++
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.