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Foreign Body, Esophageal, Emergency Medicine

Basics

Description

- 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

- 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

- 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

- 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

- 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

- 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tip and balloon pushed beyond FB under fluoroscopic control - Foley balloon inflated with contrast and catheter slowly withdrawn - Contraindicated in chronic ingestions, uncooperative patients, sharp-pointed objects - Foley catheters or dilator (bougienage) may also be used to push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

- Specific ingestions - Impacted food bolus obstructing esophagus: - Emergent removal indicated - Proteolytic enzymes (papain) not recommended because of esophageal perforation, hypernatremia, and aspiration complications

- 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.

  • 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 adultsIntoxicated patientsPatients 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:DysphagiaOdynophagiaDroolingRetching/self-induced vomitingChokingGaggingBlood-stained saliva
  • Chronically retained FB:Respiratory symptoms predominate (paraesophageal tissue swelling compromises adjacent trachea):Chest painSite of FB sensation usually corresponds to esophageal level of FBEsophageal perforation15-35% if ingest sharp object:RednessSwellingCrepitus in the neckPeritonitis<20% asymptomatic

Signs/symptoms: á

  • Refusal to eat
  • Stridor
  • Upper respiratory tract infection
  • Neck/throat pain

History

  • Adults:Usually provide unequivocal history80% present within 1st 24 hr5% will present with airway obstruction (cafe coronary)
  • Children:50% asymptomaticHistory can be unclear if unwitnessed ingestion is not witnessedDrooling, refusal to eat, unexplained gagging, cough, wheeze, chokingMore 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, aspirationPerforation-crepitus, pain, pleurisyHemorrhageOropharynx:Red, irritated throatPalatal abrasionsLung: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 woodVisualizes perforation or infection
  • Endoscopy is a method of choice for localizing and managing most esophageal FBsAbility to inspect surrounding esophageal mucosa for pathologyDiagnostic 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 cmIrregular/sharp edges (toothpicks, soda can tabs)Ingestion of multiple FBs; especially magnetsEvidence of perforationCoin at level of cricopharyngeus muscle in a childAirway compromisePresence of FB for >24 hrFood 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 contractionsFalling out of favor for endoscopyLess effective if underlying Schatzki ring or stricturePermits distal food boluses to pass into the stomachFor impactions <24 hr durationFluoroscopically guided Foley catheter extraction:Successful and safe in experienced handsFoley catheter (10F-16F) placed nasally, passed into esophagus, tip and balloon pushed beyond FB under fluoroscopic controlFoley balloon inflated with contrast and catheter slowly withdrawnContraindicated in chronic ingestions, uncooperative patients, sharp-pointed objectsFoley catheters or dilator (bougienage) may also be used to push distal FB into stomachEndoscopy:Preferred method to remove acute or chronic FBs98% effectiveAlways used with impactions of long duration (>2-4 days) because of associated esophageal irritation/edemaGeneral endotracheal anesthesia needed in difficult cases: Infants, psychiatric patients, difficult FBRisk of complications increases after 24 hr, ideal to be done within 6-12 hrSurgical intervention:Reserved for patients in whom FB cannot be removed by other methods~1-2% of all patientsToothpicks and bones common objects
  • Specific ingestionsImpacted food bolus obstructing esophagus:Emergent removal indicatedProteolytic enzymes (papain) not recommended because of esophageal perforation, hypernatremia, and aspiration complications
  • Button batteries:Extract emergentlyBatteries 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 trafficPackets usually seen on radiographsRupture or leakage of contents can be fatal.
  • Magnets/"Bucky Balls"Ł:Opposing magnets attract bringing sections of stomach/bowel together creating obstructionEarly 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)