A 2 year old previously healthy male is brought to the emergency department by his mother with a chief complaint of gagging. The patient was playing alone when his mother found him gagging and coughing. There were no apneic or cyanotic episodes and the child denied any pain. The gagging ceased after a minute and he was breathing normally. Later that evening, he was watching TV with his mother and again had a gagging episode lasting a minute. His past medical history and family history are unremarkable.
Exam: VS T 37, P 110, R 30, BP 95/60, oxygen saturation 98% on room air. He is alert, cooperative, non-toxic, and in no acute distress. The oral cavity is without lesions or erythema. Lung exam reveals clear lung fields and normal breath sounds. The remainder of the exam is unremarkable.
AP and lateral chest radiographs, obtained 3 hours after his mother noted the first episode of gagging, reveals a coin lodged in the proximal esophagus. A gastroenterologist is consulted and the child is taken to the operating room for endoscopic removal of the coin.
Eighty percent of all foreign body ingestions occur among children (1). Children aged 6 months to 3 years are especially prone to foreign body ingestions since they taste and swallow nearly everything while exploring their surroundings (2). In the United States, about 1500 ingestion cases end in death annually (3). Many of these deaths occur in children with preexisting gastrointestinal (GI) abnormalities, such as fistulas, diverticula, webs, or rings, since these abnormalities put them in danger for foreign body impaction and its complications.
While any small object is an ingestion hazard, coins, food, toy parts, disc batteries, paper clips, needles, earrings, bottle caps, and marbles are among the most common objects ingested by the pediatric population. Nearly all objects that reach the stomach will pass spontaneously over a period of 4-7 days (1,4). Three points in the esophagus represent the most narrow regions of the GI tract. These are the cricopharyngeus muscle in the proximal esophagus (where the cricoid ring impinges on the esophagus), the aortic arch crossover in the midesophagus, and the lower esophageal sphincter. The cricoid region is the most common place to find a foreign body. If the foreign body manages to pass into the stomach, it has already passed the three narrow points in the GI tract so it is very likely to pass spontaneously. However it is possible, though unlikely that the foreign body may have difficulty passing through other narrow points such as the pylorus, duodenal sweep, ligament of Treitz, and the ileocecal valve. Therefore, the clinical approach to GI foreign bodies depends on the type of object ingested and its location along the tract. Dividing the GI tract into three distinct areas, the oropharynx and esophagus, stomach, and intestines, aids in organizing the clinical approach to foreign body ingestions.
A child with a foreign body in the oropharynx or esophagus may present with a foreign body sensation in the throat, airway compromise due to impingement of the easily compressed pediatric trachea, drooling, dysphagia, coughing, gagging, vomiting, or throat or chest pain. A foreign body in the stomach or intestines will not usually cause symptoms. If symptoms are present, they commonly result from complications in these areas such as perforation or obstruction. Symptoms include abdominal pain, hematochezia, nausea, vomiting, hematemesis, or fever. Still, up to 40% of patients with foreign bodies are asymptomatic, regardless of location (1).
On physical exam, inspection of the oropharynx may reveal the foreign body, abrasions, blood, or erythema. Physical findings are unusual with esophageal foreign bodies unless there is tracheal compression, in which case stridor or wheezing may be present. Similarly, the examination of a patient with a gastric or intestinal foreign body is unlikely to reveal any specific findings. Signs indicating perforation or obstruction of the lower GI tract should be sought.
Because the symptoms of foreign body ingestion are often nonspecific, the list of differential diagnoses encompasses a wide variety of conditions. These include pharyngitis, esophagitis, reactive airway disease, pneumonia, pneumothorax, gastroenteritis, and appendicitis. Fortunately, there is often a history consistent with foreign body ingestion from the caregiver, who witnessed the ingestion or from the child, who reported the ingestion to a caregiver. Nonetheless, the possibility of foreign body ingestion should always be considered when caring for children.
Radiographic imaging from mouth to anus should be obtained in any child suspected of ingesting a foreign body, as it is often difficult to determine the exact location of the object from the history and physical. If an oropharyngeal foreign body is visualized on the physical exam of a cooperative, stable patient, attempts can be made to remove it with forceps. Otherwise, indirect laryngoscopy, fiberoptic nasopharyngoscopy, or plain films may help localize the object, most commonly a fish or chicken bone. If the object is visualized but attempts to remove it are unsuccessful, arrangements should be made for endoscopic removal. In the case where the object is not visualized by any of these techniques, endoscopic evaluation should, likewise, be obtained (3). Although an endoscopically confirmed object is found in only 17-25% of patients complaining of a foreign body sensation in the throat, endoscopy may reveal esophageal abrasions or mucosal tears that may be causing the sensation (3). Patients with potential airway compromise or evidence of perforation should first receive airway protection and then referred for immediate endoscopy.
Radiopaque objects in the esophagus are consistently visualized on the mouth to anus screening radiographs obtained for suspected foreign body ingestion. The objects will frequently be seen in one of three locations along the length of the esophagus. In the pediatric population 60- 80% of objects get caught at the level of the cricopharyngeus muscle in the proximal esophagus, 10-20% become trapped at the level of the aortic crossover, and 5-20% are found at the level of the lower esophageal sphincter (3). Coins account for the majority of esophageal foreign bodies in children. Radiographically, a coin in the esophagus is seen as a disk in the anteroposterior projection and from the side on lateral films as it is lodged in the easily compressed esophagus, which lies posterior to the trachea. Conversely, a coin in the trachea is seen from the side on anteroposterior films and as a disk on lateral films as its orientation conforms to that of the vocal cords en route to the trachea (however, most coins cannot fit in a pediatric trachea). Although AP films are sufficient to determine whether the coin is in the esophagus or trachea, based on its orientation, lateral films should also be obtained to ascertain whether there is more than one coin lodged in the esophagus, not easily seen in the AP projection. Radiolucent objects in the esophagus, such as plastic, wood, or aluminum can tabs, are difficult to detect on plain films. In this case, CT, contrast radiography or endoscopic examination should be obtained.
Management of an esophageal foreign body depends on the type and location of the object. Any sharp, rigid, or long (>5-6 cm) object should be removed endoscopically since these objects are associated with a high incidence of esophageal and lower GI tract perforation (1,2). Objects in the proximal and mid esophagus should also be removed endoscopically since they usually do not pass spontaneously into the stomach (5). A single blunt object located in the distal esophagus for less than 24 hours in an asymptomatic, otherwise healthy patient may be allowed to pass spontaneously into the stomach if close follow up can be assured. However, if passage is not seen on radiographs obtained 24 hours after ingestion, the object should be removed endoscopically since objects allowed to remain in the esophagus for more than 24 hours are associated with mucosal inflammation (6). Patients with respiratory difficulties or those showing signs of esophageal perforation should be immediately referred for endoscopy.
Several other removal techniques have been described for blunt esophageal foreign bodies in an asymptomatic or minimally symptomatic patient. The Foley catheter method, done by experienced personnel, involves inserting the deflated catheter orally, past the object. The balloon is then inflated and the catheter is slowly withdrawn, pulling the foreign body ahead of it. The use of glucagon to relax the smooth muscle of the lower esophageal sphincter and allow passage of the object into the stomach has also been described. Success rates using glucagon in children range from 30-50% (2). Frequent side effects of glucagon are nausea and vomiting. While these techniques may be cost effective, compared to endoscopy, they do not offer airway protection or allow visual evaluation of the GI tract (1).
Asymptomatic patients with foreign bodies in the stomach may be observed for spontaneous passage of the object. If movement from the stomach is not detected on follow up radiographs in 7 days or if the patient becomes symptomatic, referral for endoscopic removal is required (4). Sharp gastric or duodenal foreign bodies should be removed by endoscopy immediately since 15-35% of sharp objects will perforate the lower GI tract (3). As mentioned previously, long objects should also be removed endoscopically since these might not be able to navigate through the duodenal sweep.
Once the foreign body reaches the intestines, it will likely pass through the rest of the GI tract successfully. If the object remains in any region of the lower GI tract for more than 7 days or if the patient develops signs or symptoms of perforation or obstruction, the foreign body should be removed surgically (2). If a sharp object passes beyond the pylorus, endoscopic removal is more difficult so the patient should be followed with daily radiographs and observed for signs of perforation and bleeding. If complications do develop, the patient should be referred for surgical removal of the object. By the time a sharp object reaches the colon, it becomes surrounded by fecal material and is able to pass though the rest of the lower GI tract safely.
Complications of foreign body ingestion can occur throughout the GI tract. These include airway compromise, abrasions, perforation with resultant abscess formation, obstruction, ulceration, fistula formation, or vascular injuries. With the advent of endoscopy, more foreign bodies are successfully removed resulting in less complications.
Disk or button batteries are small, coin-shaped batteries used in hearing aids, watches, and calculators. Prior to 1982, only a few cases of disk battery ingestion were described (4). As the use of these small electronic gadgets have increased, the problem of disk battery ingestion has become more common. Seventy percent of disk battery ingestions occur in children aged 6 to 12 years (1). The danger of disk batteries is that they contain mercury, silver, zinc, manganese, cadmium, lithium, sulfur oxide, copper, and sodium or potassium hydroxide. If the battery becomes lodged in the GI tract it may cause pressure necrosis, low-voltage burns, or ulceration due to liquefaction necrosis stimulated by leakage of the battery's alkaline solution (2). As little as one hour of contact between the battery and esophageal mucosa may result in injury (4). Because of the damage that can occur in the esophagus, endoscopic removal should be done immediately after localization by radiographic imaging. On the anteroposterior projection, disk batteries can be distinguished from coins by the double-density shadow of its bilaminar structure (4).
If the battery is located in the stomach, there is a 90% chance that it will pass through the GI tract spontaneously (3). As the battery is allowed to pass, patients should be monitored for signs of perforation or bleeding. If these complications become evident or if the battery has not moved beyond the stomach in 3-4 days, endoscopic removal should be performed. Endoscopy will also allow for visualization of the upper GI tract for evidence of ulceration or necrosis caused by the battery. Batteries that pass into the intestine are generally eliminated without consequence. Though there may be concern about mercury toxicity should the contents of the battery leak out into the GI tract, mercury oxide, is not readily absorbed by the GI tract (1). Therefore, the risk of toxicity is low.
Bezoars are accumulations of exogenous material in the stomach and small intestine. They are classified according to their composition. Trichobezoars are accumulations of hair, often the patient's own. Ninety percent of patients with trichobezoars are females aged 10-19 years with trichotillomania and trichophagia (4). Phytobezoars are composed of plant and vegetable matter. Persimmons, celery, pumpkin, grapes, leeks, and grass have all been known to form phytobezoars if they are ingested in great amounts. Lactobezoars are formed by milk components. Though the reasoning is not clear, the majority of lactobezoars are found in premature, low birth weight infants (7). Factors associated with lactobezoar formation may include rapid advancement in feedings, high calcium and protein content of specialized formulas, or the unique gastric physiology of premature infants. Antacid bezoars are accretions of dehydrated antacids, commonly seen in patients with poor gastric motility or patients receiving high dose antacid therapy.
Bezoars, regardless of composition, often present with symptoms of abdominal pain, anorexia, nausea, and vomiting. The physical exam may reveal abdominal distention or a palpable abdominal mass. Bezoars may be visible on plain films but computed tomography with contrast is the imaging technique of choice since it allows for estimation of the size of the bezoar, which often directs management. Endoscopy allows direct visualization of the bezoar and also provides information on its content. Most trichobezoars are managed surgically. Small trichobezoars may be removed in fragments by endoscopy. However, the density of the bezoars often presents a challenge. Phytobezoars are frequently dissolved using a clear liquid lavage and metoclopramide or endoscopic fragmentation. Otherwise, surgical removal is required. Feeding withdrawal for 48 hours with maintenance IV hydration is usually all that is required for resolution of lactobezoars.
1. At what three areas of the esophagus are foreign bodies commonly located?
2. If a coin is seen as a disk on the anteroposterior film, is it in the esophagus or trachea?
3. True/False: A sharp object in the distal esophagus may be observed for 7 days if the patient is asymptomatic.
4. True/False: There is a high risk for mercury toxicity if the contents of a disk battery leak into the GI tract.
5. What are phytobezoars?
6. If an 12 month old swallows a penny, is there any possibility that it is in the trachea?
7. What accounts for the increased incidence of ingested disc batteries?
Esophageal coin case: Yamamoto LG. Hemoptysis Identifies An Esophageal Coin. In: Yamamoto LG, Inaba AS, DiMauro R (eds). Radiology Cases In Pediatric Emergency Medicine, 1995, volume 2, case 1. Available online at: www.hawaii.edu/medicine/pediatrics/pemxray/v2c01.html
Button battery ingestion: Yamamoto LG. A Second Look at a Coin in the Stomach. In: Yamamoto LG, Inaba AS, DiMauro R (eds). Radiology Cases In Pediatric Emergency Medicine, 1995, volume 2, case 9. Available online at: www.hawaii.edu/medicine/pediatrics/pemxray/v2c09.html
Lead (Pb) foreign body. Meister JC. Ingested Dice. In: Yamamoto LG, Inaba AS, DiMauro R (eds). Radiology Cases In Pediatric Emergency Medicine, 1995, volume 3, case 8. Available online at: www.hawaii.edu/medicine/pediatrics/pemxray/v3c08.html
1. Arnold L, Liacouras CA. Chapter 5 - Foreign Bodies and Caustic Ingestions. In: Altschuler SM, Liacouras CA (eds). Clinical Pediatric Gastroenterology. 1998, Philadelphia: Churchill Livingstone, pp. 25-29.
2. Karjoo M. Caustic ingestion and foreign bodies in the gastrointestinal system. Curr Opin Pediatr 1998;10(5):516-522.
3. Stack LB, Munter DW. Foreign bodies in the gastrointestinal tract. Emerg Med Clin North Am 1996;14(3):493-521.
4. Byrne WJ. Chapter 10 - Caustic Ingestion and Foreign Bodies. In: Wyllie R, Hyams JS (eds). Pediatric Gastrointestinal Disease: Pathophysiology, Diagnosis, Management, second edition. 1999, Philadelphia: W.B. Saunders Company, pp. 116-125.
5. Conners GP, Chamberlain JM, Ochsenschlager DW. Symptoms and spontaneous passage of esophageal coins. Arch Pediatr Adolesc Med 1995;149(1):36-39.
6. Conners GP, Chamberlain JM, Ochsenschlager DW. Conservative management of pediatric distal esophageal coins. J Emerg Med 1996;14(6):723-726.
7. Lowichik A, Matlak M, Nuttall K, Curtis J, O'Gorman M. Intestinal lactobezoars in twins receiving a reconstituted elemental formula. J Pediatr Gastroenterol Nutr 1999;28(1):104-107.
Answers to questions
1. The level of the cricopharyngeus muscle in the proximal esophagus, the aortic arch crossover in the midesophagus, and the lower esophageal sphincter.
2. The esophagus because of its orientation.
3. False. A sharp object in the esophagus should be endoscopically removed immediately to prevent perforation.
4. False. The mercuric oxide in disk batteries is not readily absorbed by the GI tract.
5. Accumulations of plant and vegetable matter.
6. A penny cannot fit in an infant's trachea.
7. More gadgets which use disc batteries increases the likelihood that these batteries will be left around the house for young children to put into their mouths.