Basics
Description
- Esophageal foreign bodies (FBs) typically lodge at 3 sites of physiologic constriction:
- Cricopharyngeal muscle-63%, most common (C6)
- Gastroesophageal junction-20% (T11)
- Aortic arch-10% (T4)
- 90% of ingested FBs pass spontaneously.
- 10-20% are removed endoscopically, and 1% or less require surgery.
Etiology
- Most common adult and adolescent FBs are food boluses and bones
- Increased risk:
- Edentulous adults
- Intoxicated patients
- Patients with underlying esophageal disease: Schatzki B-rings or peptic strictures are most common
- 80% of FB ingestions occur in pediatric age group, peak ages 6 mo-6 yr, particularly younger than 2 yr.
- Coins are most common:
- Most common: 80% of esophageal FBs
- 2 additional areas of constriction: Thoracic inlet (T1) and tracheal bifurcation (T6)
Diagnosis
Signs and Symptoms
- Acute ingestion:
- Dysphagia
- Odynophagia
- Drooling
- Retching/self-induced vomiting
- Choking
- Gagging
- Blood-stained saliva
- Chronically retained FB:
- Respiratory symptoms predominate (paraesophageal tissue swelling compromises adjacent trachea):
- Chest pain
- Site of FB sensation usually corresponds to esophageal level of FB
- Esophageal perforation
- 15-35% if ingest sharp object:
- Redness
- Swelling
- Crepitus in the neck
- Peritonitis
- <20% asymptomatic
Signs/symptoms: á
- Refusal to eat
- Stridor
- Upper respiratory tract infection
- Neck/throat pain
History
- Adults:
- Usually provide unequivocal history
- 80% present within 1st 24 hr
- 5% will present with airway obstruction (cafe coronary)
- Children:
- 50% asymptomatic
- History can be unclear if unwitnessed ingestion is not witnessed
- Drooling, refusal to eat, unexplained gagging, cough, wheeze, choking
- More likely than adults to have respiratory symptoms
Essential Workup
- History about object ingested: Type, when, and how
- Physical exam focused by degree of distress exhibited:
- Esophagus:
- Obstruction-saliva pooling, aspiration
- Perforation-crepitus, pain, pleurisy
- Hemorrhage
- Oropharynx:
- Red, irritated throat
- Palatal abrasions
- Lung:
- Abdomen:
- Peritonitis or bowel obstruction
Diagnosis Tests & Interpretation
Imaging
- Biplane chest radiograph including all of neck for FB localization:
- Food boluses usually do not need radiographs.
- Esophageal FBs often align themselves in coronal plane.
- Esophageal perforation is noted by air in retropharyngeal space, in soft tissues of neck, or by pneumomediastinum.
- Ingested, impacted bones visible on plain film <50%
- CT scan replacing esophageal contrast studies for nonradiopaque FBs:
- Radiolucent objects include small pieces of glass, bone fragments, aluminum, plastic, pieces of wood
- Visualizes perforation or infection
- Endoscopy is a method of choice for localizing and managing most esophageal FBs
- Ability to inspect surrounding esophageal mucosa for pathology
- Diagnostic and therapeutic
Differential Diagnosis
- Globus hystericus phenomenon ("lump in throat"Ł)
- Esophageal mucosal irritation
- Esophagitis
- Croup
- Epiglottitis
- Upper respiratory tract infection
- Retropharyngeal abscess
Treatment
Pre-Hospital
Cautions: á
- Airway maintenance and prevention of aspiration paramount
- Oxygen for patients in distress
- Place patient in whatever position gives most comfort.
- Ipecac and cathartics contraindicated
Initial Stabilization/Therapy
- Airway, breathing, and circulation management 1st priority
- Prevent aspiration
Ed Treatment/Procedures
- Direct laryngoscopy or fiberoptic scope may allow removal of very proximal objects
- Urgent endoscopy recommended:
- Ingestion of sharp or elongated objects
- >6 cm long
- >2.5 cm
- Irregular/sharp edges (toothpicks, soda can tabs)
- Ingestion of multiple FBs; especially magnets
- Evidence of perforation
- Coin at level of cricopharyngeus muscle in a child
- Airway compromise
- Presence of FB for >24 hr
- Food bolus with complete obstruction
- Observation can be considered
- Asymptomatic patients with coins or smooth objects (not button batteries) in distal esophagus:
- Observe up to 24 hr after ingestion to see whether it will pass into stomach.
- Objects that reach stomach and are shorter than 5 cm and <2 cm in diameter usually pass through GI tract without difficulty, but daily radiographs are still recommended.
- Danger of perforation increases after 24 hr.
- Removal options:
- IV glucagon:
- Decreases lower esophageal sphincter tone without interfering with esophageal contractions
- Falling out of favor for endoscopy
- Less effective if underlying Schatzki ring or stricture
- Permits distal food boluses to pass into the stomach
- For impactions <24 hr duration
- Fluoroscopically guided Foley catheter extraction:
- Successful and safe in experienced hands
- Foley catheter (10F-16F) placed nasally, passed into esophagus, tip and balloon pushed beyond FB under fluoroscopic control
- Foley balloon inflated with contrast and catheter slowly withdrawn
- Contraindicated in chronic ingestions, uncooperative patients, sharp-pointed objects
- Foley catheters or dilator (bougienage) may also be used to push distal FB into stomach
- Endoscopy:
- Preferred method to remove acute or chronic FBs
- 98% effective
- Always used with impactions of long duration (>2-4 days) because of associated esophageal irritation/edema
- General endotracheal anesthesia needed in difficult cases: Infants, psychiatric patients, difficult FB
- Risk of complications increases after 24 hr, ideal to be done within 6-12 hr
- Surgical intervention:
- Reserved for patients in whom FB cannot be removed by other methods
- ~1-2% of all patients
- Toothpicks and bones common objects
- Specific ingestions
- Impacted food bolus obstructing esophagus:
- Emergent removal indicated
- Proteolytic enzymes (papain) not recommended because of esophageal perforation, hypernatremia, and aspiration complications
- Button batteries:
- Extract emergently
- Batteries frequently leak: Potassium hydroxide and mercuric oxide are the most toxic constituents.
- Alkali produced from external flow of current can cause liquefaction necrosis.
- Full-thickness mucosal burns can occur within 4-6 hr (combination of chemical, electrical, pressure injuries).
- Battery in stomach will usually pass without difficulty; batteries remaining in stomach for >3-4 days should be removed.
- Once past duodenal sweep, 85% are passed within 72 hr.
- Narcotic/amphetamine packets:
- Body packing seen in regions of high drug traffic
- Packets usually seen on radiographs
- Rupture or leakage of contents can be fatal.
- Magnets/"Bucky Balls"Ł:
- Opposing magnets attract bringing sections of stomach/bowel together creating obstruction
- Early GI consult for removal vs. laparotomy
Medication
Glucagon: 1-2 mg IV push after test dose to determine hypersensitivity á
Follow-Up
Disposition
Admission Criteria
- Seriously ill patients and those with complications such as esophageal perforation, migration of FB through esophageal wall, significant bleeding
- Airway compromise
- Symptomatic patients in whom attempts to remove FB are unsuccessful
Discharge Criteria
- Asymptomatic patients in whom FB has been removed or passed distal to esophagus
- Asymptomatic patients with distal esophageal smooth FBs need re-exam within 12-24 hr to ascertain whether spontaneous passage into stomach has occurred.
Issues for Referral
GI consult for sharp or pointed esophageal FBs, those obstructed in upper or mid esophagus and battery button FBs. á
Followup Recommendations
GI referral for patients with suspected underlying etiology for esophageal obstruction á
Pearls and Pitfalls
- Perform radiographs to locate radiopaque FBs.
- Maintain a high suspicion for esophageal perforation.
Additional Reading
- Cerri áRW, Liacouras áCA. Evaluation and management of foreign bodies in the upper gastrointestinal tract. Pediatr Case Rev. 2003;3:150-156.
- Eisen áGM, Baron áTH, Dominitz áJA, et al. Guideline for the management of ingested foreign bodies. Gastrointest Endosc. 2002;55:802-806.
- Mosca áS, Manes áG, Martion áR, et al. Endoscopic management of foreign bodies in the upper gastrointestinal tract: Report on a series of 414 adult patients. Endoscopy 2001;33:692-696.
- Smith áMT, Wong áRK. Foreign bodies. Gastrointest Endosc Clin N Am. 2007;17:361-382.
- Soprano áJV, Mandl áKD. Four strategies for the management of esophageal coins in children. Pediatrics. 2000;105:e5.
Codes
ICD9
935.1 Foreign body in esophagus á
ICD10
- T18.108A Unsp foreign body in esophagus causing oth injury, init
- T18.128A Food in esophagus causing other injury, initial encounter
SNOMED
- 47609003 foreign body in esophagus (disorder)
- 217808004 Respiratory obstruction caused by foreign body in esophagus (disorder)