6.03 Swallowed Foreign Body

agk’s Library of Common Simple Emergencies

Presentation

Parents bring in a young child shortly after he has swallowed a coin, safety pin, toy, etc. The child may be asymptomatic or have recurrent or transient symptoms of vomiting, drooling, dysphagia, pain or a foreign body sensation. Disturbed adults may be brought from mental health facilities to the hospital on repeated occasions, at times accumulating a sizeable load of ingested material.

What to do:

• Ask about symptoms and examine the patient, looking for signs of airway obstruction (coughing, wheezing) or bowel obstruction or perforation (vomiting, melena, abdominal pain, abnormal bowel sounds).
• Obtain two plain x ray views of throat to at least the mid abdomen to determine if indeed anything was ingested or if the foreign body has become lodged someplace or produced an obstruction. A barium swallow may occasionally be necessary to locate a nonopaque foreign body in the esophagus.
• A foreign body with sharp edges or a blunt FB lodged in the esophagus for more than a day should be removed endoscopically, because it is likely to cause a perforation, and is still accessible.
• When a coin or other smooth object has been lodged in the upper esophagus for less than 24 hours, it can usually be removed using a simple Foley catheter techique. When available, it should be performed under fluoroscopy, although it can be done as a blind procedure. With the patient mildly sedated (e.g., midazolam (Versed) 0.5mg/kg per rectum, intranasally or po, with half an hour allowed for absorption) position with the head down (Trendelenberg) to minimize aspiration. Restrain uncooperative patients. Have a functioning larygoscope, forceps and airway equipment at hand. Test the balloon of an 8 to 12 French Foley catheter to ensure that it inflates symmetrically. Lubricate the catheter with water-solubile jelly and insert it through the nose into the esophagus to a point distal to the FB. Inflate the balloon with 5ml of air and apply gentle traction on the catheter until the FB reaches the base of the tongue. While encouraging the patient to cough or spit out the FB, further traction will cause involuntary gagging and expectoration. Immediately deflate the balloon and remove the catheter. If a first attempt at removal fails, make a second and third try, then consult an endoscopist. When removal is successful, discharge the patient after a period of observation.
• When a FB has passed into the stomach and there are no symptoms which demand immediate removal, discharge the patient with instructions to return for reevaluation in seven days (or sooner if he develops nausea, vomiting, abdominal pain, rectal pain, or rectal bleeding). Pediatricians have a saying that objects larger than two inches will not pass the second portion of the duodenum in a child under two years old. Having parents sift through stools is often unproductive (one missed stool negates days of hard work). It may be helpful to give a bulk laxative to help decrease the intestinal transit time.

What not to do:

• Do not use ipecac for FB ingestions. Emesis is effective for emptying the stomach of liquid and dissolved drugs, but not for removing FBs from the esophagus or stomach.
• Do not forcefully remove an esophageal FB, especially if it is causing pain. This may lead to injury or perforation.
• Do not automatically assume that an ingested FB should be surgically removed. The vast majority of potentially injurious FBs pass through the alimentary tract without mishap. Operate only when the patient is actually being harmed by the swallowed FB or when there is evidence that it is not moving down the alimentary tract..
• Do not attempt to push an foreign body blindly down the esophagus with a nasogastric tube or other such device. Use an endoscope.
• Do not miss additional coins after removing one from the proximal esopahgus. Take a repeat x ray after removal of one.

Discussion

The narrowest and least distensible strait in the gastrointestinal tract is usually the cricopharyngeus muscle at the level of the thyroid cartilage. Next narrowest is usually the pylorus, followed by the lower esophageal sphincter and the ileocecal valve. Thus, anything which passes the throat will probably pass through the anus as well. In general, foreign bodies below the diaphragm should be left alone. A swallowed foreign body can irritate or perforate the GI tract anywhere, but does not require treatment until complications occur.

A significant portion of children with esophageal foreign bodies are asymptomatic and therefore any child suspected of ingesting a foreign body requires an x ray to document whether or not it is present and if so where it is located. Children with distal esophageal coins may be safely observed up to 24 hours before an invasive removal procedure, since most will spontaneously pass the coins. Even safety pins and razor blades usually pass without incident.

Large button batteries (the size of quarters) have become stuck in the esophagus, eroded through the esophageal wall, and produced a fatal exsanguination; but the smaller variety, and batteries which passed into the gut, have not been such a danger.

References:

• Gracia C, Frey CF, Bodai BI: Diagnosis and management of ingested foreign bodies: a ten-year experience. Ann Emerg Med 1984;13:30-34.
• Binder L, Anderson WA: Pediatric gastrointestinal foreign body ingestions. Ann Emerg Med 1984;13:112-117.
• Schunk JE, Harrison M, Corneli HM et al: Fluoroscopic Foley catheter removal of esophageal foreign bodies in children: experience with 415 episodes. Pediatrics 1994;94:709-714.
• Connors GP, Chamberlain JM, Ochsenschlager DW: Symptoms and spontaneous passage of esophageal coins. Arch Pediatr Adolesc Med 1995;149:36-39.
• Dokler ML, Bradshaw J, Mollitt DL et al: Selective management of pediatric esophageal foreign bodies. Am Surg 1995;61:132-134.
• Ginaldi S: Removal of esophageal foreign bodies using a Foley catheter in adults. Am J Emerg Med 1985;3:64-66.
• Hodge D, Tecklinburg F, Fleisher G: Coin ingestion: does every child need a radiograph? Ann Emerg Med 1985;14:443-446.

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