A 2-year-old boy presented to his primary care physician’s office with decreased oral intake and cough of 4 days duration. He had been very irritable with a markedly decrease in intake of solids. He was seen in an urgent care 2 days prior and was discharged home with a prescription for an antibiotic but his symptoms did not improve. On examination, he had a low-grade fever with increased oral secretions and transmitted upper airway sounds but no localized wheezing. A chest radiograph performed to assess for pneumonia revealed a coin in the proximal esophagus (Figure 56-1). Due to increased oral secretions and the duration of symptoms, he was referred for immediate endoscopy. The coin was removed with ulceration of the underlying esophageal mucosa at the site of impaction noted. Oral intake soon returned to normal. He was prescribed a 1-week course of sucralfate with no long-term complications noted.

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  Foreign body ingestion is a frequent cause of emergency room visits in children and is accidental in most cases. Fortunately, 90 percent of ingested foreign bodies pass spontaneously without complication. Most children with an impacted foreign body have no underlying gastrointestinal anomalies. Food is classified as a foreign body when it leads to impaction, particularly in the esophagus. Steak, hotdogs, and chicken are the primary cause of esophageal foreign body impaction in teenagers and adults.

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  Gastrointestinal foreign bodies.

  
  
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  Swallowed foreign bodies.

  
  
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  Esophageal food impaction.

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  More than 100,000 instances of foreign body ingestion were reported in 2010, with most of these cases reported in children and adolescents.¹

  
  
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  75 percent of all foreign body ingestions occur in children, with a peak incidence between the ages of 6 months and 6 years.²

  
  
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  90 percent of all ingested foreign bodies in children are coins.

  
  
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  Most ingested foreign bodies result in an uneventful outcome, with a complication rate of less than 1 percent.

  
  
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  Only 10 percent of ingested foreign bodies require intervention to remove them.

  
  
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  There were more than 3,300 reported cases of button battery ingestion in the US between 2008 to 2010 with 50 major complications and 7 deaths, all in children less than 6 years of age.³

  
  
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  An estimated 1,700 ingestions of magnets from magnet sets were treated in US emergency departments between January 1, 2009 and December 31, 2011, with 70 percent of the victims less than 12 years of age and 20 patients requiring surgery.⁴

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  Ingestion of button batteries (Figure 56-2) is of particular concern given the high risk of severe complications and possible death.

  
  
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  Small powerful “rare earth” magnets (Figure 56-3) marketed as adult desk toys, stress relievers, and science kits present the potential for serious complications when two or more are swallowed within a short period of time.

  
  
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  Impaction and obstruction often occurs at areas of anatomical narrowing (strictures, surgical anastomoses, duodenal C-loop) or physiologic sphincters (upper and lower esophageal sphincters, pylorus, ileocecal valve).

Esophagus

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  There are three areas of anatomical narrowing in the esophagus where foreign bodies are most likely to become impacted in children:

  
  
  
  
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    Upper esophageal sphincter (70% of cases; Figure 56-4).

    
    
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    Mid-esophagus (at the aortic indentation; Figure 56-5).

    
    
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    Lower esophageal sphincter (LES) (Figure 56-6).

Stomach and Lower Gastrointestinal Tract

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  Swallowed objects that reach the stomach pass spontaneously and uneventfully through the gastrointestinal tract in 90 percent of cases.

  
  
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  As a general rule, objects >2 cm in diameter or >6 cm in length are not likely to make it past the pylorus or the duodenum and will require endoscopic removal.⁵

  
  
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  With the possible exception of multiple magnet ingestion and some sharp objects, the vast majority of objects that successfully reach the small or large intestine will pass without complications.

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  Poor parental supervision or neglect.

  
  
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  Psychological disorders.

  
  
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  Attention seeking behavior (in older children).

  
  
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  Certain factors increase the likelihood of impaction in the gastrointestinal tract after foreign body ingestion:

  
  
  
  
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    Age less than 3 years.

    
    
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    Large foreign bodies (>2 cm in diameter or >6 cm in length).

    
    
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    Functional and structural abnormalities of the esophagus:^6–8

    
    
    
    
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      Eosinophilic esophagitis.

      
      
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      Esophageal strictures from previous esophageal surgery or reflux disease.

      
      
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      Achalasia.

      
      
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      Esophageal webs/rings.