Ingested foreign bodies (FBs) account for many emergency department visits, and most pass through the gastrointestinal (GI) tract spontaneously. However, in children with prior GI tract surgeries (ie, tracheoesophageal fistula or esophageal strictures), FBs may be dislodged and may require surgical intervention. Small children tend to ingest shiny objects, mainly coins (pennies are the most frequently ingested, followed by quarters, dimes, and nickels), beads, button batteries, toys, or small parts of toys. Most FBs are usually blunt or smooth objects. Adolescents usually ingest FBs other than coins, may eat too fast and have food bolus impaction or suffer from esophageal abnormality, neurologic or psychological disorder, and have intentional ingestion of FBs (ie, pencils, nails, or razors). Patients typically present with drooling, excessive salivation, voice changes, vomiting, or respiratory symptoms.
Figure 15.1 ▪ Drooling as a Presenting Sign of an Esophageal Foreign Body (FB).
An afebrile child presented with a sudden onset of drooling and inability to eat solid foods. There was no witnessed episode of choking, gagging or any FB ingestion. An esophageal FB was suspected based on the history and subsequently confirmed (see Figure 15.2C). Drooling is a very common and consistent sign seen with a high-grade esophageal obstruction. (Photo contributor: Binita R. Shah, MD.)
Hand-held metal detectors can be used to identify the location of metallic FBs, single radiograph of neck, chest, and abdomen can help locate radio-opaque FBs. Obtain anteroposterior and lateral chest radiographs if the FB is above the diaphragm to determine if it is in the trachea or esophagus and whether there is more than one FB (eg, 2 or more coins stacked together). If the FB is suspected to be radiolucent and perforation is NOT a concern, contrast esophagram may be useful. Consider CT scan with coronal and sagittal reconstructions if FB is thought to have migrated to the extraluminal space, or perforation or fistulas are suspected (see Fig. 15.18). Objects lodged in the proximal esophagus may threaten the airway and should be removed promptly. Use endoscopy to emergently remove FB if it poses a risk of corrosive injury (ie, button battery) or risk of perforation (ie, sharp objects such as open safety pin or razor blades). Prompt endoscopic evaluation is also necessary (even if the radiographs are unrevealing) in symptomatic patients (eg, respiratory distress or difficulty managing secretions). Rigid endoscopy with forceps extraction under general anesthesia is the standard method for removal of objects that may be sharp or are embedded in the mucosa as well as objects that may have been in place for a prolonged period or for patients with previous esophageal disease or GI surgeries. This method provides a controlled setting with airway management and direct visualization of the esophagus (ie, mucosal injury or esophageal pathology). Flexible fiberoptic endoscopy, extraction by Foley catheter, or advancement with a bougie dilator for smooth or blunt objects, in place for <24 hours in patients without respiratory distress are alternative methods. Expectant management may be considered for asymptomatic healthy patients with an FB in the esophagus for <24 hours. Allow the patient to eat or drink and repeat the radiographs in a few hours to ensure spontaneous passage through the lower esophageal sphincter (LES). If the FB fails to progress beyond the LES or food is not tolerated, the patient is a candidate for endoscopic removal of FB.
| Nonspecific Symptoms of Esophageal FB | Complications of Retained Esophageal FB |
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Figure 15.2 ▪ the Three Most Common Locations Where an Esophageal Foreign Body (FB) Becomes Lodged (Sites of Normal Anatomic Narrowing of the Esophagus).
(A) Proximal esophagus at the cricopharyngeus muscle or upper esophageal sphincter at the thoracic inlet (defined as the area between the clavicles on a chest x-ray) is the most common location of entrapment. Frontal projection of the neck shows a jack impacted in upper thoracic esophagus (roughly the thoracic inlet). (B) Mid-esophagus at the level of the aortic arch (the aortic arch and carina overlap the esophagus). Frontal projection of the chest shows a battery impacted within the esophagus at the level of the aortic arch. (C) Distal esophagus just proximal to the gastroesophageal junction. Frontal projection of the chest shows a coin in region of the distal esophagus. (Photo contributor: John Amodio, MD.)
Figure 15.3 ▪ Classic Orientation of an Esophageal Foreign Body on Radiographs.
(A) Frontal view of chest shows a battery lodged in the esophagus at thoracic inlet. The battery (or coin) in the esophagus will lie in coronal plane (ie, battery seen as a disk on a frontal view) because the opening into the esophagus is much wider in this orientation. (B) Note sagittal orientation of battery on a lateral film (ie, battery seen from the side and posterior to tracheal air column). Narrowing of trachea at the level of battery is seen (arrow). (Photo contributor: John Amodio, MD.)
Figure 15.4 ▪ Esophageal Foreign Body (FB) Mimicking a Tracheal Foreign Body.
Frontal view of the chest showing a coin at the thoracic inlet. When an FB gets lodged in the trachea, the orientation of the FB is opposite that seen with an esophageal FB. With the configuration of the tracheal rings and with incomplete cartilage posteriorly, a coin in the trachea appears in the sagittal orientation (ie, the coin is seen from the side) in a frontal view (A), and in the coronal orientation (ie, the coin is seen as a disk) on a lateral view (B). However, as seen here, this rule is not always correct. These radiographs actually show an impacted esophageal coin that mimics the orientation that is classically seen with a coin lodged in the trachea. (Photo contributor: Binita R. Shah, MD.)
Figure 15.5 ▪ Radiolucent Esophageal Foreign Body.
(A) Drooling and swallowing a piece of a toy 12 hours prior were the presenting complaints of this 8-year-old child who was sent home from the ED because of a negative chest and neck x-rays. Subsequently, he returned because of the persistent symptoms. A limited contrast esophagram shows a disc-like structure with a central protrusion at the level of T1-T2 upper thoracic esophagus without any evidence of perforation or obstruction. (B) A plastic toy that was removed by direct endoscopy under general anesthesia is shown. (Photo contributor: Binita R. Shah, MD.)
Coins are the most commonly lodged esophageal FBs in children. A preceding history of ingestion may or may not be present.
Most common symptoms of ingested FB are drooling, excessive salivation, dysphagia (refusing solids), retching, hoarseness, vomiting, or respiratory symptoms.
If the FB is lodged in an unusual location (ie, other than the normal anatomic narrowing sites), suspect underlying esophageal disease.
If the duration of lodged FB is unknown, it should be removed by rigid endoscopy under GA.
Three most common locations for entrapment of a FB are:
- (1) Proximal esophagus at the cricopharyngeus muscle (C6) or upper esophageal sphincter,
- (2) Midesophagus at the level of the aortic arch (T4), and
- (3) Distal esophagus (gastroesophageal junction).
- (1) Proximal esophagus at the cricopharyngeus muscle (C6) or upper esophageal sphincter,
Eighty percent of ingested FBs occur in children <5 years of age, with the peak incidence between 6 months and 3 years of age.
The author acknowledges the special contributions of Binita R. Shah, MD, and David Tran, MD, to prior edition.
Button batteries are frequently ingested, accidently or intentionally or placed in the nose or ears by children. Common sources of the battery include child’s own hearing aid, remote controls, toys, games, watches, and calculators. Cylindrical battery ingestions are most common among adolescents. Eighty percent of patients remain asymptomatic and 60% to 86% pass the battery within 48 to 96 hours. However, if the battery becomes lodged in the esophagus, it can result in esophageal mucosal injury, ulceration, perforation, stricture, liquefaction necrosis (release of alkali) or direct pressure necrosis, tracheoesophageal fistulas, and exsanguinations after fistulization into a major blood vessel, and death. A button battery impacted in the esophagus may present with drooling, gagging, fever, vomiting, refusing food, or respiratory symptoms (eg, stridor, wheezing, cough). A button battery causing GI tract injury may present with abdominal pain, vomiting, fever, or hematochezia.
Figure 15.6 ▪ Button Battery Ingestion and Spondylodiscitis (Complication of Battery Ingestion).
(A) Frontal view of the chest shows battery impacted in esophagus at the level of aortic arch. Note that the orientation of the negative pole cannot be determined by the frontal projection. (B) Lateral view of the chest shows battery impacted within esophagus at the level of the aortic arch. Note that the smaller negative side of the battery (arrow) is posteriorly oriented (negative pole of the battery facing posteriorly on the CXR puts the patient at risk of spondylodiscitis and anteriorly facing negative pole puts the patient more at risk for tracheoesophageal fistula or esophago-aortic fistula). (C) A filling defect is noted within the barium-filled esophagus (arrow), found to be an inflammatory polyp at endoscopy. This study was performed 48 hours following the removal of the battery. (D) Five weeks later following the battery removal, the same patient presented to the ED with new onset of torticollis. Sagittal reconstruction of the cervical spine shows disc space loss and vertebral end plate irregularity at T1–T2 level (arrow) compatible with spondylodiscitis. (E) Sagittal T2 image of the cervical spine shows abnormal signal of the disc space at T1–T2 level (arrow) compatible with spondylodiscitis. There is mild impingement upon the thecal sac. (Photo contributor: John Amodio, MD [B, C, D].) (Photo [A, E]. Reproduced with permission from: Tan, et al. Neck pain and stiffness in a toddler with history of button battery ingestion. J Emerg Med. 2011;41(2):157; Elsevier Inc.)
Obtain radiographs of the neck, chest, and abdomen to locate the battery. On an anteroposterior view, the battery will have a “double density shadow” and on the lateral view the edge of the battery will have a “step-off.” Remove batteries in the nasal passage, external auditory canal, or esophagus emergently. Use endoscopy for removal of batteries lodged in the esophagus. However, if the battery has passed the lower esophageal sphincter, manage the patient conservatively with parental education of signs of perforation (pain, vomiting, or blood in stools) and serial radiographs, if clinically indicated. Batteries that remain in the stomach for >48 hours should be removed via endoscopy, and batteries >20 mm in diameter or larger will likely not pass through the pylorus and may require endoscopic retrieval. If the patient presents with signs of perforation (abdominal pain, vomiting, fever, or bleeding), surgical intervention is indicated.
Figure 15.7 ▪ Battery Ingestion: Endoscopic Findings.
Severe circumferential esophageal burn with necrosis and significant edema of surrounding mucosa are noted at the level of the cricopharyngeus after removal of the battery (about 7 hours post-ingestion). This 8-year-old girl presented at a rural hospital with abdominal and chest pain following ingestion of a button battery, which was noted at the gastroesophageal junction on a initial chest radiograph. She subsequently vomited and a repeat radiograph showed battery in the esophagus at the thoracic inlet. Her transfer to the treating institution took about 6 hours. Following the removal of the battery, esophagram did not show any perforation. However, one month later she developed intermittent dysphagia and a repeat esophagram showed a circumferential esophageal stricture at the level of the cricopharyngeus requiring balloon dilation. (Photo contributor: Stephen E Nanton, MD.)
Button batteries lodged in the esophagus can cause severe tissue damage in 2 hours.
Hospitalize all patients with batteries lodged in the esophagus or with evidence of complications related to ingestion.
Button batteries lodged in the nose, ear, or vagina can cause tissue necrosis and must be removed emergently.
Routine use of steroids or antibiotics is not recommended.
Do NOT induce vomiting!
Removal via Foley catheter should be avoided (does not allow direct visualization, risk of esophageal perforation may be increased, and the battery may be aspirated during retrograde movement).
Figure 15.8 ▪ Interpreting Radiography in Battery and Coin Ingestion.
(A, B) Compare the close-ups of a battery with a coin from two different patients clearly demonstrating the radiographic differences. Battery has a lucent center and double ring or halo appearance and coin has a homogenous density with smooth edges. (C) Compare the size and appearance of a button battery with that of a penny. (Photo contributor: Binita R. Shah, MD.)
In countries where fish and chicken are one of the major dietary resources, children commonly swallow fish or chicken bones, and with impacted swallowed bones, patients present with “something” stuck in the throat or throat pain while eating. Symptoms are often due to minor mucosal injury (eg, abrasion or laceration). A lateral plain radiograph with soft tissue technique may show the presence of a bone. Plain radiographs are not always useful. Salmon, mackerel, and trout bones are radiolucent; cod, haddock, and halibut are radio-opaque. However, the radiograph may still be negative and an actual bone is identified in only 20% to 30% of such patients.
Direct inspection of oropharynx and hypopharynx, indirect laryngoscopy, and/or fiberoptic pharyngoscopy are used to make the diagnosis. Consult otolaryngology. Local anesthetic spray may aid in the evaluation and removal of a retained bone or patients may require sedation analgesia.
