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FOREIGN BODY INGESTION
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The American Association of Poison Control Centers reported in 2014 that 50% of all ingestions were in children under 6 years of age. Coins are the most frequently ingested object in young children. The incidence of food impactions, while less frequent, is increasing in part due to the increase incidence of other esophageal disorders, such as eosinophilic esophagitis. Other foreign body ingestions (FBIs) include button batteries; magnets; and sharp, long, or absorptive (objects containing superabsorbent compounds) objects. While most FBIs will pass spontaneously through the gastrointestinal tract, another 10% to 20% will require endoscopic removal. Fortunately, less than 1% will require surgical intervention. Any history of possible FBI requires immediate attention with the need for and timing of removal being dependent on the nature of the FBI as well as the patient’s symptoms.
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PATHOGENESIS AND EPIDEMIOLOGY
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The esophagus is the site of FBIs in 20% of cases. Because of specific physiologic and anatomic narrowing, FBIs tend to lodge at the upper esophageal sphincter at the cricopharyngeus muscle, the midesophagus at the region of the aortic arch and left main stem bronchus, and immediately above the lower esophageal sphincter. Children with underlying esophageal motility disorders, or those who have undergone prior esophageal operations, are at increased risk of impaction, perforation, or obstruction. Mucosal thickening, lamina propria sclerosis, and esophageal strictures are all mechanisms of FBs lodging in the esophagus in patients with eosinophilic esophagitis.
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The pathogenesis of esophageal injury from FBIs is dependent on the nature of the object. The injury from button batteries is a result of hydrogen radicals that cause caustic alkaline injury. The industry change to lithium batteries that are greater than 20 mm in diameter has resulted in increased morbidity and mortality. Ingestion of magnets rarely results in esophageal injury but is associated with intestinal ischemia, especially with multiple magnet ingestion. Sharp and long objects may lacerate the mucosa and in rare cases perforate the esophagus. Food and FBs that result in lumen obstruction cause pressure injury. Absorptive FBI results from the ingestion of objects that contain superabsorbent polymers found in some feminine hygiene products and some toys. These compounds absorb fluid in the lumen of the esophagus and expand, resulting in pressure-induced injury.
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CLINICAL MANIFESTATIONS
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A young child with an FBI in the esophagus may present with choking, coughing, drooling, vomiting, or food refusal. Older children may complain of dysphagia, odynophagia, or chest pain. Respiratory compromise may be present due to compression of the trachea or larynx. A high index of suspicion must be maintained, as approximately 40% of FBIs are not witnessed, and the child is asymptomatic in about half of all cases.
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The diagnosis is based on history and is supported by the radiographic finding of a foreign body. ...