Body Aspiration. Pediatrics in Review. 2000; 21:86-90.
  5. Walner, David. Preventing choking in children. AAP News. (2011).
  6. Waltzman M.L. Randomized Trial of the Management of Esphogeal Coins Pediatrics Sept 2005
  7. Litovitz T. Emerging Battery-Ingestion Hazard: Clinical Implication Pediatrics June 2010
  8. Brumbaugh D et. al. Management of Button Battery induced Hemorrhage in Children.  Journal of Pediatric Gastroenterolgy and Nutrition.  May 2011
  9. MMWR August 31, 2012.  Injuries from Batteries in Children aged <13 years in US 1995-2010