Esophageal Foreign Bodies
Cardinal Presentations / Presenting Problems, Gastrointestinal
- 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.
- 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?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Kramer RE, Lerner DG, Lin T, Manfredi M, Shah M, Stephen TC, Gibbons TE, Pall H, Sahn B, McOmber M, Zacur G. Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee. Journal of pediatric gastroenterology and nutrition. 2015 Apr 1;60(4):562-74.
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Feb 20, 2019
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