Esophagial Foreign Body


Article Author:
Timothy Schaefer


Article Editor:
Doug Trocinski


Editors In Chief:
Yvonne Carter
Jason Wallen


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
3/16/2019 1:33:09 PM

Introduction

Most patients who present for evaluation of a foreign body in the esophagus do so after accidental ingestion of a known object, and the patient has mild symptoms and is in stable condition. The challenges come from patients who are unable or unwilling, for example, infants, children, mentally-impaired, psychiatric, prisoners, to provide a history of the object ingested or when it occurred. Also, the wide range of possible symptoms and clinical presentations, plus the wide range of potential complications, can make this a difficult condition to evaluate and manage.[1][2][3][4]

Etiology

In adults, the esophagus is approximately 20 to 25 cm in length extending from the hypopharynx to the stomach. The esophagus has an inner mucosa layer and a muscle layer made up of inner circular muscles and outer longitudinal muscles. The upper third is voluntary striated muscles that allow initiation of swallowing, while muscles of the lower third are involuntary smooth muscles.

The esophagus is the most common site for acute foreign body or food impaction in the gastrointestinal tract and 80% to 90% of swallowed objects that reach the stomach will eventually pass without intervention.

While a wide variety of objects could be ingested, common accidental esophageal foreign body ingestions include food bolus (mostly meat), fish or chicken bones, dentures, and coins. The type of objects ingested varies between different regions and cultures. For example, in southern China, fish bones were the most common esophageal foreign body impaction.[4][5][6]

Epidemiology

Children make up roughly 80% of patients presenting to emergency departments with an esophageal foreign body.[1][7] These are typically accidental ingestions of small objects such as coins, sharp-pointed objects (pins, needles) batteries, toy parts, crayons, fish and chicken bones, large food bolus, jewelry, among others. Coins are the most common foreign body ingested by children. Most children have normal anatomy. However, there is an increased risk of impactions with abnormalities such as eosinophilic esophagitis, prior esophageal atresia repair, and prior Nissen fundoplication.[8]

In adults, similar accidental foreign body ingestions occur however the most common cause of impaction in adults is a food (mostly meat) bolus. The estimated annual incidence of food impaction is 13.0 per 100,000. Eighty percent to 90% occur in the distal esophagus associated with anatomic or motor abnormalities. These abnormalities include diverticula, webs, rings, strictures, tumors, eosinophilic esophagitis, achalasia, scleroderma, or esophageal spasms. For this reason, it is recommended that adults with a history of food impaction, even if it resolves spontaneously, need follow-up evaluation of the esophagus.

Pathophysiology

The normal esophagus has 3 primary areas of physiologic narrowing: the upper esophageal sphincter (UES) that includes the cricopharyngeus muscle, the middle esophagus where esophagus crosses over the aortic arch, and the lower esophageal sphincter (LES). In children, approximately 74% of foreign bodies are entrapped at the UES level. In adults, approximately 68% of obstructions occur at the distal esophagus associated with pathologic abnormalities.[9]

Possible complications include local injury to the mucosa such as abrasion, lacerations, necrosis, and stricture formation. Other serious complications include injury beyond the esophagus such as airway obstruction, esophageal perforation, tracheoesophageal fistula, vascular injury (e.g., aortoesophageal fistula), retropharyngeal abscess, mediastinitis, pericarditis, or vocal cord injury.[10]

Three special types of foreign body ingestions with a higher risk of complications are button batteries (also called “disc” or “coin” batteries), multiple magnets and sharp-pointed objects.

If a button battery becomes impacted in the esophagus, then an electrical current is created between the positive and negative poles. This current can cause thermal injury plus produces hydroxide ions with a rapid rise in the local pH resulting in a caustic alkaline injury. Injury begins within 15 minutes and can lead to a perforation in hours. Complications can include localized esophageal mucosal necrosis and chronic stricture formation. More serious complications involve esophageal perforation and erosion into adjacent structures such as the mediastinum, trachea, or vascular structures. Leinwand et al. reported on 13 cases of serious complications, including 30.8% perforation, 23.1% stricture formation, and 23.1% mortality from aortoesophageal fistula formation and exsanguination. More than 90% of serious complications occurred in children 5 years old or younger, with batteries 20-mm diameter and greater and impactions for prolonged periods.[2][10]

While a single, small, smooth magnet will usually pass without complications, multiple magnets create complications. Tissue may become trapped between the magnets leading to pressure ischemia, perforation, fistula formation, obstruction or volvulus.[11]

Sharp-pointed object stuck in the esophagus also have a higher risk of perforation and need urgent removal. 

History and Physical

Key factors to consider in assessing patients with ingested foreign bodies include type and number of objects, location, time since ingestion and presenting signs and symptoms. These factors will help determine if the object needs to be retrieved emergently, urgently or if the patient can be safely managed with observation and follow-up.

Most adults and older children can give a history of foreign body ingestion and time of onset. The most common symptoms are foreign body sensation or difficulty swallowing (dysphagia). Symptoms typically develop in minutes to hours. Foreign bodies in the upper esophagus are more accurately localize by the patient. However, impactions in the mid or lower esophagus may be described as a vague discomfort, ache or chest pain.  Other symptoms include hypersalivation, retrosternal fullness, regurgitation, gagging, choking, hiccups, and retching. If patients report painful swallowing (odynophagia), this may indicate more serious problems such as esophageal laceration or perforation.

On exam, the patient may appear anxious and uncomfortable with swallowing. If the patient is unable to swallow saliva, this indicates a complete obstruction is needing more urgent treatment.

Infants, younger children, mentally impaired or prisoners may be unable or unwilling to provide history. In these situations, a high index of suspicion is needed. For infants and young children, symptoms may include gagging, poor feeding, drooling, or irritability. Also, an esophageal foreign body might press on the trachea causing respiratory symptoms such as wheezing, cough, dyspnea, or stridor. However, airway foreign bodies would also need to be considered.

The physical exam should initially focus on airway patency, vital signs, patient’s ability to handle secretions, and looking for signs of complications such as hematemesis, abnormal breath sounds, tenderness in the neck, chest, or abdomen, or subcutaneous air.

Evaluation

Routine x-rays are usually the first step if a radio-opaque object is suspected. This will help determine the object, the location, and possible complications. Chest x-ray (posterior-anterior (PA) and lateral views) is usually adequate, but the neck and abdominal x-rays may be needed depending on clinical presentation. Flat objects like coins, bottle caps, or disc batteries are usually oriented in the coronal plane if they are lodged in the esophagus and appear round on the frontal (PA) view. However, if they are lodged in the trachea, they orient in the sagittal plane and appear round on the lateral view. If a circular “coin-like” object is seen on the x-ray, the object needs careful review looking for a “halo” or “double-ring” appearance which identifies it as a button battery and the need for emergent removal. A chest x-ray can differentiate coins from button batteries with sensitivity, specificity, and accuracy of approximately 80%. Food, plastic, wood, and aluminum are not radio-opaque so are not seen on routine x-rays. Bones and glass may or may not be seen on x-rays. If nothing is seen on routine x-rays, but suspicion of a foreign body remains high, then diagnostic endoscopy or CT scan may be indicated. CT scans have a high sensitivity for detecting foreign bodies plus are useful for detecting complications such as perforation.

Treatment / Management

Assuming a stable airway and no developing complications, the treatment and management are guided by the type of foreign body, the location, the degree of obstruction and the duration. Endoscopic removal is the procedure of choice and is successful more than 90% of cases with less than 5% complication rate. Endoscopic management can be divided into emergency, urgent, and nonurgent.[12][13][14][15]

Emergency

  • Esophageal Obstruction: Inability to handle oral secretions
  • Disk batteries in the esophagus
  • Sharp-pointed objects in the esophagus

Urgent (within 12 to 24 hours)

  • Esophageal objects that are not sharp-pointed
  • Food impactions without complete obstruction
  • Sharp-pointed objects in the stomach or duodenum
  • Objects greater than 6 cm in length above duodenum
  • Multiple magnets (or single magnet plus another ferromagnetic object within endoscopic reach)
  • Coins in esophagus

Nonurgent

  • Objects in the stomach greater than 2.5 cm diameter
  • Disk battery in stomach up to 48 hours if asymptomatic
  • Blunt objects that fail to pass stomach in 3 to 4 weeks

Several types of medical management have been studied. In theory, medications that relax the smooth muscles of the LES might allow smooth, blunt objects to pass spontaneously into the stomach. Glucagon is the most commonly discussed agent; dose 0.25 mg to 2 mg intravenously (IV) over 1 to 2 minutes in a sitting patient. This is followed by oral water or carbonated-beverage in 1 minute to promote esophagus distention along with LES relaxation. Glucagon can cause nausea and vomiting. Vomiting may dislodge the object but also may increase the risk of esophagus rupture. Unfortunately, most studies looking at glucagon have a variety of weaknesses including small sample size, exclusions criteria making them non-generalizable or are underpowered for evaluating side-effects, so most results show slight or no benefit over placebo.[8][16]

Papain (an ingredient in meat tenderizers) is not recommended for meat bolus impactions because of possible complications and a theoretical risk of damage to the esophagus.

A disc battery impacted in the esophagus is a true emergency and needs immediate removal. The greatest concern is the potentially fatal complication of an aortoesophageal fistula with the highest risk in children less than five years old, battery size 20 mm or greater, impaction at the aortic arch level, prolonged impact and any degree of hematemesis. In these specific cases, a multidisciplinary approach potentially including pediatric gastroenterology, pediatric surgery, cardiothoracic surgery, anesthesia, and radiology with management in the operating room or cardiac catheterization lab may be indicated.

Asymptomatic children with a coin impacted in the esophagus can be managed urgently with the observation of up to 24 hours without risk of further complications. Coin location is important with 10% of proximal esophageal coins, 26% middle esophagus coins, and 43% of distal esophagus coins passing spontaneously within 16 hours of ingestion.

Differential Diagnosis

Esophageal abrasions can cause a foreign body sensation that remains after the passage of a foreign object. If the patient is stable and tolerating oral intake, they can be reassessed within 12 to 24 hours, and if symptoms continue, then CT scan or endoscopy may be needed.

Other conditions that might cause a foreign body sensation without a foreign body present include:

  • Infection such as Candida, herpes simplex virus (HSV), or cytomegalovirus (CMV)
  • Esophagitis (acid reflux, pill esophagitis, eosinophilic esophagitis)
  • Esophageal spasm
  • Globus pharyngeus (also called globus hystericus) which is a sensation of a lump or foreign body in the throat of uncertain etiology.

Again, if the patient is stable and tolerating oral intake then begin appropriate treatment for the underlying condition and/or arrange follow-up.

Prognosis

Eighty percent to 90% of ingested foreign bodies will pass spontaneously within 3 to 7 days.[1]

Children with esophageal injury from disc battery need short and long-term follow-up to look for complications related to erosion or perforation and esophageal stricture.

Adults with food impactions have abnormalities 85% to 90% of the time and will need evaluation and treatment of the underlining abnormalities.[8][9]

Enhancing Healthcare Team Outcomes

The management of foreign bodies in the esophagus requires a multidisciplinary team. Most patients will present to the emergency department and once the diagnosis is made, consultation with the appropriate specialist is highly recommended. Most foreign bodies in the esophagus pass spontaneously but about 3-10% may require some type of intervention. Some may require removal of the foreign item with endoscopy and others may require surgery. The outcomes for most patients with foreign bodies in the esophagus are excellent.[17][18] (Level V)


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Esophagial Foreign Body - Questions

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In children, where are the majority of foreign bodies in the esophagus found?



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For a stable patient who is able to handle secretions, how long may one observe blunt objects, other than button batteries, in the esophagus before performing an endoscopy for removal?



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A 4-year-old has an AP x-ray which reveals a coin lodged in the esophagus. If the child is asymptomatic, what is an acceptable length of time to wait before attempting to remove the coin via endoscopy?



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A 4 year old is being evaluated whose AP x-ray reveals a coin lodged in the esophagus. What length of time is acceptable for observation prior to undertaking upper endoscopy, assuming that the child is in no respiratory distress?



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A healthy 21-month-old was playing in his room alone for a few minutes. His mother heard him coughing, but the cough resolved after a few minutes. The child was well except for drooling, and he refused to eat. What is the most likely diagnosis?



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What is the most common foreign body found in the esophagus of children?



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A child is brought to the emergency department and found to have a coin lodged in the proximal esophagus. Which of the following would be most appropriate?



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A child is found to have a button battery in the esophagus on X-ray. Which of the following is an appropriate treatment?

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    Contributed by Scott Dulebohn, MD
Attributed To: Contributed by Scott Dulebohn, MD



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Which of the following statements best describes esophageal foreign bodies in children?



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You are working in the emergency department when a 58-year-old male presents stating he’s got some food “stuck” and he can’t swallow it. This started 3 hours ago when he was eating steak. He appears stable in no distress, speaking in full sentences and breathing normally. He does appear mildly anxious, sitting up, leaning forward, and spitting into a cup what appears to be his saliva. He attempts to drink a sip of water, gags and spits it up. Vital signs and exam are otherwise normal. What would be the most appropriate evaluation and treatment?



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A 73-year-old woman with severe dementia is brought to the emergency department by her caregiver because of concerns for dehydration. The patient cannot provide any history but the caregiver reports for the past 3 days the patient has not been eating well, intermittently vomiting some of her feedings, and drooling more. The caregiver assumed the decrease feeding was because they lost the patients dentures 3 days and changed to a soft diet. The patient is not able to cooperate with an exam, appears uncomfortable when moved to the exam cart but in no distress, pulse 110 bpm, respirations 24/minute, blood pressure 103/60 mmHg, temperature 99 F (37.2 C), and pulse oximetry 95% on room air. The patient has decreased breath sounds in the left lung base, and a crackling sensation is felt in the skin at the base of the neck. What is the most appropriate first imaging study?



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You are working in the emergency department when a 58-year-old male presents stating he had some food “stuck” but he thinks he just swallowed it and now feels fine. This started 3 hours ago when he was eating steak. He appears stable in no distress, speaking in full sentences and breathing normally. Vital signs and exam are normal. He drinks a cup of water without difficulty. What would be the most appropriate recommendation at this point?



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A 3-year-old female is brought to the emergency department by her parents after she told her mother she ate some of “Daddy’s shiny candies”. The parents are concerned she ingested some of the 5 mm spherical magnets that are part of a magnetic ball sculpture. They suspect this happened about 2 hours ago. The child is in no distress, denies any pain, appears comfortable and has a normal exam. Abdominal x-rays show what appear to be 5 or 6, 5 mm spherical, radio-opaque foreign objects at the level of the stomach. What would be the most appropriate management for this patient?



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Esophagial Foreign Body - References

References

Al Lawati TT,Al Marhoobi RM, Timing of Button Battery Removal From the Upper Gastrointestinal System in Children. Pediatric emergency care. 2018 Dec 27;     [PubMed]
Zhang XR,Li Q, [A case of magnetic pharyngeal foreign body in children]. Lin chuang er bi yan hou tou jing wai ke za zhi = Journal of clinical otorhinolaryngology, head, and neck surgery. 2018 Sep;     [PubMed]
Malik SA,Qureshi IA,Muhammad R, Diagnostic Accuracy Of Plain X-Ray Lateral Neck In The Diagnosis Of Cervical Esophageal Foreign Bodies Keeping Oesophagoscopy As Gold Standard. Journal of Ayub Medical College, Abbottabad : JAMC. 2018 Jul-Sep;     [PubMed]
Al Lawati TT,Al Marhoobi R, Patterns and Complications of Ingested Foreign Bodies in Omani Children. Oman medical journal. 2018 Nov;     [PubMed]
Shatani N,Alshaibani S,Potts J,Phillips B,Bray H, Chest Radiograph Alone Is Sufficient as the Foreign Body Survey for Children Presenting With Coin Ingestion. Pediatric emergency care. 2018 Nov 19;     [PubMed]
Aiolfi A,Ferrari D,Riva CG,Toti F,Bonitta G,Bonavina L, Esophageal foreign bodies in adults: systematic review of the literature. Scandinavian journal of gastroenterology. 2018 Nov 5;     [PubMed]
Huang T,Li WQ,Xia ZF,Li J,Rao KC,Xu EM, Characteristics and outcome of impacted button batteries among young children less than 7 years of age in China: a retrospective analysis of 116 cases. World journal of pediatrics : WJP. 2018 Dec;     [PubMed]
Bolton SM,Saker M,Bass LM, Button battery and magnet ingestions in the pediatric patient. Current opinion in pediatrics. 2018 Oct;     [PubMed]
Ham PB 3rd,Ellis MA,Simmerman EL,Walsh NJ,Lalani A,Young M,Hatley R,Howell CG,Hughes CA, Analysis of 334 Cases of Pediatric Esophageal Foreign Body Removal Suggests that Traditional Methods Have Similar Outcomes Whereas a Magnetic Tip Orogastric Tube Appears to Be an Effective, Efficient, and Safe Technique for Disc Battery Removal. The American surgeon. 2018 Jul 1;     [PubMed]
Anderson KL,Dean AJ, Foreign bodies in the gastrointestinal tract and anorectal emergencies. Emergency medicine clinics of North America. 2011 May;     [PubMed]
Arana A,Hauser B,Hachimi-Idrissi S,Vandenplas Y, Management of ingested foreign bodies in childhood and review of the literature. European journal of pediatrics. 2001 Aug;     [PubMed]
Triadafilopoulos G,Roorda A,Akiyama J, Update on foreign bodies in the esophagus: diagnosis and management. Current gastroenterology reports. 2013 Apr;     [PubMed]
Gretarsdottir HM,Jonasson JG,Bj�rnsson ES, Etiology and management of esophageal food impaction: a population based study. Scandinavian journal of gastroenterology. 2015 May;     [PubMed]
Leinwand K,Brumbaugh DE,Kramer RE, Button Battery Ingestion in Children: A Paradigm for Management of Severe Pediatric Foreign Body Ingestions. Gastrointestinal endoscopy clinics of North America. 2016 Jan;     [PubMed]
Alfonzo MJ,Baum CR, Magnetic Foreign Body Ingestions. Pediatric emergency care. 2016 Oct;     [PubMed]
Bekkerman M,Sachdev AH,Andrade J,Twersky Y,Iqbal S, Endoscopic Management of Foreign Bodies in the Gastrointestinal Tract: A Review of the Literature. Gastroenterology research and practice. 2016;     [PubMed]
Cervi E, Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: management of asymptomatic children with a history of coin ingestion. Emergency medicine journal : EMJ. 2010 May;     [PubMed]
BET 1: use of glucagon for oesophageal food bolus impaction. Emergency medicine journal : EMJ. 2015 Jan;     [PubMed]

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