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    Esophageal Foreign Bodies

    Cardinal Presentations / Presenting Problems, Gastrointestinal

    Last Updated Feb 20, 2019
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    Context

    • Of more than 100,000 cases of foreign body ingestion reported each year in the United States, 80 percent occur in children, the majority being between the ages of six months and three years.
    • Most (90%) foreign bodies that reach the gastrointestinal tract pass spontaneously.
    • In adults, impaction is more likely to occur in the distal esophagus, whereas in pediatric patients most impactions occur proximally.
    • Most impactions in adults result from food boluses (38%–59%) followed by bones (16%–18%), dental prostheses (2%–10%), pills (3%), coins (2%), and batteries (1%). In contrast, most impactions in children are a consequence of coin ingestions.
    • Only 10 to 20 percent require endoscopic removal, and less than 1 percent require surgical intervention.
    • Although mortality from foreign body ingestion is extremely low, deaths have been reported.

    Recommended Treatment

    • Medications are largely ineffective in assisting esophageal transit:
      • IV glucagon has success rates ranging from 12% to 50%. 1 to 2 mg and can be repeated once. Nausea, vomiting, and hyperglycemia are typical side effects.
      • Some advocate benzodiazepines in conjunction with glucagon.
      • Calcium channel blockers, nitrates, and anticholinergic medications have not been shown to be effective.
      • Papain, meat tenderizer, and gas-forming pellets are NOT RECOMMENDED because they can lead to complications of esophageal digestion, perforation, and pulmonary edema.
    • Effervescent drinks and thick liquids (i.e. ensure) may help.
    • Endoscopy within 24 hours for low risk patients is the next logical step, because radiography alters management extremely rarely (in only 1.5% [4 of 267] in one series) and it allows for removal of the foreign body (FB) and assessment for any secondary injury.
    • However, because many patients are asymptomatic, physical examination is usually normal, and availability of esophagoscopy is limited, there should be a low threshold for obtaining plain radiographs. Plain films usually detect radiopaque FBs such as glass and metal, but most ingested objects (food bolus, toothpick, aluminum beverage pull-tab, and many fish and chicken bones) are missed by plain films.
    • An increasingly widely available alternative is non-contrast CT of the neck and mediastinum. In one study, CT found all impacted bony FBs located by endoscopy.

    HIGH RISK CASES:

    • Esophageal button batteries = emergent endoscopy as they contain an alkaline solution that can rapidly cause liquefaction necrosis of the esophageal mucosa within 4 hours. If a child can cooperate, an attempt should be made to pass the battery into the stomach with swallowed water. Endoscopic removal of a button battery is challenging because of their smooth edges, and a collective review demonstrated that endoscopic removal failed 62.5% of the time.
    • Gastric button batteries probably require urgent endoscopy.
    • Distal GI batteries – high risk include > 15 mm or age < 6.
    • Rare Earth Magnets.
    • Airway compromise (including stridor, coughing, or wheezing), evidence of obstruction or any FB that has been impacted for more than 24 hours, or if signs of perforation are present.
    • Sharp or elongated objects in esophagus.

    Criteria For Hospital Admission

    • Evidence or suspicion of esophageal rupture
    • Need for endoscopy
    • Airway compromise
    • Caustic ingestions

    Criteria For Close Observation And/or Consult

    • Unable to manage secretions.
    • Febrile and concerns for Boerhaave’s Syndrome or esophageal rupture.

    Criteria For Safe Discharge Home

    • Foreign body benign and symptoms resolved spontaneously or via treatment.

    Quality Of Evidence?

    Justification

    Low

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