Discussion Author: Adam M Lenger
Roughly one third of foreign bodies found in the GI tract are located in the esophagus (Weissberg 2007). Each year, thousands of children in the United States are found to have a foreign body in the esophagus. Boys account for a little more than half of the patientâ€™s seen with the majority of cases in children under 5 (Rooks 2007). The majority of children who swallow a foreign body will have a benign course with spontaneous passage through the GI system. Patients are at risk for damage and obstruction as the object passes through the GI tract. Size, physical structure, and properties of the object play an obvious role in the variable risks associated with different foreign bodies.
Signs and symptoms of foreign body ingestion range from an asymptomatic incidental finding during x-ray examination for another issue to esophageal rupture, infection, and difficulty breathing. An object that becomes trapped puts the patient at risk for local inflammatory reactions leading to potential infection, esophageal stricture, and possible tissue rupture leading to passage of the foreign body outside of the GI tract and further damage (Rooks 2007). In battery ingestion, frequent findings include: vomiting, retching, abdominal pain, low-grade fever, persistent drooling, dark or bloody stool, or even a rash secondary to nickel metal allergy (Steinberg 2005).
Plain films are the initial imaging study of choice to determine the location, foreign body characteristics, and potential structural damage (Rooks 2007). According to information published in Pediatrics International in 2005, x-ray imaging has a rather low sensitivity when detecting foreign bodies aspirated into the lungs frequently missing objects which are radio-lucent or poorly positioned with respect to imaging angles. However, a positive finding on imaging does provide a high positive predictive value. Patients with foreign body aspiration are noted to have variable presentations and may even by asymptomatic (Midulla 2005). A high level of suspicion is therefore imperative in pursuing definitive diagnosis and treatment through direct bronchoscope visualization. These findings concerning the reliability of imaging can be extrapolated to foreign bodies lodged in the GI tract. A contrast esophagram is the next step in diagnosis if a radiopaque foreign body. For the combinations of a negative x-ray and a positive contrast esophagram or high clinical suspicion, the use of contrast CT should be considered. This has the added benefit of providing information on local soft tissue swelling and possible perforation. The upper esophagus is the most common site of lodged foreign body occurring at the level of the thoracic inlet. (Rooks 2007)
It appears that spontaneous passage of acutely swallowed coins occurs in 30% of all patients. (Conners, 2008). Depending on the foreign body ingested and in the absence of any anatomical contraindications, including bowel obstruction, consideration should be given for 12-24 hours of patient waiting for spontaneous passage. The ingestion of PO fluids and bread may be of some help (Conners, 2008). Careful follow up with repeat imaging at 24 hours is warranted when expectant management is undertaken (Rooks 2007). A variety of catheters can be used to attempt removal of a lodged foreign body. Weissberg and Refaely concluded that rigid esophagoscopy should be the treatment of choice in removal of foreign bodies from the esophagous (2007).
Battery ingestion is a medical emergency. In the case of suspected battery ingestion, patients should go straight to the emergency room. Emergent removal is indicated in the following cases: 1. the battery is lodged in the esophagous; 2. If symptoms develop like bloody emesis or abdominal pain; 3. The battery is large and is unable to pass through the stomach in 48 hours. Transit time may last from 12 hours to 14 days, but usually averages 72 hours. Frequent radiographs should be taken to note progression through the GI tract until the battery is passed. The patient or caretaker should strain stools until the object is recovered (Steinberg 2005). It is a good idea to always take precautions at home especially following an incident of ingestion. One risk factor for future ingestion or aspiration is a history of the same.
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