A foreign body is something that is stuck inside you but isn’t supposed to be there. You may inhale or swallow a foreign body, or you may get one from an injury to almost any part of your body. Foreign bodies are more common in small children, who sometimes stick things in their mouths, ears, and noses.
Aspirated and Ingested Foreign Bodies Epidemiology
Possibly 1500 to 3000 deaths per year in U.S.
80 % of cases are pediatric
80 % of adult esophageal impactions have underlying esophageal disease
< 10 % of pediatric cases have esophageal disease
Male to female ratio in children is 2:1
10 to 20 % require endoscopy
1 % require surgery
Eighty percent of foreign bodies occur in the pediatric age groups , followed by edentulous adults, prisoners, and psychiatric patients.
The wearing of dentures is the one most commonly associated with foreign body ingestion in adults . The presence of dentures eliminates the tactile sensitivity of the palatal surface so vital to identification of small items that may be included in an ingested bolus of food .
When a foreign body is ingested, 80% will enter the gastrointestinal tract and 20% will go into the tracheobronchial tree.
Objects thicker than 2.0 cm and longer than 5.0 cm tend to lodge in the stomach Long foreign bodies (>lO cm) tend to hang up in the duodenal sweep where perforations may also involve the right kidney .
Effects of Aspirated Foreign Bodies
Complete upper airway obstruction : death
Partial upper airway obstruction: Wheezing, chest pain, mucosal injuries : bleeding
Lower airway obstruction: pneumonia, decreased breath sounds
Objects Commonly Ingested or Aspirated by Children
peanuts : most common lower airway object
coins
bones
balloons
buttons
toys
pins
hair
clips
marbles
Emergency Treatment for Aspirated Foreign Bodies
- Back blows
- Chest thrusts
note : none of these should be applied if patient is able to speak or cough
- Finger sweep / grasp
should be done only if object is visible and will not be wedged deeper
Symptoms of Foreign Body Aspiration into the Tracheobronchial Tree
Respiratory arrest
No symptons (up to 40 %)
Classic triad (in 40 %)
Wheezing, coughing, dyspnea
Differential Diagnosis of Partial Airway Obstruction in Children
Foreign bodies
Iatrogenic
laryngeal nerve paralysis
tracheal ulceration or granuloma
infections
epigloititis
diphtheria retropharyngeal
Neoplasms
Hemangioma
Angiofibromas
Teratomas
recurrent respiratory papillomatosis
Foreign Body Ingestions : Risk Factors
Developmental immaturity
Psychiatric illness
Altered level of consciousness
Abnormal deglutition
High risk foods
Chicken bones
fish bones
Foreign Body Ingestions : Most Common Types
Meat : most common in adults
Chicken bones : most common cause of perforation
Sewing needles
Safety pins
Pills – Doxycycline & AZT can cause esophageal ulcers if impacted
Esophageal Foreign Bodies : Symptoms
Stridor
Choking
Gagging
Coughing
spitting
Refusal to eat
Vomiting
Chest or neck pain
The person can often point to the level of the obstruction
Dysphagia
Odynophagia
Most Likely Sites of Esophageal Foreign Body Impaction
Sites of esophageal narrowing :
Cricopharyngeus (15 to 17 cm. from incisors)
Aortic arch (22 to 24 cm. from the incisors)
Left mainstem bronchus (28 to 30 cm. from incisors)
Gastroesophageal sphincter (40 cm. from incisors)
Pathologic narrowing of esophagus
Intrinsic : tumors, strictures
Extrinsic : tumors, vascular lesions
Coin Ingestions
Zinc is more corrosive than copper
Coins tend to lodge in frontal (coronal) plane in esophagus (sagitally if in trachea)
Up to 30 % of children with coins lodged in the esophagus may be asymptomatic
larger coins lodge at the level of the cricopharyngeus muscle or just distal to it .
In the trachea, the anteroposterior view will reveal the edge of the coin, whereas the flat surface will be seen on the lateral view.
The reverse is true if the coin is in the more posterior esophagus, with the flat surface being seen on the anteroposterior and the edge being seen on the lateral projection .
The single most important consideration in managing coins and other foreign bodies at the level of the cricopharyngeus muscle or retrieving them through this area is to maintain an airway at all times.
Treatment
After induction of anesthesia, the endoscopist has two choices of instruments to be used through the endoscope: the polypectomy snare or the foreign body grasping forceps. The Olympus alligator-type grasping forceps are superb and have facilitated coin retrieval.
They can be passed through endoscopes with operating channels of 22.8 mm, but will not pass through the smaller pediatric endoscopes. The forceps have excellent grasping power and will rarely drop the coin, especially at the level of the cricopharyngeus muscle.
Once grasped, the coin and endoscope should be pulled straight out and not rotated, as the coin will be lying in the coronal or transverse plane of the esophagus, which has the widest diameter.
However, blunt foreign bodies, such as marbles, that cannot be grasped with instruments can be removed easily under direct vision by using through the scope esophageal dilating balloons with the patient under general endotracheal anesthesia.
No fluoroscopy is needed with this technique.
If the foreign body is <20 mm in diameter, it can be gently pushed into the stomach where it should pass through the gastrointestinal tract without difficulty.
An alternative method for removing coins and blunt foreign bodies from the esophagus is the use of the Foley catheter .
Although the coin located in the esophagus should be removed promptly, once it passes into the stomach it is a different matter.
Meat Impaction:
Meat impaction in the upper and lower esophagus is the most common foreign body seen in adult
The “cafe coronary” or “steakhouse syndrome” is a manifestation of meat impaction that occurs when a large piece of meat (or occasionally, other food) becomes impacted at the level of the cricopharyngeus muscle and cervical esophagus, causing anterior pressure on the trachea with resulting respiratory obstruction.
A symptomatic patient presenting with a history of meat impacted in the esophagus needs no radiographs or barium studies. These simply make the task of the endoscopist more difficult by obscuring visualization of the foreign body and any pathology.
Conservative” Initial Treatment for Impacted Food in the Esophagus
Glucagon 0.5 to 2.0 mg IV or IM Success rate 20 to 50 %
Nifedipine 10 mg SL
Nitroglycerin 0.4 mg SL
Diazepam 5 to 10 mg IV
Atropine 0.5 to 1.0 mg IV or IM
“Invasive” Removal of Esophageal Foreign Bodies
Flexible fiberoptic endoscopy
Usually method of choice
General anesthesia may be required in children
If food impaction, may be pushed into stomach rather than removed
- Foley catheter extraction
Patient must be in head – down position
Only suitable for upper esophageal impactions
- Nasogastric suction or magnet (needs fluoroscopy)
Rare earth cobalt magnet useful for button batteries
- If the patient is salivating and unable to handle his oral secretions, endoscopy should be performed immediately to prevent aspiration. If the patient can handle his saliva, emergency endoscopy is not necessary. Time and sedation will often allow the meat to pass into the stomach if one is waiting overnight to perform endoscopy, and time is the more important of the two. However, the bolus should not be allowed to remain in the esophagus for 12 hr, as complications may begin to arise.
- Of the three major groups of foreign bodies-coins, meat, and sharp objects-the management of meat impaction is the most controversial. Enzymatic disruption of the meat with papain (Adolph’s Meat Tenderizer) is known to be effective . However, papain may digest the esophageal wall as well as the meat bolus.
- contraindications for the use of papain as
(a) a history of impaction exceeding 36 h, which could compromise esophageal viability;
(b) suspected perforation above the impaction; and
(c) radiographic evidence of a bone fragment in the meat bolus.Glucagon has also been used to relieve meat impaction in the distal two-thirds of the esophagus.
The ability of glucagon to decrease lower esophageal sphincter pressure.
It is a safe drug, causing only nausea and vomiting in some patients, and is contraindicated only in those patients with an allergic history to the drug, an insulinoma, or a pheochromocytoma .
Glucagon does not relax distal esophageal rings or strictures.
patients who have a history of meat impaction and are symptomatic are not sent to the radiology department for examination; and when they are seen in the endoscopy unit, glucagon is not used. Flexible endoscopy offers immediate relief of symptoms, evaluation of the pathology, and immediate dilation, if needed.
Gas-forming agents have also been used in treating the impacted meat bolus . It is believed that the sudden release of gas helps push the food bolus into the stomach.
Pushing the meat into the stomach blindly with a dilator should be mentioned but is not recommended for fear of perforation.
Also, passing a nasogastric tube by the meat bolus under direct vision and applying suction, as described by McCray has not been needed, nor has postural disimpaction, as described by Partridge .
To reiterate, the best method of managing meat (or food) impaction is with the flexible endoscope, as described above.
Button Battery Ingestions
Button batteries are 6 to 23 mm. in diameter
Used in calculators, cameras, electronic games, hearing aids, watches, etc.
Types :Mercuric oxide, Manganese dioxide, Zinc-airthe gastrointestinal tract is most frequently involved, the auditory and nasal passages have also been implicated .
Just as with coins, it is the larger button batteries >21 mm in diameter, that usually cause problems. Children <5 yr of age are the most common victims
The three most commonly involved battery systems are the manganese dioxide, the silver oxide, and the mercuric oxide;
These three systems contain an alkaline electrolyte that is usually a 26%- 45% solution of potassium hydroxide, but may be sodium hydroxide . This alkaline solution is strong enough to cause rapid liquification necrosis of tissue.
In battery ingestion, the mechanism of injury can be caused by three different means: direct corrosive action, low voltage burns, and pressure necrosis.
The mechanism that most frequently leads to perforation is the direct corrosive activity of the battery contents on the gastrointestinal mucosa .
When considering endoscopic management of button batteries, the gastrointestinal tract is divided into three parts: the esophagus, stomach, and intestines.
Management differs for all three.
A button battery lodged in the esophagus is a true emergency because of the extremely rapid action of the alkaline substance on the mucosa and the probability of a catastrophic complication, such as an esophagotracheal or esophagoaortic fistula .
Radiologists compilcation disguish between a coin and a button battery lodged in the esophagus .
When viewed in an anterior projection, the latter demonstrates a double density shadow due to the bilaminar structure of the battery.
On the lateral view, the edges of the battery are round and again present a stepoff at the junction of the cathode and anode. A coin has a much sharper edge on the lateral view.
The battery can rarely be grasped with the foreign body forceps because it is too smooth. It is best removed from the esophagus with a through-the-scope balloon under direct vision.
The balloon is passed distal to the battery and inflated, and then the balloon, battery, and endoscope are removed as a unit. Because there may be reaction between the edge of the disk and adjacent tissue, biopsy forceps may be necessary to “dissect” the battery free before removal.
Once the battery has been removed, the area of involved esophagus is closely evaluated endoscopically for the amount of tissue damage.
A barium swallow is obtained 24-36 h after endoscopy to rule out a fistula. A second barium swallow is obtained 10-14 days later to rule out a stricture or a late developing fistula.
The patient is placed on antibiotics, but not steroids, if the involved area of the esophagus appears to have significant tissue damage.
A Foley catheter is not used to remove a button battery without general anesthesia because of the possibility of fatal airway problems and the inability to visualize the area of impaction and the amount of tissue damage.
Once the button battery has moved beyond the pylorus and duodenal sweep, it cannot be retrieved from above endoscopically. As in the stomach, however, it will usually pass, without difficulty.
Cimetidine is often administered to decrease the acid in the stomach, thus decreasing the battery reaction. Laxatives are given to hasten transit time through the intestine.
Dangers of Button Battery Ingestions
Esophageal impaction
Corrosion & esophageal perforation
Some deaths reportedDissolution & heavy metal poisoning
Stomach and Intestinal Foreign Bodies
Only 1 % of objects that reach the stomach will require surgical removal
Somewhat higher risk for ingested Christmas ball ornaments (have thinner, sharper glass)
90 % of foreign bodies will pass in less than 7 days
Sharp and Pointed Foreign Bodies
Sharp and pointed foreign bodies, as well as elongated foreign bodies, can be very challenging and difficult to manage; but, fortunately, they are not common.
The most common foreign bodies in this group are toothpicks, nails, needles, bones, razor blades, safety pins, and dental prostheses .
Objects longer than 5 cm and wider than 2 cm will rarely pass the stomach . These
foreign bodies can be removed from the duodenal bulb or duodenal sweep with success ,but are more difficult. The narrow lumen and fixed position of the duodenum make maneuvering more difficult.
Glucagon given intravenously (0.4-0.6 mg in adults) for difficult foreign bodies in the duodenum and stomach can greatly facilitate their extraction.
The open safety pin always represents a major problem. If a safety pin is in the esophagus with the open end proximal, it is best managed with the flexible endoscope by pushing the pin into the stomach, turning it, and then grasping the hinged end and pulling it out first. An overtube or a rigid esophagoscope may be necessary with large open safety pins. Removal of multiple objects from the stomach is also made easier with an overtube.
The closed safety pin, once in the stomach, will pass without difficulty.
The ingested razor blade is a traumatic experience for both the patient and the endoscopist. Fortunately, the single edge blade is usually seen today, rather than the double edge blade.
This can be managed with the rigid esophagoscope in both the child and adult by pulling the blade into the instrument. In this type of foreign body removal, the foreign body, the forceps, and the endoscope often have to,be removed as a unit. In adults, the razor blade can also be managed with the flexible endoscope and overtube, especially if it has reached the stomach.
Once a razor blade has negotiated the stomach, surprisingly, it will usually pass through the lower gastrointestinal tract without difficulty .
Although <l% of all foreign bodies perforate the gut , all sharp and pointed foreign bodies should be removed before they pass from the stomach because 15%-35% of this type will lead to intestinal perforation, usually in the area of the ileocecal valve .
When foreign bodies reach the middle of the transverse colon, they become centered in the feces. This facilitates passage of objects through the remaining portion of the large bowel and anal canal .
Indications for Surgical Removal of Stomach or Intestinal Foreign Body
Signs of obstruction
Persistent vomiting
Progrssive abdominal distention
- Abdominal pain / peritonitis
- Gastrointestinal bleeding
- The ingestion of 1-3 g of cocaine in a powdered form can be fatal; rupture of even one package carries the risk of death .
- One should be careful performing a rectal examination because a packet could be disrupted.
- The usual methods of gastrointestinal decontamination (ipecac syrup, lavage, enema, and cathartics) should be avoided because of the possibility of packet rupture .
- The safest means of removing the packets is with surgery. The endoscopist should not try to deliver the packets from above with the gastroscope or from below with the colonoscope.
- Packet rupture has resulted from attempts at endoscopic removal .
- Patients who are at increased risk of toxicity are those
(a) who have passed broken containers or demonstrate them on x-ray;
(b) who are symptomatic;
(c) who have gastrointestinal obstruction;
(d) who have a time lapse of >24-48 h since ingestion; or
(e) who have an abdominal x-ray demonstrating packets highly susceptible to breaking .This patient requires stabilization, activated charcoal and surgical removal of the containers.
Radiolucent Foreign Bodies
Pieces of glass, bone fragments, aluminum (e.g., canned drink pop tabs), plastic, and pieces of wood can often be difficult to see in the hypopharynx and cervical esophagus on routine radiographs .
If the patient has complained of swallowing a foreign body and it is not seen on routine radiographs, thin barium is used to try to outline the object.
If the foreign body is Identified radiographically, endoscopy is performed.
If no foreign body is seen radiographically, but the patient remains symptomatic, endoscopy is also performed.
If no foreign body is seen radiographically
and the patient has become asymptomatic, no endoscopy is necessary.
Miscellaneous Foreign Bodies
large foreign bodies containing a hole, such as rings or keys, can be removed with a string technique.
The string can be tied above the bending section of the endoscope or allowed to trail outside the endoscope. The other end is held with the biopsy forceps, passed through the hole in the foreign body, dropped, the biopsy forceps extracted back through the hole, and then the string picked up to form a closed loop. This technique, although effective, is rarely needed.
Objects with a small hole can be retrieved on occasion by simply passing the closed biopsy forceps through the aperture and opening them.
The entire assembly-foreign body, forceps, and endoscope then withdrawn as a unit.
The use of the intragastric balloon for treatment of morbid obesity is a relatively new concept.
One should remember to deliver the widest diameter of a large foreign body up the esophagus in the transverse or coronal plane because it is very difficult to deliver such a foreign body at the level of the cricopharyngeus muscle with the largest diameter in the anteroposterior position.
One has to always consider maintaining the airway with large foreign bodies and the consequences of dropping the foreign body at the level of the trachea and vocal cords.
Foreign Bodies at the Level of the Pharynx and Cricopharyngeus
These foreign bodies, usually in the form of fish bones or the toy jackstone, require different management.
After sedation, the patient is placed in the supine position, and the endoscopist stands at the head of the stretcher. An open rigid laryngoscope is used, along with a long surgical grasping clamp McGill foreign body forceps.
The patient can always identify the side on which the foreign body is located, and it almost always will be anterior to the epiglottis in the base of the tongue or in the area of the tonsillar pillar.
The fish bone can often be felt initially with a gloved index finger. If removal is
unsuccessful, the patient is placed in the left lateral position and flexible endoscopy is performed.
The jackstone is difficult to remove because of its prongs. After general endotracheal anesthesia is administered, the endoscopist stands at the head of the table and elevates the epiglottis with the laryngoscope.
The jackstone can usually be seen and can be grasped with the Kelly clamp and removed in an everting or obstetrical forceps delivery fashion.
It is difficult to pull it out with a polypectomy snare and flexible endoscope if the sharp prongs are lodged posteriorly.
Management of Cocaine Packet Ingestion
X-ray to locate & count bags
If symptoms of bag rupture :
Pretreat with labetolol or phentolamine
Emergent surgical removal
- If asymptomatic :
Sorbitol or osmotic cathartic
Do followup X-rays to document clearance
Save passed bags for police
Rectal Foreign Bodies
Should get pelvic / abdominal X-rays first
Emergent surgery indicated if any sign of perforation
May require perianal block or general anesthesia for removal
Can insert foley beyond object & inflate balloon to assist removal
After removal do sigmoidoscopy to look for mucosal injury or perforation
Nasal Foreign Bodies
May present in children as :
Extremely bad body odor
Unilateral rhinorrhea
Epistaxis
SinusitisMay require general anesthesia for removal
Sometimes removable with suction, alligator forceps, or inflatable balloon catheter
May need antibiotics post-removal
Ear Canal Foreign Bodies
Insects (cockroaches) are most common
Patients have been misdiagnosed as psychiatric
Can fill ear canal with 2 % lidocaine to cause bug to seize & jump out
May require general anesthesia for removal
May need otic antibiotic drops afterward if canal wall injured
Postprocedural Considerations
Once foreign body extraction has been accomplished, one should always consider a perforation of the esophagus. If the extraction has been difficult, an immediate radiographic contrast study should be done.
In the follow-up period, one should diligently watch for signs and symptoms of perforation, such as fever, tachycardia, shortness of breath, chest pain, abdominal pain, and crepitation in the neck.
The diagnosis is usually made with a chest film that shows mediastinal air.
Postprocedural respiratory problems in infants are always a consideration, and overnight observation is sometimes required.
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