Ingestions

Ingestions / Foreign bodies

Background

Presentation of foreign body lodged in the esophagus constitutes an EMERGENCY and is associated with significant morbidity and mortality secondary to the potential for perforation and sepsis
>100k peds foreign body (FB) ingestions in U.S. annually
Most occur in patients 6mo -5yr (older children with developmental delay/psych Dx)
Coins are the most common FB ingested
Food impaction more common in adults but seen in patients with EoE, esophageal atresia, Nissen

a patient presenting with food impaction and dysphagia -92% chance of EoE

Signs and Symptoms

30% of pts with esophageal FB are asymptomatic - take any Hx of FB ingestion seriously!
Typically impaction will occur at one of 3 sites (sites of anatomic narrowing):

level of Cricopharyngeus (UES)
Aortic Arch
GE junction (z -line) above diaphragm (LES)

Distal impaction may occur

pylorus
at the junction of the descending and transverse duodenum
ileocecal valve

Increased risk for impaction and complication - obstruction/perforation

h/o GI tract surgery
congenital GI malformation

Esophageal impaction:

choking
hoarseness
refusal to eat
vomiting
drooling
bloodstained saliva
wheezing/respiratory distress
chest pain/ throat pain/ sternal notch pain

If longstanding impaction

neck mass, chronic cough/stridor, aspiration PNA, dysphagia

Oropharyngeal /esophageal perforation:

neck swelling/erythema, tenderness, crepitus

Intestinal impaction/obstruction

vomiting, abd distension

Plain films: AP/PA neck, chest, abd. Lateral views of neck and chest

Coins

in esophagus: Flat on AP, on end on Lat
in trachea: Flat on Lat

Disc Battery

double halo on AP and step off on Lat views
**Children <5yo and ingestion of battery >20mm at highest risk for

necrosis
TE fistula
perforation
stricture
vocal cord paralysis
mediastinitis
aortoenteric fistula

Failure to visualize object with plain film in symptomatic patient warrents urgent endoscopy

CT with 3D reconstruction may increase sensitivity
Use of Barium contrast studies is discouraged (potential for aspiration and complicates attempts at removal)

assess risk for airway compromise
Chest CT with Surgical consult if suspected airway perforation
Endoscopic visualization, mucosal inspection, removal of object with FB-retrieval accessory with ET tube protecting the airway

Removal within 2 hrs of presentation

Button Batteries - remove regarless of last PO - they can cause mucosal injury in <1hr and involve full thickness of esophagus within 4hrs

Urgent removal within 12hrs of presentation

sharp objects

multiple Magnets
single magnet with metal object
FB assoc w/ respiratory symptoms

Observe for up to 24hrs (patient in no acute distress)

asymptomatic blunt objects
coins in esophagus

radiology may be able to pass foley beyond the coin under fluoroscopy, inflate bulb and withdraw to remove coin (pt in prone oblique position)
alternative may be to use bougienage toward the stomach in uncomplicated cases where endoscopy unavailable

meat impaction -if no problem handling secretions

glucagon (0.05mg/kg IV) if no h/o esophageal surgery to lower LES pressure
meat tenderizers and gas forming agents are not recommended

all objects should be removed by 24hrs or immediately if duration unknown

Blunt objects beyond the esophagus can be observed for spontaneous passage

failure to pass from stomach should be removed endoscopically

guidelines for observation period range from 4 days to 4 months

Objects longer than 5cm should be removed from stomach as they may not clear duodenal sweep or ileocecal valve
Sharp objects in stomach or duodenum should be removed

distal objects should be monitored, if no progression x 3 days, consider removal

Food impaction

following visualization in esophagus, remove or push into stomach after distal visualization to ensure no stricture present

**Notes on Disc Batteries:

Mechanism of injury:

electrical discharge (Li batteries = higher voltage, more damage) tissue hydrolysis, corrosive injury
pressure necrosis
leakage of contents

Disc batteries >20mm = greater complications (some recommend battery >15mm in child <6yo = endoscopic removal)
Dead batteries can still have enough charge to cause damage
National Battery Ingestion hotline: https://www.poison.org/battery

Call 800-498-8666 for guidance if someone swallows a battery.
If readily available, provide the battery identification number, found on the package or from a matching battery.
In most cases, an x-ray must be obtained right away to be sure that the battery has gone through the esophagus into the stomach. (If the battery remains in the esophagus, it must be removed immediately. Most batteries move on to the stomach and can be allowed to pass by themselves.) Based on the age of the patient and size of the battery, the National Battery Ingestion Hotline specialists can help you determine if an immediate x-ray is required.
Don't induce vomiting. Don't eat or drink until the x-ray shows the battery is beyond the esophagus.
Watch for fever, abdominal pain, vomiting, or blood in the stools. Report these symptoms immediately.
Check the stools until the battery has passed. Follow up plain films if not passed in 1-2wks
Your physician or the emergency room may call the National Button Battery Ingestion Hotline at 800-498-8666 for consultation about button batteries. Expert advice is available 24 hours a day, 7 days a week

9 of 13 reported fatalities reported to NIBH database involved exsanguination from esophageal fistulas into major arteries. delayed unanticipated, uncontrollable bleeding occurred up to 18 days after battery removal
FOLLOW UP WITH THESE PATIENTS REGULARLY

References:

Kliegman, Robert. Nelson Textbook of Pediatrics. Edition 21. Philadelphia, PA: Elsevier, 2020.
Tortora, Gerard J. Principles of Anatomy and Physiology. 15th ed. Hoboken, NJ: J. Wiley, 2009. Print.
Moore, Keith L.,, Arthur F. Dalley, II, and Keith L Moore. Clinically Oriented Anatomy. Fifth edition. Baltimore: Wolters Kluwer Health, 2009. Print.
Kleinman RE, Goulet O, Mieli-Vergani G, et al, eds. Pediatric Gastrointestinal Disease: Pathophysiology, Diagnosis, and Management. 5th ed. Hamilton, Ontario: BC Decker; 2008.
The NASPGHAN fellows concise review of pediatric gastroenterology, hepatology, and nutrition. 1st edition (2011)
Wyllie, Robert & Hyams, J.S.. (2011). Pediatric Gastrointestinal and Liver Disease. 10.1016/C2009-0-53242-4. (Accessed online Feb 2020)
Coran, Arnold G, and N S. Adzick. Pediatric Surgery. Philadelphia, PA: Elsevier Mosby, 2012. Internet resource.