Ingestion of Foreign Bodies


Ingestion of Foreign Bodies




Esophageal Foreign Bodies


Foreign body (FB) ingestions are a common occurrence in infants and young children. The exact incidence is unknown since many cases are not reported. In 2010, the Annual Report of the American Association of Poison Control Centers noted over 116,000 cases of FB ingestion. More than 86,000 occurred in children ≤5 years of age.1 The vast majority of ingestions in children are accidental.2 The most common type of FB varies by geographic region. In the USA and Europe, coins are the most common.2,3 Other commonly ingested objects include toys, batteries, needles, straight pins, safety pins (Fig. 11-1), screws, earrings, pencils, erasers, glass, fish and chicken bones, and meat. However, in areas of the world where fish contributes a significant portion of the diet, such as in Asia, a fish bone may be the most common FB ingested in children.2,4



FB ingestions usually present after a witnessed event or disappearance of an object. Also, there may be heightened suspicion for an ingestion by a caregiver based on the child’s description. The initial presentation can vary from the child being completely asymptomatic to a variety of symptoms including drooling, neck and throat pain, dysphagia, emesis, wheezing, respiratory distress, abdominal pain, or distention. The majority of patients will have a normal physical exam; however, the child should be evaluated for signs of complications. Physical exam findings that raise suspicion of a potential complication include oropharyngeal abrasions, crepitus, or signs of peritonitis.


The esophagus is the narrowest portion of the alimentary tract and is thus a common site for FB impaction. Within the esophagus itself, there are three areas of anatomical narrowing that are potential areas of impaction: the upper esophageal sphincter, the level of the aortic arch, and the lower esophageal sphincter. Other areas of potential impaction may be found in the esophagus of children who have underlying esophageal pathology (i.e., strictures or eosinophilic esophagitis), or prior esophageal surgery (i.e., esophageal atresia).


Symptoms of esophageal FB impaction are nonspecific and include drooling, poor feeding, neck and throat pain, vomiting, or wheezing. Radiopaque objects can be detected on the anteroposterior (AP) and lateral neck and chest radiographs (Fig. 11-2), while radiolucent objects may require further workup with a gastrografin esophagram or esophagoscopy depending on the symptoms and level of suspicion (Fig. 11-3).




The most common round, smooth object ingested that is amenable to extraction or advancement techniques is a coin. The majority of esophageal coins will appear en face in the anteroposterior view, and from the side on the lateral radiograph (see Fig. 11-2). On occasion, more than one coin will have been ingested (Fig. 11-4).



The location of the object on the radiograph is important in determining the treatment options. Approximately 60–70% of FB impactions are located in the proximal esophagus at the level of the upper esophageal sphincter or thoracic inlet.57 The majority of FB impactions found in the upper or mid-esophagus will remain entrapped and require retrieval. Options for retrieval include nonemergent endoscopy (rigid or flexible) (Fig. 11-5) and Foley balloon extraction with fluoroscopy (Fig. 11-6). The Foley balloon extraction technique should be limited to round, smooth objects that have been impacted for less than one week in appropriately selected children without any evidence of complications.8 This technique has been shown to have a success rate of 80% while significantly lowering costs. Objects that are impacted in the lower esophagus often spontaneously pass into the stomach. For this reason, certain lower esophageal impactions may be observed for a brief duration of time, or attempted to be advanced into the stomach with bougienage or a nasogastric tube in the emergency department without anesthesia.9 Rarely, a chronic esophageal coin can cause esophageal perforation, but this will usually be contained (Fig. 11-7).






Gastrointestinal Foreign Bodies


FB ingestions that are found to be distal to the esophagus are usually asymptomatic when discovered. Signs and symptoms including significant abdominal pain, nausea, vomiting, fevers, abdominal distention, or peritonitis should alert the provider to potential complications including obstruction and/or perforation. The majority of FBs that pass into the stomach will usually pass through the remainder of the gastrointestinal tract uneventfully. These patients can be managed as an outpatient. Occasionally, a FB will remain present in the bowel after a period of observation and serial radiographs (Fig. 11-8). Prokinetic agents and cathartics have not been found to improve gut transit time and passage of the FB.10 Often parents are instructed to strain the child’s stool; however, in up to 50% of cases, the FB is not identified even with successful passage.5,11 If the child remains asymptomatic and the FB has not been identified, a repeat abdominal radiograph can be performed at two to three week intervals. Subsequent endoscopy is usually deferred for four to six weeks. Rarely, a chronic esophageal coin can cause esophageal perforation, but this will usually be contained (Fig. 11-8).




Special Topic Ingestions



Batteries


Battery ingestions deserve special attention due to the potential for significant morbidity associated with esophageal battery impactions. Button batteries are more commonly ingested than cylindrical batteries in young children.12 Symptoms occur in less than 10% of cases.12 Button batteries will appear as a round, smooth object on radiographs and are often misdiagnosed as coins. However, on close inspection, some larger button batteries will demonstrate a double contour rim (Fig. 11-9).


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Jun 18, 2016 | Posted by in PEDIATRICS | Comments Off on Ingestion of Foreign Bodies

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