Foreign Body Ingestions - June 2007

Introduction
Most gastrointestinal foreign bodies occur in children. In 2003, there were more than 116,000 incidents involving ingested foreign bodies and batteries in children or adolescents(1). Children under three years of age are most likely to ingest a foreign body. While most ingestions are witnessed or children may admit to the ingestion, some foreign bodies are found incidentally during the evaluation of dysphagia, pneumonias, wheezing or asthma. Coins are the most commonly ingested objects. Less frequently, children ingest toy parts, batteries, or experience food impactions. Older patients may have meat impactions. Fish bones, not usually radio-opaque, are more commonly reported in countries where fish is a dietary staple(2). Patients with eating disorders may ingest instruments used to induce vomiting. Developmentally delayed patients are also prone to ingesting foreign bodies.

Symptoms
Symptoms vary by site. Esophageal foreign body symptoms in young children can be nonspecific, including drooling or dysphagia. Older children may complain of chest pain. Respiratory symptoms due to compression of the airway or tissue swelling are more common in infants, and can include wheezing, stridor and poor phonation(3). Sixty to seventy percent of coins lodge in the thoracic inlet. 10-20% lodge in the mid-esophagus, near the overlap of the aortic arch and carina, and 20% lodge at the lower esophagus at the gastroesophageal junction. Patients at increased risk for esophageal foreign bodies include those with a history of esophageal surgery, history of prior injury or caustic ingestion, or eosinophilic esophagitis(4,5). Stomach and intestine foreign bodies are usually asymptomatic; however there can be a risk of obstruction and perforation. The duodenal c-loop and ileocecal valve are potential sites for obstruction and subsequent complication. Deaths are rare.

Evaluation
Important in the evaluation of a foreign body ingestion is the type, location, patient size and duration of the ingestion or impaction. Batteries, especially button-type batteries are frequently ingested. Larger batteries carry a greater risk of complications. A majority of foreign bodies will pass spontaneously, especially if the object has reached the stomach(6). Multiple magnets can cause perforation or fistula. Sharp objects can cause perforation, and should be removed. If a tack or nail has passed to the small intestine, it is important to know that advancing points perforate but trailing points do not. Therefore, objects with trailing points are sometimes managed conservatively(7). Long large objects such as toothbrushes or utensils should be removed if they are wider than 15-20 mm (unlikely to pass through pylorus), longer than 10 cm (unlikely to pass through duodenal c loop). Narcotic ingestions should not be managed endoscopically. Management should be with charcoal, cathartics or surgery(8). Bezoars are masses of food, vegetable matter, inorganic matter or hair. They can cause gastric outlet obstruction, pain, weight loss, halitosis, anemia or malnutrition. Trichobezoars may need surgical intervention(9).

Management
Esophageal foreign bodies
Initial evaluation should include a radiograph. On an AP film, esophageal coins are enface.
A tracheal coin is seen on its edge on an AP film. Indications for urgent removal are batteries and sharp objects. If the object causes drooling or acute respiratory symptoms or is a high aspiration risk (above the mid esophagus), the object also merits urgent removal. If a patient has an esophageal coin, but can swallow, endoscopy is indicated in 12-24 hours. Risks of waiting include strictures, tracheal compression, diverticula, mediastinitis, and fistula. In an esophageal battery, sodium or potassium hydroxide can cause mucosal burns and possibly perforation. Later complications can include strictures, stenosis, fistulas or death. Food impactions, especially meat, usually occur in the setting of a structurally or functionally abnormal esophagus. Inability to swallow secretions merits immediate removal, due to aspiration risk. Otherwise, food can be removed within 12-24 hours. Do not use meat tenderizers, as they can also tenderize the esophagus.

Gastric foreign bodies
Symptomatic batteries should be removed. Complications can include ulceration and heavy metal poisoning. Asymptomatic batteries in the stomach can be observed, since >80% will pass by 48 hours. Five percent may take longer than a weak. Batteries greater than 15 mm that have not passed by 48 hours should be removed. Objects that have passed to the stomach can be managed conservatively if the patient does not have symptoms of gastric outlet obstruction. Most objects will pass in one week. Radiographs can be obtained every two weeks. Prokinetics are usually not helpful. Removal is indicated if it has not passed in four to six weeks. If an object is in the stomach and causing pyloric obstruction, it needs to be removed urgently.

Removal techniques
Patients should have endotracheal intubation to protect the airway. Patients awaiting evaluation should be made npo in case of need for sedation. X-ray confirmation is usually required immediately prior to the removal procedure. If possible, bringing an identical object to the ingested object can help the endoscopist select the correct instruments for the procedure. The Foley catheter technique, popular on television, is not recommended; rare complications such as respiratory arrest have been reported from coins displacing into an unprotected airway(10).

References
1. Watson, et al. 2004 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 2005 Sep; 23(5): 589-666.
2. Wong KK, Fang CX, Tam PK. Selective upper endsocopy for foreign body ingestion in children: an evaluation of management protocol after 282 cases. J Pediatr Surg 2006; 41(12): 2016-18.
3. Cheng W, Tam PK. Foreign-body ingestion in children: experience with 1265 cases. J Pediatr Surg 1999; 34: 1472-6.
4. Li ZS, et al. Endoscopic management of foreign bodies in the upper-GI tract: experience with 1088 cases in China. Gastrointest Endosc 2006; 64(4): 485-92.
5. Kerlin P, et al. Prevalence of eosinophilic esophagitis in adults with food bolus obstruction of the esophagus. J Clin Gastroenterol 2007; 41(4): 356-61.
6. Arana A, et al. Management of ingested foreign bodies in childhood and review of the literature. Eur J Pediatr 2001; 160(8): 468-72.
7. Kay M, Wyllie R. Pediatric foreign bodies and their management. Curr Gastroenterol Rep 2005; 7(3): 212-8.
8. Chakrabarty A, et al. Smuggling contraband drugs using paediatric “body packers.” Arch Dis Child 2006; 91(1): 51.
9. Hall JD, Shami VM. Rapunzel’s syndrome: gastric bezoars and endoscopic management. Gastrointest Endosc Clin N Am. 2006; 16(1): 111-9.
10. Berggreen PJ, et al. Techniques and complications of esophageal foreign body extraction in children and adults. Gastrointest Endosc 1993; 39(5):626-30.

This information provided by Christine Nguyen, M.D., Pediatric Gastroenterology & Nutrition, California Pacific Medical Center Department of Pediatrics.