From
StayCurrentMD
Digestive Foreign Bodies: Diagnosis and Management
With Dr. Vince Mkotta · hosted by Dr. Rae Hanke
Chapter 2 of 10 · Fundamentals
Epidemiology
Common Locations and Age Groups for Foreign Body Ingestion
Cued at 2:04 · press play
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What the experts said
Esophageal foreign bodies most commonly lodge at three locations: high at the cricopharyngeus, where the aorta crosses over (less common), and at the lower esophageal sphincter (most common retrieval site).
The most common age group for foreign body ingestion is 6 months to 6 years (just mobile infants through toddler age range).
Foreign body ingestion can occur in very young infants, such as when a toddler tries to feed an infant.
Coins are by far the majority of ingested foreign bodies.
There has been a rash of issues with magnets where older kids pretend to get piercings by putting magnets across their tongue and swallow them by accident.
Many patients who swallow small objects never reach specialists because pediatricians appropriately recognize the object is likely to pass in asymptomatic children.
Children with esophageal foreign bodies may present with odynophagia (pain with swallowing), intolerance of secretions and drooling, pointing to one spot on their throat, vomiting after trying to swallow, chest pain, or refusal to eat.
Physical examination findings are usually unremarkable in children with ingested foreign bodies.
Initial imaging for suspected foreign body ingestion should be a two-view abdomen and chest X-ray.
The classic teaching that coins in the esophagus appear coronal and coins in the airway appear sagittal on X-ray is not always the case according to published evidence.
For radiolucent objects in asymptomatic patients with strong suspicion, a contrast study may be performed if nothing is seen on plain X-ray, though contrast can make endoscopic retrieval more difficult.
Workup for eosinophilic esophagitis is warranted when there is family history of the condition or frequent food impactions, strong atopic history (food allergy, asthma, severe eczema, rhinitis), or when objects that should pass easily become lodged.
Button batteries are the biggest and most common need for emergent removal of ingested foreign bodies.
On X-ray, button batteries classically show a double-edged sign with a step-off, especially on lateral view, though this may not always be visible depending on how long the battery has been present.
Esophageal button batteries are treated as emergencies and should be removed within 2 hours in the operating room.
When concerned about a button battery, imaging should include the whole neck and chest to rule out a more proximal battery that may have been cut off the film.
For gastric button batteries in asymptomatic patients, guidance suggests they can sometimes be observed, but many practitioners retrieve them immediately due to fatal gastric button battery ingestions.
If an esophageal coin has been lodged for 24 hours, it can cause significant problems.
Esophageal foreign bodies are generally retrieved rather than observed.
For short-duration asymptomatic esophageal foreign bodies, patients are frequently admitted overnight with repeat X-ray in the morning; if the object has not moved, it should be retrieved.
Relatively large foreign bodies (4 or 5 centimeters) in the stomach may not pass the pylorus and have higher likelihood of requiring retrieval.
Round gastric foreign bodies unlikely to cause injury in asymptomatic children can be observed and allowed to pass, with monitoring of stool.
Single-sided sharp objects that reach the stomach generally pass through the GI tract without significant injury, with the theory that they flip and go blunt side down.
Double-headed sharp objects like toothpicks should be retrieved if at all possible.
Open safety pins should be retrieved if reachable.
For sharp objects like nails or pins in the stomach, retrieval is attempted if reachable, but once beyond the stomach they are observed for symptoms rather than pursued.
When removing an open safety pin, always pull it out with the point facing downward or away; if the point faces toward the mouth, push it down into the stomach first, then grab and pull it backwards.
Very proximal esophageal foreign bodies are very difficult to retrieve with a flexible scope and are preferably removed by surgery or ENT using a rigid scope.
Gastroenterology typically uses flexible scopes for all foreign body retrievals.
Proximal esophageal foreign bodies can sometimes be removed with a rigid scope or McGill forceps with a protected airway, without needing to place an airway.
The approach to foreign body removal depends on the age of the child, as rigid scopes can reach distally even in two-year-olds.
The majority of ingested foreign bodies will eventually make it into the stomach, but esophageal foreign bodies are the primary concern for emergency removal.
Certain batteries can cause esophageal damage within 2 to 6 hours by causing liquefactive necrosis.
If a magnet is ingested, assume there is more than one magnet present.
If magnets pass the pylorus, the patient must be watched to ensure the magnets do not stick to each other in a way that compromises the bowel.