4 What are the common esophageal sites for lodgment of foreign bodies?

Most esophageal foreign bodies (60–70%) lodge at the level of the thoracic inlet at the cricopharyngeus muscle (Fig. 14-1). The other sites of lodgment include the lower esophageal sphincter and the level of the aortic arch. Patients with histories of congenital esophageal abnormalities or acquired strictures have objects (usually meaty foodstuffs) that impact at the area of anatomic narrowing.

Figure 14-1 Coin in the esophagus (plain radiography).

McGahren ED: Esophageal foreign bodies. Pediatr Rev 20:129–133, 1999.

Schunk JE, Corneli H, Bolte R: Pediatric coin ingestions: A prospective study of coin location and symptoms. Am J Dis Child 143:546–548, 1989.

5 What is the most common esophageal foreign body in children?

Coins are the most common esophageal foreign body, and pennies the most common coin in the United States. In cultures where fish is a main food staple, fish bones are common.

6 For a patient with a quarter in the stomach, how much time should be allowed for passage out of the stomach?

Some authors recommend a long period of observation (up to 6 weeks) for passage. Complications are uncommon; however, family members may not be willing to wait that long.

7 For an ingested coin that is in the stomach or beyond, should the family check the stool to ensure safe passage?

There is no good reason to recommend this unless the family interest level is particularly high. If the foreign body is not found, the family may request more unnecessary x-ray studies. Blunt small objects (coins) pass the remainder of the gastrointestinal tract without complications, typically in 3–8 days. The clever physician might suggest that the family “watch for any change.”

8 How should an esophageal foreign body be removed?

There is no single answer; not all esophageal foreign bodies are the same, and not all operators are created equal. Local referral patterns and provincial practice guide this decision. Esophagoscopy, used at many centers, is effective for essentially all types of foreign material, and complications are rare. Typically this is performed after the child receives general anesthesia. Alternatively, flexible endoscopy can remove some foreign bodies and may not require general anesthesia.

For blunt objects, the fluoroscopic Foley catheter technique can be used when skilled operators are available. The catheter is passed (through the nose) under fluoroscopic guidance beyond the coin; the balloon is inflated; and the object is pulled into the mouth, where it is expectorated. Alternatively, it can be pushed into the stomach. Bougienage also is used to advance blunt objects into the stomach. The “penny pincher” technique involves an endoscopic grasping forceps within a soft rubber catheter. The catheter is advanced under fluoroscopic guidance and the grasping forceps used to retrieve the coin. These three methods should not be used for sharp objects (e.g., screws, staples, or the little “scotty dog” from the Monopoly game), or when there is associated respiratory distress or stridor. These methods without direct visualization should not be used for objects impacted more than a few days.

Gauderer MW, DeCou JM, Abrams RS, Thomason MA: The “penny pincher”: A new technique for fast and safe removal of esophageal coins. J Pediatr Surg 35:276–278, 2000.

Schunk JE: Foreign body-ingestion/aspiration. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 307–314.

Schunk JE, Harrison AM, Corneli HM, Nixon GW: Fluoroscopic Foley catheter removal of esophageal foreign bodies in children: Experience with 415 episodes. Pediatrics 94:709–714, 1994.

Soprano JV, Mandl KD: Four strategies for the management of esophageal coins in children. Pediatr 2000;105:e5.

9 Is there a role for observation of impacted esophageal coins?

Many studies have shown that some (at least 30%) impacted esophageal coins pass spontaneously. If a blunt foreign body (e.g., coin) has been impacted for only a short duration, it is reasonable to allow for a short period (<1 day) for spontaneous passage as long as the child is comfortable. Repeated x-ray is needed to demonstrate that the coin has moved into the stomach.

Conners GP, Cobaugh DJ, Feinberg R, et al: Home observation for asymptomatic coin ingestion: Acceptance and outcomes. The New York State Poison Control Center Coin Ingestion Study Group. Acad Emerg Med 6:213–217, 1999.

Sharieff GQ, Brouseau TJ, Bradshaw JA, Shad JA: Acute esophageal coin ingestions: Is immediate removal necessary? Pediatr Radiol 33:859–863, 2003.

Soprano JV, Fleisher GR, Mandl KD: The spontaneous passage of esophageal coins in children. Arch Pediatr Adolesc Med 153:1073–1076, 1999.

10 What site of esophageal impaction is most likely to pass spontaneously?

Traditional teaching suggested that spontaneous passage of impacted esophageal foreign bodies, and particularly coins, was more likely from the lower esophageal sphincter. However, it is clear that spontaneous passage can occur from all typical (and nonpathologic) impaction sites.

Conners GP, Cobaugh DJ, Feinberg R, et al: Home observation for asymptomatic coin ingestion: Acceptance and outcomes. The New York State Poison Control Center Coin Ingestion Study Group. Acad Emerg Med 6:213–217, 1999.

Soprano JV, Fleisher GR, Mandl KD: The spontaneous passage of esophageal coins in children. Arch Pediatr Adolesc Med 153:1073–1076, 1999.