A 2-year old previously healthy boy is brought to the emergency department for choking episode, throat pain & frequent coughing that started suddenly while playing with some toys. On examination, he looks comfortable in no respiratory distress, no drooling. Normal ear/nose/throat exams. Chest is clear with no wheezing.What will be your initial differential diagnosis? What X-rays will you order?
Just as you order the x-rays, you are called to see a 4-year old boy for episodes of vomiting starting today. 2-days prior, he swallowed a coin and radiograph done somewhere else confirmed the coin ingestion. She was told the child will likely pass it. The mother told you the child has had bowel movements but she checked and did not see the coin. He was otherwise doing well until the vomiting episodes today.What do you do now? Orders x-rays or reassure the mother that this is a viral gastritis and discharge home?
Foreign body ingestion in children
Foreign body ingestion is a common reason for pediatric visit to the Emergency Department. Infants put everything into their mouth and toddlers eat about anything. Majority of foreign body ingestion occur in children between 6 months – 4 years. Coins are the most common foreign body ingested in children (mainly pennies). Others objects include toys, toy parts, magnets, batteries, safety pins, screws, marbles, bones, and food boluses. Children with developmental delays are at risk of having bezoars due to repeated episodes of multiple foreign body ingestion.
Most foreign body that reaches the gastrointestinal tract passes spontaneously. 10-20% will require endoscopic removal and less than 1% requires surgical intervention.
Sites of entrapment for include the proximal esophagus/thoracic inlet (most common site, ~60-80% of cases due to change from skeletal to smooth muscle and the cricopharyngeus muscle), the mid-esophagus (where aortic arch crosses over), the lower esophageal sphincter, pylorus, the ligament of Treitz and the ileocecal valve.
Foreign body ingestions are frequently brought to medical attention after a caregiver witnesses the ingestion or the child reports it. In acute cases, majority of children are often asymptomatic. Symptoms are often related to the location of the foreign body and children may present with neck/throat pain, foreign body sensation, chocking, drooling, dysphagia, stridor, wheezing, chest pain, emesis, food refusal. Chronic presentation may be due to complications and include vomiting, hematemesis, abdominal pain/distension, fever, hematochezia, failure to thrive, weight loss.
Initial evaluation of a patient suspected of having a GI foreign body should include anteroposterior (AP) and lateral plain films of the neck, chest, and abdomen (i.e. from mouth to anus). Esophageal flat objects (e.g. coins/disk batteries) usually appear as circular objects on AP projection and from the side on the lateral film (Fig. 2), whereas objects lodged in the trachea are often seen as circular on lateral projection (Fig. 3).
Symptomatic patients with history consistent with foreign body ingestion but normal findings on plain films require additional evaluation such as endoscopy, CT, MRI.
Asymptomatic patients in whom study results are normal can be observed as out-patients.
Hand held metal detectors have variable success in locating coins, and may be quicker and avoid radiation. It is however less reliable in detecting metallic objects other than coins, limiting its use.
For ingested foreign bodies, the type of object, its location, and the child’s symptoms dictate treatment.
Most ingested foreign body distal to the esophagus pass spontaneously without complication.
Asymptomatic patient with blunt foreign objects in the esophagus may be observed for 12-24 hours because spontaneous passage often occurs. Objects lodged in the esophagus for more than 24 hours or for an unknown duration should be removed promptly.
Urgent intervention is indicated for:
– Sharp, long (>4-6 cm) objects in the esophagus or stomach
– High-powered magnets or magnetic objects
– Button/Disk battery in the esophagus/stomach
– Signs of airway compromise
– Signs of near-complete esophageal obstruction (e.g. drooling, unable to swallow secretions)
– Signs of inflammation or intestinal obstruction (e.g. vomiting, abdominal pain, fever)
Endoscopy can both be diagnostic and therapeutic in management of esophageal and gastric foreign bodies. The team performing the removal is institution-specific and may include gastroenterologist, otolaryngologist and pediatric surgeons.
Button batteries are found in hearing aids, calculators, small devices. They may be misdiagnosed as coins on radiograph. A double contour can be seen with larger button batteries on radiograph (Fig. 4). Button batteries that lodge in the esophagus require urgent endoscopic removal. National Button Battery Hotline (202-625-3333).
Sharp, elongated objects (e.g. straight pins) pose increase risk of perforation. Those longer than 4-6 cm are more likely to fail passage through the small intestine.
Magnets found in building sets, jewelry, and other toys may be ingested in multiples or with other metallic items. Magnets that attract each other across different parts of the bowel can cause pressure necrosis, perforation, fistulas, obstruction, and volvulus.
Less frequently ingested foreign body may present with complications such as mucosal erosion, abrasion, perforation or obstruction in objects that are retained for more than 24 hours. Scarring may lead to strictures. Infectious complications include abscess. Tracheal compression and respiratory distress may result from esophageal foreign body.
Caregiver education and attention to toy safety. Encourage the use of age appropriate toys and eliminate small parts in toys for young children. The American Academy of Pediatrics lists common objects and foods that pose choking hazards along with prevention strategies on their website (http://www.aap.org)
Schunk JE. Foreign body ingestion/aspiration. In Fleisher GR, Ludwig S. Textbook of Pediatric Emergency Medicine. 6th edition. 2010:276-282
Louie MC, Bradin S. Foreign body ingestion. Pediatrics in Review. Vol.30 No.8 August 2009
Gilger MA, et al. Foreign bodies of the esophagus and gastrointestinal tract in children. Uptodate. August 2014.
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