INGESTED FOREIGN BODY

Etiology• Foreign Bodies Many foreign bodies pass uneventfully through

the digestive system, but some become lodged in the esophagus and require surgical removal

• In Western literature, meat is the most common esophageal foreign body found in adults and coins are the most common in children

• Fish bones in the pharynx are commonly encountered in the Far East and in Greece.

• In Turkey watermelon seeds are the most frequently aspirated objects.

• Coins are a universal danger particularly for pharyngo-oesophageal impaction and nuts for tracheobronchial aspiration.

Etiology

• Nonspherical objects equal to or less than 1.5 inches (38.10 mm), and particularly spherical objects equal to or less than 1. 75 inches (44.50 mm) in diameter, are especially dangerous.

Sign and symptom

• Patients may be asymptomatic, or they may have dysphagia or emesis or develop stridor, fever, or a cough aggravated by eating

• Hawkins reported that 50% of children with ingested coins had them lodged for longer than 3 days, and every patient with coins lodged for longer than 7 days had respiratory symptoms, and some were febrile or had respiratory infections.

• Even coins can cause stridor, esophageal erosion, aortoesophageal or tracheoesophageal fistula, mediastinitis, or paraesophageal abscess

Coin in the oesophagus

Coin in the oesophagus

Complication

• Major complications include retropharyngeal and mediastinal abscess, migration of the foreign body into deep structures, oesophageal perforation (from either the foreign body or endoscopic procedure) and luminal stenosis.

• Alkaline batteries are particularly dangerous because the tissue necrosis can be devastating and fatalities have been described.

Complication

• Oesophageal edema • laceration or erosion• hematoma• granulation tissue• mediastinitis• arterial-esophageal fistula with massive hemorrhage• respiratory problems• strictures• and proximal esophageal dilation• fatalities have been reported.

Identification

• Two-view neck and chest radiographs are often useful in identifying both the location and shape of a foreign body or its sequela, such as an esophageal air-fluid level.

• Barium is sometimes indicated to define a foreign body or to elucidate an underlying anatomic condition predisposing to foreign-body lodgment.

• Radiologic signs suggestive of perforation include retropharyngeal air, widening of the retropharyngeal soft tissue, leakage of contrast, or an extraluminal foreign body.

Management

• Compared rigid esophagoscopy to fiber-optic esophagoscopy with conscious sedation

• Foley catheter technique under fluoroscopy (usually without sedation)

• Blind bougienage with Maloney dilators• Passage of a nasogastric tube to force the

object into the stomach • Administration of intravenous glucagon or

nifedipine.

Management

• Although some foreign bodies can be safely removed using a fiber-optic esophagoscope, rigid esophagoscopes with Hopkins rod telescopes remain the gold standard for evaluation and removal of esophageal foreign bodies.

Management

• Alternative methods of removal, such as dislodging with a Foley catheter, are contraindicated if the foreign body has an unfavorable shape or if the patient has symptoms of airway involvement or any other complication.

Management

• Reported complications of Foley catheter removal include fatal airway obstruction, transient apnea, coin displacement to a main bronchus, esophageal perforation, esophageal tear, pneumomediastinum, bleeding, missed second coin, foreign body lost in the nasopharynx, aspiration pneumonia, and an inability to remove the coin.

• Blind bougienage with Maloney dilators and insertion of nasogastric tubes to push the object into the stomach are occasionally used, but current opinion favors abandoning these methods as lacking safety and efficacy.

Management

Management

• Pharmacologic agents such as nifedipine have been used with varying degrees of success to facilitate the passage of an impacted foreign body by manipulating esophageal muscular tone; glucagon does not appear to be effective in the dislodgment of esophageal coins in children

Management

• Rigid endoscopy gives a much better view of the hypopharynx, cricopharyngeus and the first few centimetres of the cervical oesophagus, whereas a flexible endoscope gives an excellent view in the thoracic oesophagus and oesophago-gastric junction

Management

• The use of rigid angled nasendoscopes and curved forceps designed for fish bone removal has greatly facilitated fish bone removal from the oropharynx under local anaesthetic in adults, but general anaesthesia is more likely to be needed in a child.