Chapter 395. Other Esophageal Disorders

Approximately 80% of all foreign body ingestions occur in children, with the peak incidence between 6 and 36 months of age.1,2,3 Coins are the most frequently ingested object in young children. Food impactions are less common and, when seen, are more likely to be associated with an underlying esophageal disorder, such as eosinophilic esophagitis. Of those foreign body ingestions that come to medical attention, 80% to 90% will pass spontaneously through the gastrointestinal tract, another 10% to 20% will require endoscopic removal, and fewer then 1% ultimately require surgery.4 Any history of possible foreign body ingestion requires immediate attention, as outlined in Figure 395-1. Foreign body aspiration is disussed in Chapter 118.

Esophageal Foreign Bodies

The esophagus is the site of foreign body impaction in 20% of cases.1 Areas of physiologic narrowing, including the upper esophageal sphincter at the cricopharyngeus muscle, the mid-esophagus at the impression made by the aortic arch and left main stem bronchus, and immediately above the lower esophageal sphincter are sites where foreign bodies typically lodge. Children with underlying esophageal motility disorders, or those who have undergone prior esophageal surgery, are at increased risk of impaction, perforation, or obstruction.5

A child with a foreign body in the esophagus may present with a choking episode, coughing, drooling, vomiting, or food refusal (Table 395-1). Older children may complain of dysphagia or chest pain. Respiratory symptoms may be present due to compression of the trachea or larynx and occasionally are the single presenting symptom of an esophageal foreign body. A high index of suspicion must be maintained, as approximately 40% of foreign body ingestions are not witnessed, and the child is asymptomatic in about half of all cases.1,2,5,6

Diagnosis is based on history and is supported by the radiographic finding of a foreign body. On an anteroposterior radiograph, a coin in the esophagus will be positioned with the flat surface of the coin in the coronal plane. This compares to seeing the edge of the coin on an anteroposterior view if it is in the trachea (Fig. 395-2). It is more difficult to diagnose radiolucent foreign bodies. Computed tomography (CT), ultrasound, or magnetic resonance imaging (MRI) may be helpful; however, if there is suspicion of an esophageal foreign body, it is reasonable to proceed directly to endoscopy for removal. Barium esophagography is not routinely recommended due to the associated risk of aspiration and the fact that the contrast may interfere with subsequent endoscopy.7

Foreign bodies in the esophagus need to be removed urgently if the child is symptomatic with respiratory distress or is at risk for aspiration. Urgent removal is also recommended if a button battery or sharp object is impacted in the esophagus, since button batteries have the potential to cause low-voltage burns and a corrosive injury as early as 4 hours after impaction,8 and sharp objects are more likely to perforate the esophagus. If a child has an ingested coin or other blunt object impacted in the esophagus and is asymptomatic, it is reasonable to allow a 12- to 24-hour period of observation to allow the foreign body to pass spontaneously. About 25% of ingested coins that are initially lodged in the esophagus will pass spontaneously into the stomach over the next 24 hours. If repeat radiography 4 to 6 hours after initial presentation shows no progression of the coin, endoscopic removal is indicated.9,10 All esophageal bodies should be removed from the esophagus within 24 hours of ingestion, even if the child is asymptomatic. Flexible or rigid esophagoscopy is a safe procedure that is used to retrieve esophageal foreign bodies. Selection of technique (flexible or rigid) is dependent upon the community expertise available and upon the type and location of the foreign body. If underlying esophageal pathology is suspected, tissue for biopsies should be obtained at the time of the endoscopic procedure. In those cases where the time of esophageal foreign body impaction is indeterminate, or if it exceeds several days, extreme caution should be exercised during removal since there is a potential risk of erosion of the foreign body through the esophageal wall, which could lead to an aortoesophageal fistula and massive gastrointestinal bleeding upon removal of the object.11

Other options for removal of esophageal coins or other blunt objects include the Foley technique and the bougienage technique. Both techniques should be considered for removal of coins or blunt objects only in an otherwise asymptomatic child with no known history of underlying esophageal pathology or previous esophageal surgery. It is also mandatory that a good history assures that the foreign body was ingested less than 24 hours prior to removal. The Foley technique is accomplished by passage of an uninflated balloon catheter beyond the object, following which, the balloon is inflated and the object is removed by traction using fluoroscopic guidance. This technique is successful 84% to 96% of the time.12,13,14 Esophageal bougienage consists of passage of a bougienage catheter through the pharynx and esophagus so that the foreign body is pushed into the stomach. This technique is effective, safe, and relatively inexpensive.15 Only experienced personnel should attempt removal of any esophageal body using any of these techniques. Previously reported techniques to aid in foreign body removal that are either ineffective or contraindicated include the administration of glucagon16,17 to relax the esophageal muscle and the use of proteolytic enzymes to digest impacted meat. Proteolytic enzymes should not be used due to the risk of hypernatremia, erosion, and esophageal perforation.

Gastric and Intestinal Foreign Bodies

Once a foreign body has passed beyond the esophagus and into the stomach, removal is usually not indicated. In an otherwise asymptomatic child, the majority of objects (93–99%) will pass through the remainder of the gastrointestinal tract spontaneously.18 Those foreign bodies that are longer than 4 to 6 cm or larger than 2.5 cm are less likely to pass out of the stomach or through the duodenum, so early endoscopic removal is recommended. In addition, early endoscopic removal is also recommended if a child has ingested more than one magnet, as there is some risk that, if separated, the magnets may later adhere tightly to each other with intervening bowel wall, causing necrosis of the bowel and possible perforation. Children who have anatomic abnormalities causing narrowing at sites along the gastrointestinal tract (eg, previous surgery or Crohn disease) are at increased risk for gastrointestinal obstruction by an ingested foreign body and potentially warrant more aggressive attempts to remove a foreign body from the stomach. If a child who has ingested a foreign body develops peritoneal signs and/or fever, exploratory surgery is necessary.

If smaller foreign bodies remain in the stomach for more than 3 to 4 weeks, they are unlikely to pass on their own and should be removed by endoscopy. If a child or adolescent has ingested plastic bags or condoms containing illicit drugs (body-packing), management depends upon the type of bag and drug.19 Endoscopic removal should not be attempted due to the risk of perforation of a bag. In patients who present without symptoms, conservative treatment with activated charcoal, whole-bowel irrigation, and observation in an intensive care unit is recommended. Radiographic documentation of passage of all packets is required prior to discharge. If the patient develops symptoms of bowel obstruction or acute drug toxicity, surgical treatment is required.

Esophageal perforation is most frequently observed as a complication of diagnostic and therapeutic procedures.20,21 In adults, iatrogenic perforation occurs at a frequency of 0.03% following flexible upper endoscopy and about 0.1% following rigid esophagoscopy,22,23 accounting for 60% of all cases of esophageal perforation.24 Perforation of the cervical esophagus occurs during passage of the endoscope or during tracheal intubation, whereas perforation of the distal esophagus is most frequent following esophageal dilation of strictures or for achalasia. Perforation may also occur following procedures such as sclerotherapy25 or during transesophageal echocardiography.26 Extrinsic damage and perforation may occur during surgical procedures performed at sites adjacent to the esophagus. Relatively common noniatrogenic causes include caustic ingestion and damage due to a lodged foreign body. Other less frequent causes include forceful vomiting (eg, Boerhaave syndrome), abrupt increases in abdominal pressure (as occur with falls, child abuse, automobile accidents, and during fights), and penetrating injuries. Medical conditions that are associated with spontaneous perforation include connective tissue disorders such as Ehlers-Danlos and Marfan syndromes.

Clinical Presentation

The initial symptoms and signs of esophageal perforation are often nonspecific. The most common presenting symptoms are neck, chest, or epigastric pain, followed by fever, dyspnea, and crepitus.27 Following cervical esophageal perforation, neck ache and stiffness are more common than complaints of severe pain. Onset of any of these symptoms or findings in a subject that recently underwent a procedure associated with a risk of esophageal perforation warrants immediate evaluation. Similarly, patients with a history of foreign body ingestion or corrosive esophagitis are at higher risk for esophageal perforation.

There are a number of complications that can arise from an esophageal perforation. Dissection of air into the mediastinum and neck results in subcutaneous emphysema in about 30% of patients. If unrecognized, esophageal perforation can results in soilage of the pleura, mediastinum, or peritoneum with swallowed food and secretions or gastric contents. The intense inflammatory response that results is associated with rapid deterioration, with leukocytosis, sepsis, and shock, potentially developing within hours of perforation.

Diagnosis

Figure 395-3 shows an algorithm for the diagnosis and management of a patient with a suspected esophageal perforation. Upright chest radiographs suggest the diagnosis in up to 90% of patients, but in cases of cervical esophageal perforation, a lateral neck film may be more revealing. When the intra-abdominal esophagus perforates, free air may be observed below the diaphragm. Findings of mediastinal emphysema and pleural effusion may not be observed for several hours after the injury.28 This is particularly true following iatrogenic injury from instrumentation causing small perforations. In suspect cases, contrast esophagography is diagnostic in most cases, although false-negative rates of up to 10% have been reported.29 Water-soluble contrast agents such as gastrografin (meglumine sodium) are recommended, since barium extravasation can cause mediastinitis. However, some prefer to use barium initially, or following gastrografin, because the higher density and improved mucosal adherence result in better visualization of small perforations. If clinical suspicion remains high following 1 study, repeat evaluation with a contrast esophagram may be warranted, since false-negative exams are expected. CT imaging is very sensitive for finding mediastinal or extraluminal air and can detect soilage or abscess cavities that require drainage.30 Diagnostic esophagoscopy is generally not recommended when esophageal perforation is suspected because, theoretically, insufflation of air could extend a small submucosal tear into a large perforation.

Treatment

The initial management of an esophageal perforation is to eliminate a focus for sepsis by promoting drainage of contaminated extraluminal spaces and administering appropriate antibiotics and hydration. The specific techniques applied depend upon the size and location of the perforation, whether the patient has systemic symptoms indicating sepsis, and the time since perforation.20 Traditionally, all esophageal perforation was managed with immediate surgical intervention. Stable patients underwent primary repair with or without autogenous tissue reinforcement. Less stable patients would undergo placement of a T tube for drainage and possibly esophageal resection or diversion, with feeding access being provided by a gastrostomy or jejunostomy tube. Cervical esophageal perforation is generally treated by drainage alone, since extraluminal contamination is better contained. In patients with a megaesophagus, as from achalasia, esophagectomy is usually indicated. Newer interventional and surgical techniques include thorascopic repair, stent placement, and endoscopic clipping.31 The role of each of these approaches remains to be established for pediatric patients.

Nonoperative treatment can be safe in a highly selected group of patients with a contained esophageal perforation and no, or minimal, contamination. However, even in this group, the nonoperative approach appears to slightly increase the risk of mortality from 12% to 18%,24 so vigilant management with operative intervention if the patient fails to improve or deteriorates is mandatory. Patients who are managed nonoperatively should be fed either via a jejunal tube or with parenteral feeds, receive antibiotics, and be carefully observed for 7 to 10 days, at which time a repeat esophageal contrast study should be performed to evaluate healing of the perforation.