Ingestion of a foreign body is commonly encountered by pediatricians. Principles of management depend on the type of foreign body ingested, the location of the object along the gastrointestinal tract, and the associated history and physical examination. However, much of the care nationally is based on personal experience because clear guidelines for management have not been completely validated. For example, Bendig and Mackie reviewed the literature to identify the recommended period that patients who have asymptomatic smooth or blunt gastric foreign bodies should be observed. They found that it ranged from 2 to 3 days to indefinitely.1
This article provides an evidence-based review of the principles for management based on the types of foreign bodies ingested, their location along the alimentary tract, and the associated history and physical examination. Common and rare complications are discussed to illustrate the potential significant morbidity and mortality that may result from ingestion of foreign bodies.
The 1999 annual report of the American Association of Poison Control Centers noted 182,105 cases of ingestion of a foreign body by children younger than 20 years.2 The precise incidence of ingestion of a foreign body is unknown because most cases have a benign clinical course. They generally resolve without the need for medical care and are mus unreported. Eighty percent of all patients who seek medical attention after ingestion of a foreign body are children, and the peak incidence is between 6 months and 3 years of age.3 Most ingested items pass spontaneously without the need for endoscopic retrieval, so surgical intervention is rarely required. In a review of the preendoscopic era, spontaneous evacuation occurred for 93% to 99% of blunt objects.1 The need for surgical intervention to remove a foreign body is approximately 1%. Although coins and smooth, blunt objects make up most of the ingested items in large pediatric series, there is a significant geographic and cultural influence. Of 343 Chinese children who had foreign bodies removed, 146 had ingested fish bones and 134 had ingested coins.4 Older children may mimic adults in that they may have an associated psychiatric or neurologic disorder and can thus ingest items other than coins.
In general, children can ingest just about anything they can put into their mouths and swallow. This produces the potential for significant morbidity and possible mortality. Reported complications have ranged from a grape obstructing the intestine in an infant, to unshelled sunflower seeds causing severe obstipation, to needle perforation of the intestine. Occasional erosion of a supposedly benign esophageal foreign body into the tracheobronchial tree or the aorta has occurred with dire consequences. In addition to creating problems because of their physical size and shape, some ingested foreign bodies (eg, lead and batteries) also harbor toxic chemical components that can be poisonous. Ingestion of a foreign body accounts for approximately 1,500 deaths in the United States annually.3
Smooth, small, round objects that have passed into the stomach rarely require medical attention. However, foreign bodies that have the potential to damage the gastrointestinal tract because of their shape, because they may become lodged, or because they have toxic components should be identified so that a strategy for management can be developed. If there is a significant risk for potentially severe complications, some items may warrant endoscopic retrieval or surgical removal. Others may be safely observed.
Significant morbidity resulting from ingestion of a foreign body includes bowel obstruction, perforation with leakage of intestinal contents, erosion into adjacent organs, and absorption of the ingested object's toxic component. Objects commonly obstruct the gastrointestinal tract at naturally narrow sites such as the cricopharyngeal area and the pylorus. However, preexisting abnormalities such as tracheoesophageal fistula, duodenal web, annular pancreas, and Meckel's diverticulum place children at greater risk for objects to lodge in unusual places. Investigative studies are required if a small object becomes lodged in an unusual position along the gastrointestinal tract.
ESOPHAGEAL FOREIGN BODIES
Adults often witness infants and young children ingesting foreign bodies, whereas older children will usually report swallowing a foreign object. Because objects that are swallowed by children tend to be small and have smooth edges, they generally pass easily into the stomach and cause no initial clinical distress. However, if the foreign body is lodged in the esophagus, there may be substernal pain, drooling, and dysphagia. Some children may even have respiratory symptoms such as wheezing or coughing. All esophageal foreign bodies should be removed or advanced into the stomach despite the fact that only half of these children will have symptoms. There are real risks for mucosal erosion and catastrophic perforation when a foreign body is left in the esophagus. Even a supposedly benign object such as a coin can erode into the aorta, causing sudden exsanguination and death.5
Figure 1. A chest radiograph demonstrating a coin in the esophagus of an T8-month-old child who was treated for new-onset asthma for 1 month. The child had an unwitnessed ingestion and the length of time that the coin was in the esophagus was unknown. On endoscopy, there was significant edema and inflammation where the coin was eroding into the esophageal mucosa.
Occasionally, infants and small children may have swallowed a foreign body that was not witnessed and have symptoms that pediatricians and caretakers do not generally associate with this ingestion. A chest radiograph for a child who presents with new-onset wheezing may reveal symptoms that are related to an esophageal foreign body and not to asthma (Fig. 1). This is especially useful for small children who have recalcitrant wheezing despite the administration of bronchodilators. When a foreign body is discovered and it is not clear how long it has been in the esophagus, it should be retrieved with an endoscope. The object can be embedded in the esophageal mucosa and difficult to extract. Thus, an attempt at extraction by Foley balloon or bougienage should not be made.
In Cheng and Tarn's series of 552 documented ingestions, the only death was due to a chicken bone that had eroded into the left bronchus with subsequent fistula formation and empyema.6 This happened to an institutionalized child with mental retardation who had fever and respiratory distress for 5 days. No one had seen her swallow the bone. Ingestion of a foreign body was not suspected until a chest radiograph was done.
Foreign bodies in the esophagus tend to lodge in one of three naturally narrow areas: (1) the cricopharyngeus muscle; (2) the middle third of the esophagus where the left mainstem bronchus compresses the esophagus; and (3) the lower esophageal sphincter or esophagogastric junction. Children with a history of tracheoesophageal fistula or esophageal atresia can present with foreign bodies lodged in the mid esophagus due to poor motility and occasional narrowing at the anastomotic site. Additionally, stricture of the lower esophagus may arise due to esophagitis secondary to recurrent gastroesophageal reflux. More investigative studies are warranted for children who have had a foreign body lodged at an unexpected location along the esophagus. A barium esophagogram should be performed to evaluate the esophageal anatomy because unsuspected anomalies (eg, pulmonary artery sling or double aortic arch) may be responsible.
The simplest evaluation for an esophageal foreign body is a radiographic study. The image should include the neck, the chest, and the upper abdomen. Radiopaque objects can be easily discerned on plain radiographs. Occasionally, a barium esophagogram is indicated (eg, when a radiolucent foreign body is suspected because a child has drooling, dysphagia, or recurrent wheezing despite bronchodilators).
Foreign bodies located in the esophagus should be removed. The three main techniques for removal of esophageal foreign bodies include Foley catheter, bougienage, and endoscopic retrieval. Foley catheter retrieval and bougienage are limited to smooth objects such as coins. The choice between these two methods primarily depends on the treating physician's preference. In a literature review by Conners, 97.7% of 1,746 attempts to remove coins from the esophagus were successful, with a 2.1% complication rate.7 The costs of bougienage and Foley catheter retrieval are approximately the same ($614 and $660, respectively), but endoscopic retrieval was nearly four times more ($2,701).
Foley catheter retrieval is easy to perform and generally successful for removing smooth objects such as coins from the esophagus. However, this technique has been controversial since it was first described by Bigler in 1966.8 Proponents cite ease of technique, lower costs, no anesthetic risk, and a high success rate for selected foreign objects. Opponents cite potential airway compromise, discomfort for the awake child, risk of esophageal injury, inability to visualize the esophagus, and a lower success rate than endoscopic retrieval.
Harned et al. found that 96% of 337 coin extractions attempted using the Foley catheter under fluoroscopic guidance were successful with no complications.9 They excluded individuals who had radiographic evidence of edema that might signify potential tracheal compromise. Similarly, Morrow et al. successfully retrieved 84% of esophageal foreign bodies using a Foley catheter.10 Seven percent passed into the stomach and 9% could not be removed with the catheter.
To ensure proper safety of this technique, the physician should be trained in the management of the pediatric airway and appropriate suction or resuscitation equipment should be available during the procedure. Sedatives are avoided to minimize the risk of aspiration, so physical restraint is required during the procedure. The Foley catheter is introduced into the mouth to reduce the risk of impacting the foreign body in the nasopharynx. However, in an uncooperative child, the catheter can be placed through the nose. Some physicians recommend fluoroscopic guidance, but this is not necessary in experienced hands. Objects that have been lodged for more than 2 to 3 days may be impacted and should be removed under endoscopic guidance.
Bougienage is a useful and easy method for pushing smooth objects into the stomach with the expectation that approximately 90% to 95% of them will spontaneously evacuate. Calkins et al. showed that a selected group of children who met their criteria for bougienage (a single coin ingested, less than 24 hours since ingestion, no history of esophageal abnormalities, no history of prior ingestion, and no respiratory distress) could be readily cared for using this technique and that the cost was only 10% of mat for an endoscopic retrieval.11 An anesthetic can be avoided and the hospital visit is brief. Although the use of bougienage is limited by strict criteria, when it is appropriately applied, the success rate is high with little morbidity. Opponents cite concerns because of the discomfort of the technique. Additionally, a small percentage of advanced foreign bodies will not spontaneously evacuate. These lodged objects can lead to obstruction or perforation and require endoscopic retrieval or surgical exploration for removal. However, proper selection to limit the types of esophageal foreign bodies that can be advanced by bougienage should minimize the potential for later complications.
Endoscopic retrieval is the most complete and thorough technique for the removal of foreign bodies in the esophagus, with a success rate that approaches 100%. Infants and children are given general anesthesia, and a careful evaluation of the esophagus can be done at the time of retrieval of the foreign body. Objects that are impacted or sharp can be safely removed under direct vision. Mucosal injury can also be evaluated and appropriate therapy implemented. Critics of this technique cite the risk of general anesthesia, the high cost, and the skill level needed to perform it.
For esophageal foreign objects that have been present for an unknown duration, endoscopic extraction should be the only acceptable therapeutic procedure. An embedded esophageal foreign body that has been present for some time (> 2 weeks) has a significant chance of having eroded into the surrounding structure with potential dire consequences. Thoracotomy may be required to retrieve foreign bodies from the mediastinum and to repair an injured structure such as the aorta, the esophagus, or the bronchus.
To save costs, a general algorithm can be generated from evidence-based studies. The caveats are that only trained physicians who can manage a child's airway should perform these procedures and that no foreign body should be left within the esophagus. Foley catheter retrieval or bougienage advancement can be performed if (1) the ingested item is smooth or blunt; (2) the ingestion is less than 24 hours old; (3) there is no history of an esophageal disorder; and (4) there are no respiratory symptoms. For all other esophageal foreign bodies, endoscopic retrieval is the procedure of choice.
DISK OR BUTTON BATTERIES
Disk or button batteries require special attention because they cause damage by direct corrosive effects, voltage burns, and pressure necrosis. Litovitz and Schmitz reviewed a national registry during a 7-year period and found that 2,320 batteries were ingested, with 76% of the cases occurring in children younger than 13 years.12 Overall, 9.9% of all patients were symptomatic. Interestingly, 312 of these children removed the battery from their own hearing aid prior to ingesting it. Two children had severe esophageal burns with subsequent formation of a stricture that required repeated dilatations. One had a lithium battery removed within 9.5 hours after ingestion, but a burned area was noted on esophagoscopy. Three others had a tracheoesophageal fistula and a fourth child had a perforated esophagus.
Battery size and type may affect management and outcome. Lithium batteries cause more adverse effects because of their large size and greater voltage. Mercury can be toxic and blood levels may be elevated after ingestion of mercury batteries due to their fragmentation. Fortunately, mercury oxide is poorly soluble and not readily absorbed.
Emergent endoscopic removal of all esophageal batteries should be done because burns and injury can occur as early as 4 hours after ingestion.12 In contrast, batteries in the stomach or the rest of the alimentary tract may be observed because an overwhelming majority will spontaneously evacuate without sequelae. The administration of ipecac syrup is not advised because it can lead to esophageal lodgment of a battery that was previously in the stomach. Furthermore, emesis may lead to aspiration of the battery. Of 37 patients given emetics, only 1 expelled the batteries.12 Surgical intervention is warranted for (1) patients who have signs of major gastrointestinal injury, including hematochezia and severe abdominal pain; (2) the ingestion of multiple batteries; or (3) the ingestion of a large battery (> 15 mm) that fails to traverse the pylorus after 48 hours.
SUBDIAPHRAGMATIC FOREIGN BODIES
Smooth or blunt foreign bodies that have passed beyond the esophagus do not generally warrant endoscopic retrieval or surgical exploration for removal unless there are other indications, such as their intrinsic toxicity. In separate reports prior to the endoscopic era, Gross and Pellerin presented a total of 1,481 children who had foreign bodies of all types (blunt and sharp) in the subdiaphragmatic region documented on radiographs. They found that 1,434 (97%) of the foreign bodies were evacuated spontaneously.1314 Of the 47 foreign bodies that required surgical removal, only 1 was a smooth or blunt object.
Figure 2. An abdominal radiograph revealing an ingested pencil. Sharp objects within the stomach that can be readily retrieved endoscopically should be removed. Although the incidence of surgery required for extraction of a foreign body is approximately 1 %, the risk of complications with a subsequent need for surgery is much higher for the ingestion of sharp foreign bodies.
Most investigators recommend endoscopic retrieval of sharp or large gastric foreign bodies because of their potential for becoming impacted in the intestinal mucosa with subsequent erosion into the peritoneal cavity or direct perforation of the bowel wall (Fig. 2) Although the incidence of surgery for all ingested foreign bodies is only approximately 1%, the rate of surgery for ingested sharp objects is 15% to 30%.3,13,14 Commonly ingested sharp objects include toothpicks, bones, nails, safety pins, needles, and sharp toys.
Additionally, large or long objects have been reported to navigate the duodenal sweep poorly and tend to become lodged, with the potential for obstructing the bowel lumen or eroding through the wall of the bowel. Studies of adults suggest that smooth objects thicker than 2 cm and longer than 5 cm tend to lodge in the stomach and should be retrieved.15 Other studies have noted that foreign bodies longer than 10 cm will not pass easily around the duodenal sweep and thus present a higher risk for obstruction and perforation.14 Defined dimensions for ingested objects are useful for guiding care.
Infants and children have smaller pyloric channels and, therefore, smaller items will lodge there. Fortunately, they also tend to ingest smaller items. For infants, items larger than 2 cm or longer than 3 cm can have difficulty traversing the pyloric channel and thus may warrant endoscopic retrieval.1,4,14,15 In general, waiting 8 weeks before attempting endoscopic removal of a smooth or blunt gastric foreign body is recommended. However, if a large or long foreign body is present, a shorter waiting period of 2 weeks is recommended.
The argument for removing blunt or smooth objects from the alimentary tract once they have traversed the esophagus can be made for those that harbor toxic components. Various reports of toxicity from ingesting lead, copper, nickel, and zinc exist. These are generally found in batteries, but removal once they have passed into the stomach is rarely indicated. Occasionally, ingestion of lead material such as pellets has resulted in acute toxicity with the need, for chelation therapy.16 However, a substantial amount of lead needs to be ingested (in the absence of long-term exposure) to actually cause acute lead intoxication. In the case of acute lead toxicity mentioned earlier, the child had ingested thousands of pellets.
Once foreign objects have passed distal to the stomach, they rarely lodge along the rest of the alimentary tract. The only other significant site that is naturally narrow is the ileocecal valve. There are scattered reports of ingested sharp foreign objects that have eventually perforated the bowel. However, these cases are uncommon and surgery is unwarranted unless signs or symptoms of perforation develop. Fewer than 1% to 2% of these patients will need surgery.6,14,15 Toothpicks and bones are the most common foreign bodies requiring surgery. Surgical exploration can be done via laparotomy or laparoscope The procedure depends on the type of complication.
Routine radiologic examinations to evaluate the progress of a foreign body are unnecessary. Instead, parents or patients should be instructed to report abdominal pain, fever, hematemesis, or vomiting. Failure to spontaneously evacuate the foreign body by 8 weeks suggests an underlying abnormality in the bowel. The decision to surgically remove the foreign body should be made on an individual basis at that time.
Rectal foreign bodies may also be encountered, but are uncommon among children. Unless witnessed, children may not confess to placement of an object into their rectum. They may complain of pelvic, abdominal, or even rectal pain. Small items can be easily retrieved, but large foreign bodies may require anesthesia for removal. Evaluation of the rectal mucosa by endoscopy or a contrast enema study is required after removal of sharp or large objects. Rarely, a laparotomy is required to retrieve a rectal foreign body that has migrated into the colon or perforated the peritoneal cavity.
RADIOLUCENT FOREIGN BODIES
Occasionally, radiolucent objects that cannot be visualized on plain radiographs will be ingested. A thin (diluted) barium esophagogram can be done to outline the radiolucent foreign body. This procedure should also be performed for infants or small children who have no history of ingestion (eg, unwitnessed ingestion), but who have symptoms consistent with ingestion of a foreign body. If a foreign body is identified in the esophagus, endoscopic retrieval should be performed. In the case of a witnessed ingestion, no intervention is warranted if the esophagogram does not identify a foreign body and there is no clinical evidence of esophageal obstruction. Rarely, children will swallow sharp radiolucent objects such as pieces of glass or wood. These children should have an upper gastrointestinal tract barium study. Sharp items present in the stomach should be retrieved. If no foreign body is identified, appropriate counseling and expectant management are recommended.
Bezoars are foreign bodies that have accumulated over time in the alimentary tract. Common concretions include plant and vegetable matter (phytobezoar), hair (trichobezoar), and persimmons (disopyrobezoar). In addition to these common ingestions, children may present with an accumulation of just about anything from gum to carpet (Fig. 3).17 The term bezoar is derived from the Arabic badzehr and the Persian panzehr. The original meaning was "counterpoison or antidote." Bezoars were collected from the stomachs of goats for medicinal purposes as early as 3,000 years ago.17
Figure 3. A 3-year-old girl who had been chewing her towels had a bezoar consisting of strings. She had obstructive symptoms and the bezoar could not be endoscopically removed. A gastrotomy was done to extract the entire bezoar.
Indigestible foreign materials may accumulate in the stomach because of their size, and delayed gastric emptying or obstruction of the gastric outlet can also aid in their formation. Patients who have had antrectomy or vagotomy have reduced output of gastric acid and poor emptying. They are thus predisposed to bezoars. Psychiatric evaluation may be needed for patients who present with trichobezoar or for those who have recurrent bezoars.
Pica is another condition worm remembering. Risk factors include young age, female gender, mental retardation, lower socioeconomic background, and African American or aboriginal race.18
Clinically, a bezoar causes symptoms because of its physical size. Children may have obstructive symptoms with occasional bleeding, but bezoars rarely cause perforations. Bezoars can become large enough to produce early satiety, abdominal pain, halitosis, anorexia, or nausea. Children may also present with symptoms of gastric outlet obstruction. Occasionally, the mass may pass into the small bowel and cause small bowel obstruction. Because symptoms tend to be nonspecific, diagnosis can be difficult. Most children will not volunteer information about their ingestion of unusual materials, and parents are often unaware. Abdominal tenderness and an epigastric mass may be palpated on physical examination. Plain abdominal radiographs may not reveal the bezoar well. Therefore, symptoms suggesting obstruction warrant investigation. An upper gastrointestinal tract barium study can be used to outline the concretion collected in the stomach or the small bowel.
Small bezoars in the stomach may be retrieved endoscopically or elnrtinated by enzymatic fragmentation. Chymopapain, cellulase, and acetylcysteine may be useful for small bezoars. Laparotomy is occasionally required for large obstructing bezoars in the stomach or the small bowel. When a child has a small bowel obstruction caused by a bezoar, the stomach needs to be thoroughly evaluated because the incidence of concurrent gastric bezoars is approximately 20%.19
Ingestion of a foreign body is a common clinical problem. Most children have a benign course and will spontaneously evacuate the foreign object. Esophageal foreign bodies require removal. An ingested battery in the esophagus is a surgical emergency, and it should be removed immediately to minimize the potential for a significant esophageal burn. Small, smooth objects that have passed distal to the esophagus rarely cause problems, so routine retrieval is unnecessary. Removal of sharp or large objects from the stomach may be safer, but careful follow-up is sufficient if they have passed beyond the pylorus. There is no indication for a prophylactic laparotomy to retrieve foreign bodies. Surgery is reserved for those who have complications due to the ingestion.
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