Anatomy

The esophagus is a muscular tube 20 to 25 cm in length. There are three anatomic areas of narrowing in which FBs are most commonly entrapped: in the upper esophageal sphincter, which consists of the cricopharyngeus muscle; in the midesophagus at the crossover of the aortic arch; and in the lower esophageal sphincter (LES) (Fig. 39-1). The LES is the narrowest point of the esophagus and the entire GI tract.

Epidemiology

Patients with retained esophageal FBs generally fall into one of the following categories: pediatric patients, psychiatric patients, prisoners, and adults who either are edentulous or have underlying esophageal pathology.

Children account for 75% to 85% of esophageal FBs seen in the ED, with the peak incidence occurring at the age of 18 to 48 months.1–9 The incidence is equal in boys and girls. Inquisitive children frequently place objects in their mouth and unintentionally swallow them. As a result, children most commonly ingest coins, but they also swallow buttons, marbles, beads, screws, and pins.^1,2,4,9–13 Unlike adults, children who have entrapped, accidentally swallowed FBs do not normally have underlying esophageal disorders.¹⁴ However, this is not the case in children with esophageal meat impaction, and these patients will need further evaluation for underlying esophageal disease.¹⁵

Patients with an anatomic abnormality of the esophagus or a motor disturbance are more prone to FB entrapment.12,15,16 Anatomic abnormalities include strictures, webs, rings, diverticula, and malignancies. Motor disturbances include achalasia, scleroderma, and esophageal spasm. Adults who have dentures or underlying esophageal anatomic or motor abnormalities may accidentally ingest food boluses, chicken bones, fish bones, glass, toothpicks, fruit pits, or pills while in the act of eating.¹³

Prisoners and psychiatric patients ingest a wide variety of objects, some of which may be quite unusual: spoons, razor blades, pins, nails, or practically any other object.¹²

Complications

Impacted FBs of the esophagus must be removed or dislodged. The time frame under which this mandate must be carried out varies widely and depends on many circumstances. In general, however, the esophagus does not tolerate FBs well or for prolonged periods because it is prone to pressure, edema, necrosis, infection, and eventually perforation. FBs can transit the esophagus in a matter of seconds or minutes or may adhere to the mucosa. Retained objects may become less symptomatic after time, and the clinician must resist the urge to allow esophageal FBs to “pass by themselves” or “dissolve.” Once FBs become stuck in the mucosa, they may become less symptomatic, but they rarely pass on their own. The one exception may be children with coins, especially those lodged at the LES. Approximately one third of these coins may pass spontaneously within 24 hours, and some authors have advocated an observational approach, although this is more poorly accepted by parents.17–21

A wide array of complications can arise from retained esophageal FBs (Box 39-1), including benign mucosal abrasions, lacerations, esophageal stricture, and necrosis from corrosive agents such as button batteries. Esophageal perforation^21–27 can lead to life-threatening conditions such as retropharyngeal abscess,²⁸ mediastinitis, pericarditis, pericardial tamponade,²⁹ pneumothorax, pneumomediastinum, tracheoesophageal fistula, and vascular injuries, including injuries to the subclavian vein and aorta.^20,30,31 Complications are more common when FBs are entrapped for longer than 24 hours^2,32,33 and when they are sharp.³⁴ An estimated 1500 deaths occur annually as a result of esophageal FBs, primarily from complications of esophageal perforation.⁹

Clinical Findings

Esophageal FB impaction is usually an acute condition, particularly in adults who have a clear history of ingestion. Children also commonly remember an ingestion, but some will have a vague history or symptoms. As many as one third of children with proven esophageal FBs are asymptomatic on initial evaluation20,34–36; therefore, a high index of suspicion is indicated, especially in children who were seen with an object in their mouth that subsequently disappeared. This is particularly true if transient coughing or gagging occurred, even though the actual ingestion was not witnessed. Poor feeding, irritability, fever, stridor, cough, wheezing, and aspiration can all be caused by an underlying esophageal FB in a child, especially a young infant.^15,37–39

Dysphagia is a common initial complaint with esophageal FBs. Drooling is suggestive of high-grade obstruction, and complete inability to handle oral secretions is a sign of total obstruction. Infants with a clandestine esophageal FB can exhibit wheezing or a chronic cough. They may appear to have bronchospasm and may be treated for asthma. Stridor from an FB can mimic epiglottitis.

The esophagus is well innervated proximally, and patients can typically accurately localize FBs in the oropharynx or upper third of the esophagus. However, scratches or abrasions of the esophagus can create a persistent FB sensation. Upper esophageal FBs often cause gagging or vomiting. In rare cases, an upper esophageal FB can impinge on the trachea, especially in children, and mimic infection by inducing wheezing, stridor, or frank respiratory distress. The lower two thirds of the esophagus is not as well innervated, and FBs in this location typically cause vague symptoms of discomfort, fullness, or nonlocalizing pain. Swallowed coins that lodge in the lower part of the esophagus in children may cause no overt symptoms until feeding is attempted.

The location of retained esophageal FBs is related to age (Table 39-1). Children more typically have objects entrapped in the upper part of the esophagus at the level of the cricopharyngeus muscle, whereas adults more commonly have entrapment at the LES.^{18,38,40–42}

Evaluation

The most useful aspect of the evaluation is the history. The time of the ingestion, size and shape of the ingested object, and any current symptoms should be ascertained. Findings on physical examination are frequently normal in patients with esophageal FBs, unless complete obstruction is present. In this case they will be drooling, spitting, and unable to handle oral secretions. Even though a patient may be asymptomatic at initial encounter, transient coughing or gagging should raise the index of suspicion for an esophageal FB. Examination of the oropharynx, neck, respiratory system, cardiac system, and abdomen is essential in the evaluation of potential complications.

After attending to life-threatening conditions such as airway compromise, the goal of ED evaluation is to localize the FB to determine what, if any, interventions need to be undertaken to remove it or assist its transit into the stomach. Once an FB passes into the stomach, it has a greater than 90% likelihood of passing through the entire GI tract without any further problems.³⁴ Even large, irregular, and seemingly dangerous FBs will often transit the entire GI tract with relative ease.

Background

Radiographic imaging of a patient with a suspected esophageal FB is a common practice and is particularly useful for detecting radiopaque FBs. Traditionally, an inability to quickly identify the object by physical examination encouraged the use of plain radiography in an attempt to verify and localize the retained FB. However, the limitations of plain radiography require that other diagnostic approaches be considered as well.

Indications

Interactive, verbal patients can provide valuable information about the ingested object and can typically localize the retained FB with reliable accuracy.⁴³ In such cases the diagnostic workup should be tailored to localization of the symptoms and ingested material. However, nonverbal patients, including preschool children and those who are demented or debilitated, warrant a low threshold for screening radiography in cases with a suspicious history. Examples include a child seen with an object in the mouth that “disappeared” or a patient with symptomatology suggestive of an esophageal FB, such as drooling, gagging, or unexplained respiratory symptoms.

Plain Radiographs

Plain radiographs reliably verify and localize radiopaque FBs such as glass and metal of sufficient size and are indicated as the main method of radiologic evaluation for these objects.

Unfortunately, many ingested FBs are nonopaque, including nonbony food, plastic, wood, and aluminum. Some pull tabs from beer cans may be seen if oriented in the coronal plane. A metal detector has been reported to help localize radiolucent aluminum pull tabs.44,45 Calcification of fish and chicken bones is often incomplete, but cooking alters the structure of bones and makes them radiolucent on plain films. The degree of bony calcification varies with the fish species and between different samples of the same species, thus preventing useful guidelines.^46–49 For these reasons, plain films provide little substantive evidence in the majority of cases of fish or chicken bone dysphagia. They detect only 25% to 55% of endoscopically proven bones and carry a high rate of false-negative and false-positive interpretations.^43,48–53 Because of the lack of diagnostic value for detecting bones, many clinicians do not routinely order plain radiographs and instead initially opt for computed tomography (CT) in cases in which radiographic evaluation is required.^54,55

When used, a complete oropharyngeal radiographic series includes the nasopharynx to the lower cervical vertebra in both lateral and anteroposterior views. Optimum-quality radiographs are mandatory. Patients should be positioned upright with the neck extended and the shoulders held low. Use of a soft tissue technique enhances the discrimination of weak radiopaque FBs. Phonation of “eeeee” during radiography prevents motion artifact from swallowing, distends the hypopharynx, and enhances soft tissue landmarks. As previously mentioned, FBs are most frequently entrapped at one of three locations in the esophagus: the cricopharyngeus muscle (Fig. 39-2), the aortic crossover (Fig. 39-3), and the LES (Fig. 39-4).

Plain radiography of the neck is limited by the radiographic properties of ingested materials and the complicated anatomy of the upper aerodigestive tract. The base of the tongue, palatine and lingual tonsils, vallecula, and piriform recesses are common regions for entrapment of small, sharp objects and deserve careful interpretive attention (Fig. 39-5). Superimposition of the mandible contributes to suboptimal resolution of this region on lateral neck films. Calcified airway cartilage often masquerades as FBs and contributes to false-positive rates as high as 25%.^{43,48,50,52,56–58} Normal ossification of airway cartilage begins in the third decade and progresses with age.⁵⁹ The typical curvilinear contour and well-defined margins of bony FB fragments may help distinguish them from normal laryngeal calcifications. The orientation of bony FBs is variable. The C6 vertebra approximates the level of the cricopharyngeus, a common site of FB impaction. Increased prevertebral soft tissue width, air within the cervical esophagus, and soft tissue emphysema are rare indirect findings that may help identify radiolucent objects.^49,60

Posteroanterior (PA) and lateral views of the chest are used to evaluate the remainder of the esophagus. Both projections are indicated to identify multiple objects and FBs visible in only one plane. Esophageal FBs typically lie in the vertical plane and are differentiated from airway bodies or calcifications by their location posterior to the tracheal air column on lateral radiographs. As a rule, flat objects such as coins perch in the coronal plane in the esophagus and in the sagittal orientation in the trachea. Intraesophageal air and air-fluid levels represent indirect evidence of esophageal obstruction and may aid in the verification of radiopaque FBs. Soft tissue swelling, extraluminal air, and aspiration pneumonitis can occasionally help identify complicated impactions radiographically.

In children, a film from the nasopharynx to the anus is frequently obtained to allow visualization of the entire nasopharynx, throat, and esophagus, as well as the abdomen in case the FB has passed into the stomach or beyond. Radiation exposure can be minimized if adult-sized radiograph cassettes are used. Swallowed coins or other FBs may become lodged in the nasopharynx, usually after gagging or vomiting, and could be missed if this area is not included on the radiograph. In adults, if neck or chest films are negative, abdominal films are sometimes obtained for reassurance of the presence of the FB in the stomach.

Contrast-Enhanced Esophagograms

CT

Non–contrast-enhanced CT of the neck and mediastinum is an easy, rapid, cost-effective, and noninvasive means of detecting or ruling out upper GI FBs (Fig. 39-7)^{48,49,51,54,55} and has garnered support in the clinical setting of suspected FB entrapment.^64–66 CT further excels at localization and characterization of the impacted FB and identification of associated complications such as perforation.^{49,64,67–69}

CT clearly provides improved diagnostic utility for fish bone FBs over plain radiography with or without barium enhancement.48,49,51,54 Use of CT in patients in whom clinical suspicion for a retained FB is high has the potential to reduce the number of unnecessary endoscopies.⁵¹

Conclusions

Diagnostic radiography for esophageal FBs requires individualization of cases. Plain radiographs clearly assist the clinician in several situations: (1) screening of children, adults with dementia, and nonverbal patients with a history or symptoms suspicious for purposeful or inadvertent FB ingestion that can be assumed to be radiopaque and (2) localization of known radiopaque ingestants to clarify the necessity for and means of FB extraction. Conversely, attempts to verify radiolucent FBs, including bones, by plain radiography are often misleading. Contrast-enhanced esophagograms may be used in special situations but have largely been replaced by CT and direct endoscopy. The use of CT to exclude fish bones and other FBs is effective when initial routine plain films are avoided.⁶³

Background

Since the LES is the narrowest portion of the entire GI tract, most FBs that reach the stomach eventually move through the GI tract without further problems. Because a large number of entrapped esophageal FBs are lodged at the LES, especially in adults, several therapeutic maneuvers have been developed to assist transit into the stomach, including pharmacologic relaxation of the LES. In theory, agents that promote smooth muscle relaxation should improve mobility through the LES. Although many clinicians use pharmacologic adjuncts for all esophageal FBs, objects lodged at the LES will probably benefit most from such interventions. Nonspecific pain relief, anxiolysis, vomiting, and spontaneous passage over time may account for the success attributed to many pharmacologic manipulations of esophageal FBs.

Several pharmacologic agents, including diazepam, meperidine, and atropine, have been shown to be unsuccessful in removing or resolving esophageal impaction by FBs.¹³ These agents, alone or in combination, have success rates below 10%, which is no better than observation alone.² Glucagon, nitroglycerin, nifedipine, and gas-forming agents (Table 39-2) are described later and are the most effective pharmacologic agents for treatment of distal esophageal food impaction.

Indications and Contraindications

The indication for pharmacologic relaxation of the LES is the presence of a smooth or blunt FB such as a coin or food bolus. Angulated, abrasive, or sharp FBs should not be treated with pharmacologic modalities but instead should be removed by esophagoscopy. Analgesics and sedatives are routinely indicated if pain is present or the patient is excessively anxious.

Glucagon

Nitroglycerin and Nifedipine Pharmacology

Both sublingual nitroglycerin and nifedipine have been used in a manner similar to glucagon to relieve LES tone and allow the passage of a distal esophageal FB.85–87 Although these two agents have been used less than glucagon for the treatment of esophageal FBs, both are useful for the relief of chest pain associated with esophageal smooth muscle spasm⁶⁴ and may be administered concurrently with glucagon. Manometric and radiographic studies after the administration of nitroglycerin have revealed abolition of the repetitive high-pressure wave contractions characteristic of esophageal spasm. Nifedipine, conversely, significantly reduces LES pressure without changing contraction amplitudes in the body of the esophagus. Thus, nitroglycerin may relieve partial or complete obstruction of the middle or lower part of the esophagus secondary either to intrinsic esophageal disease or to simple FB impaction, and nifedipine, like glucagon, is most likely to succeed when the bolus is lodged at the gastroesophageal junction.

Gas-Forming Agents

Papain

Papain is not recommended for treatment of an esophageal FB. It is a proteolytic enzyme that has been touted for its ability to dissolve meat impactions.⁹¹ Papain is available commercially in a variety of meat tenderizers. This therapy has never been tested in a clinical trial. Although it is harmless when in brief contact with a normal esophagus, if it is left in an obstructed esophagus too long, papain may begin to dissolve the esophageal mucosa underlying an FB. This is likely to occur when the esophageal wall is ischemic secondary to FB impaction and the resultant wall pressure, when esophageal injury results from small bony spicules in the FB, or when an underlying lesion is responsible for the obstruction. The subsequent rupture and leakage of proteolytic enzymes result in a self-perpetuating mediastinitis. Patients with esophageal FBs are at increased risk for aspiration, and pulmonary aspiration of papain results in acute hemorrhagic pulmonary edema. Papain is not currently recommended because of the unacceptable risk for complications and the availability of safer, more effective interventions.

Magill Forceps Removal of Esophageal FBs

Foley Catheter Removal of Esophageal FBs

Esophageal Bougienage

Childhood Coin Ingestion

Coins are among the most commonly ingested objects by preschool-age children. In most cases, the ingestion is quickly realized by a caretaker, and in the majority of cases the coins pass uneventfully.¹¹⁴ Rarely, an esophageal coin can be clandestine for many weeks or months and produce a variety of vague respiratory or GI symptoms.¹¹⁵ In addition, many coin ingestions are not witnessed,³⁹ so maintain a high index of suspicion for children with dysphagia, drooling, or crying, who may have esophageal FBs, most likely coins.

Most coins pass from the esophagus to the stomach with only transient symptoms. The child may be in pain for a few minutes as the coin migrates, but on arrival at the ED, the child is often asymptomatic. Coins that remain in the esophagus are likely to but do not always produce continued symptoms (e.g., drooling, pain, dysphagia, refusal to eat or drink). Rarely, esophageal coins can cause airway distress by external compression of the trachea and simulate an asthmatic attack. Coins below the diaphragm are asymptomatic, and the presence of pain or symptoms requires further evaluation. Coins in the trachea produce immediate and obvious respiratory distress.

The first clinical decision is whether to obtain a radiograph. Although some authors recommend that asymptomatic children not be radiographed, it is important to remember that up to 44% of children with esophageal coins may be asymptomatic. Therefore, it is prudent to obtain plain radiographs in all children with a suggestive history.³⁵ In most cases a single film that includes the pharynx, esophagus, and stomach will suffice to prove or exclude an ingested coin (Fig. 39-14). Another advantage of obtaining radiographs is to rule out multiple FB ingestions, which are not uncommon in children.¹¹⁶ Only a single PA chest film is needed to prove the presence of a coin, but a lateral projection is also suggested. If the flat surface of the coin is seen (see Figs. 39-2 to 39-4), this orientation ensures an esophageal position. If the edge of the coin is seen, this orientation suggests that it has traversed the vocal cords, but a coin in the airway is not subtle and produces obvious distress. It is advisable to also routinely obtain a lateral radiograph to determine whether multiple coins are stacked on top of each other (Fig. 39-15).

Once a coin’s presence has been documented, a decision concerning removal must be made. The approach varies, and there is no agreed standard. Overall, about 25% of coins will pass spontaneously, even if the coin is located proximally. Observation for 8 to 16 hours is a reasonable approach for asymptomatic children if the ingestion has taken place within 24 hours. Coins in the upper and middle third of the esophagus are less likely to pass spontaneously, and some prefer to remove them as soon as the diagnosis is made.¹⁸ Coins in the distal end of the esophagus will pass spontaneously in one third to one half of patients within 24 hours.^18,35,117

The decision regarding management of these patients depends on various factors: clinician comfort and experience with removal techniques, local protocols and procedures developed by the medical staff of each institution, and comfort level of the caretakers with various therapeutic options. Regardless of the approach, a radiograph should be taken just before removal to ensure that spontaneous passage has not occurred.

One suggested protocol (Fig. 39-16) involves radiologically localizing the coin and, if the child is symptomatic, immediately removing the coin. If the patient is asymptomatic, the coin may be removed immediately or the patient may be observed either as an inpatient or at home. If the child is asymptomatic, one common practice is to allow the child to drink a carbonated beverage and eat a small amount of soft food in the ED, wait about 1 to 2 hours, and obtain another radiograph. If sent home with an asymptomatic retained FB, the patient is allowed to eat or drink but should be rechecked in 12 to 24 hours with the knowledge that up to 50% of asymptomatic coin FBs will pass into the stomach spontaneously.^18,35,118

The techniques of Magill forceps removal, esophageal bougienage, and Foley catheter removal have been described earlier. All are options for single coins present in the esophagus for less than 24 to 48 hours. Another option for coins impacted at the LES is pharmacologic relaxation of the sphincter to aid passage into the stomach. The most common method to remove esophageal coins in use today is esophagoscopy.

About half of ingested coins are in the stomach at the time of first investigation, and such patients can be released home safely to allow almost certain spontaneous passage with a normal diet. Spontaneous passage of a coin from the stomach to the anus usually requires 3 to 7 days. There is no need for routine cathartic use. Parents should be advised to check the stool for the coin and return for repeated radiographs if the coin is not found in 1 to 2 weeks. Most coins are passed unknowingly by the patient. Any abdominal discomfort or distention warrants reevaluation in the ED. If a follow-up radiograph demonstrates a persistent coin in the intestines for more than 3 to 4 weeks, an obstructive lesion may be present, and further evaluation is warranted.

Finally, there are theoretical concerns about U.S. pennies, which contain 97.5% zinc. Theoretically, zinc can lead to mucosal ulceration from the caustic nature of zinc¹¹⁹; however, the evidence to date suggests no increased risk from ingested pennies.¹²⁰

Fish or Chicken Bones in the Throat

Patients who complain of a “bone” in their throat usually arrive at the ED within several hours of the onset of symptoms and have generally tried a home remedy, such as swallowing a piece of bread. These patients are typically able to pinpoint the location of their discomfort and have an FB sensation that is exacerbated by swallowing. Patients who are markedly symptomatic, vomiting, or unable to swallow require definitive therapy. Those with minor complaints may be evaluated safely over a period of a few days, often as outpatients.

In cooperative patients, careful examination of the oropharynx by either direct or indirect laryngoscopy, or both, should be done. If the bone is seen, it should be removed with forceps.

If the patient feels pain in the upper part of the throat, special attention is directed to the tonsils because bones often lodge in this area (Fig. 39-17). Strands of saliva may mimic a bone, and small bones may be difficult to see. More commonly, the area of complaint is below the oropharynx. In these patients, indirect laryngoscopy or nasopharyngoscopy should be the first step, once again removing the bone if one is seen. This can also be accomplished with local oropharyngeal anesthesia by topical spray and direct visualization with a laryngoscope blade or commercial videoscope blade and then removal of any bone with forceps.

Most patients with an oropharyngeal FB will not have an easily identified or visualized object on examination. These patients present a diagnostic dilemma for several reasons. Only 17% to 25% of patients complaining of an FB sensation after eating chicken or fish have an endoscopically proven bone present, and only 29% to 50% of endoscopically proven bones are seen on plain films.64,121,122 The symptoms in patients with an FB sensation but no FB on endoscopy are believed to be due to esophageal abrasions.

For these reasons, a two-tiered, but individualized approach to managing these patients is proposed.6,9,34 The patient receives a physical examination and the bone is removed if seen. Carefully examine the tonsils, posterior pharynx, and base of the tongue, which are common places for bones to lodge. If the bone is removed and the symptoms disappear, no further intervention is required and follow-up is instituted as needed. Removal of a bone usually provides immediate and complete relief of symptoms. Persistent symptoms are cause for further evaluation based on individual circumstances.

If no bone is seen on physical examination, the bone may have passed after causing local irritation that persists, or the bone is present and not visualized because of location or consistency. Minor symptoms in the upper part of the throat probably represent persistent local irritation. Minimally symptomatic patients can be discharged and reevaluated in 24 hours. Those with complaints of an FB below the visualized pharynx or with very bothersome persistent symptoms should be evaluated with a CT scan of the neck or possibly the chest if the symptoms are distal. Positive scans are an indication for endoscopic removal of the bone. If the CT scan reveals no FB or postbone complication and the patient is stable, the patient is discharged home with follow-up within 24 hours. Patients with oropharyngeal abrasions will usually be asymptomatic at that time. If still symptomatic on follow-up, endoscopy is advocated.

A small bone lodged in the esophagus for a few days is annoying and painful, but it is not generally an emergency. However, impacted bones can cause serious sequelae, often weeks later, and continued complaints cannot be ignored. Importantly, a lodged bone will not dissolve and rarely passes spontaneously once lodged in the mucosa. Referral and possible endoscopy are necessary if complaints persist for more than 2 to 3 days, even if the examination and CT scan are negative.

Sharp Objects in the Esophagus

Sharp objects cause the majority of complications seen in patients with esophageal FBs. Such objects include tacks, pins, open paper clips, bobby pins, toothpicks, and razor blades (Fig. 39-18). They will not usually pass spontaneously and should be removed. The only appropriate removal technique is under direct visualization with endoscopy. Swallowed dentures or partial plates are a particular hazard in elderly, demented, or mentally challenged patients. Frequently, there is no history of such, and patients have a variety of complaints, such as a sore throat or persistent vomiting (Fig. 39-19). Prisoners and psychotic patients are well known to clandestinely swallow multiple bizarre and sharp objects.

Attempts at radiographic localization are appropriate for metallic or radiopaque FBs. Most objects in the stomach, even those considered problematic, will transit the remainder of the GI tract if less than 6 cm in length or 2 cm in diameter. If larger than this, consult a gastroenterologist. If radiographs show the FB in the esophagus, endoscopic removal is indicated, and attempts to remove such objects in the ED by other methods are not indicated. Complication rates for endoscopic removal of sharp FBs range from 0% to 3%.8,40

Nonradiopaque Objects in the Esophagus

Objects such as toothpicks, aluminum pull tabs from beverage cans, plastic, and food boluses cannot be visualized on plain radiographs and will normally not pass spontaneously. Toothpicks cause a higher percentage of complications than any other type of esophageal FB. As with fish bones, toothpicks often lodge in the tonsils or posterior pharynx and can be seen on direct vision. The imaging modality of choice is CT. Removal is mandatory and time-sensitive for sharp objects, especially toothpicks.

Impacted Food Bolus

A large bolus of food may become impacted in the esophagus, usually at the LES. This occurs most frequently in the elderly, those intoxicated while eating, or those with dentures. Frequently, underlying esophageal pathology is present, such as a stricture or web, even in the young (see Fig. 39-6). The diagnosis is usually straightforward, and patients may be in significant distress, gagging, and unable to swallow. A barium swallow may be used to confirm the diagnosis, but this is rarely necessary. Proceeding directly to endoscopy appears most reasonable. Food boluses may be amenable to pharmacologic relaxation of the LES, but the definitive intervention is endoscopy to both remove the bolus and evaluate the esophagus for pathology. The specific approach, however, is varied and not standard.

The most logical ED approach is initial aggressive relief of symptoms (judicious narcotics, sedatives, antiemetics), followed by attempts at pharmacologic manipulation of the LES. If the bolus passes, esophageal evaluation can be performed at follow-up. Papain is contraindicated. An esophagogram can be performed but seems unnecessary if the diagnosis is obvious (it usually is) and endoscopy is available or planned. A barium swallow should not be used because it can delay definitive treatment. Removal of impacted food is an urgent issue but need not be done immediately on arrival at the ED or in the middle of the night with inadequate resources. Frequently, pain relief and a few hours of relaxation will allow the bolus to slowly break up. Vomiting occasionally dislodges the impaction.

Button Battery Ingestion

Button batteries lodged in the esophagus should be considered an emergency because of the potential for serious morbidity and mortality.22,24,123,124 These batteries range in size from 7 to 25 mm and are radiopaque (Fig. 39-20). Batteries appear as round densities, similar to an impacted coin, but some demonstrate a “double-contour” configuration. It is important to distinguish between a coin and a button battery because button batteries require immediate removal. Batteries consist of two metal plates joined by a plastic seal. Internally, they contain an electrolyte solution (usually concentrated sodium or potassium hydroxide) and a heavy metal such as mercuric oxide, silver oxide, zinc, or lithium.

If ingested, these batteries often lodge in the esophagus. Mechanisms of injury include electrolyte leakage, injury from electrical current, heavy metal toxicity, and pressure necrosis. Of particular concern is the development of corrosive esophagitis or perforation as a result of caustic injury and prolonged mucosal pressure. Though essentially harmless in the stomach and intestines, batteries lodged in the esophagus should be considered an emergency situation because even new batteries are subject to corrosion and leakage, which can result in mucosal necrosis within a few hours of contact with the esophagus.23,24,123,124

Esophageal impaction mandates immediate removal. Options include Magill forceps removal, Foley catheter removal, esophageal bougienage, or esophagoscopy. Esophagoscopy allows direct esophageal evaluation and a more controlled extraction. In addition, the “invasive” nature of batteries may lead to rapid edema, thus making the catheter technique more difficult.

Once in the stomach, button batteries do not require removal. They may be monitored radiographically to demonstrate passage, with little risk for GI injury or heavy metal poisoning, even if the battery opens.125–128

Magnets

Swallowed small magnets from toys and household items have become a serious health hazard in children. Some children with complications from multiple magnet ingestion have underlying conditions such as developmental delay or autism, but older children can inadvertently swallow magnets when using them to imitate a pierced tongue. In 2011 the U.S. Consumer Safety Product Commission issued an alert describing the safety risks from swallowed magnets (http://www.cpsc.gov/cpscpub/prerel/prhtml12/12037.html). Buckyball magnets are small round strong magnets used to make toys of various shapes, and if multiple balls are swallowed, they will become adherent inside the bowel (Fig. 39-21). Multiple magnets, especially if ingested at different times, may attract each other across layers of bowel and lead to pressure necrosis, fistula, volvulus, perforation, infection, or obstruction. A piece of bowel may be pinched by two magnets that are swallowed simultaneously. Hence, suspected magnet ingestion requires urgent evaluation. Radiographs of the neck and abdomen should be obtained to prove magnet ingestion, but radiographs cannot determine whether bowel wall is compressed between the magnets. Identification of magnets that appear to be stacked but slightly separated raises concern for bowel entrapment.

Management of swallowed magnets depends on the timing, location, type, and number of magnets. Because even single magnets have some risk, endoscopic removal should be considered if the magnet is accessible. Magnets in the esophagus or stomach should be promptly removed via endoscopy. Single magnets passed beyond the stomach can generally be managed conservatively initially, but serial outpatient radiographs should be obtained to confirm that the magnet is progressing through the gastrointestinal tract. Theoretically, the child should be kept away from any magnetic or metallic material (such as metallic buttons or buckles in clothing) until the magnet has passed. Ingestion of multiple magnets is associated with a high risk for complications and warrants preemptive removal. Management of patients with multiple magnets beyond the stomach depends on the symptoms and progression. Asymptomatic patients who have swallowed multiple magnets should be admitted and monitored closely with serial radiographs and physical examination every 4 to 6 hours. Alternatively, magnets can be removed by enteroscopy or colonoscopy if accessible. Symptomatic patients or any patient with multiple magnets that do not progress on serial radiographs should undergo surgery for operative removal of the magnets.

The Patient in Distress

Pharyngeal or upper esophageal FBs can cause respiratory distress or respiratory arrest, usually in infants and the elderly. The Heimlich maneuver can be attempted in the prehospital setting or the ED when the situation is appropriate. The first intervention is to ensure an adequate airway, which can be obvious by the situation or may require laryngoscopy or other means of direct visualization. Forceps may be required to remove obstructions under direct vision. Because FBs may mimic multiple other pathologies, the approach to an acutely choking patient is challenging and every situation individual. Upper esophageal FBs can compress the trachea and cause stridor and respiratory compromise; these are indications for immediate removal.

ED Evaluation of FB Sensation in the Throat

FB impactions in the esophagus are usually straightforward, but patients may seek treatment in the ED because of a lump in the throat or difficulty swallowing with no apparent reason or history of FB ingestion. Such complaints require an examination and an investigation based on the clinical encounter and individual circumstances. Complete evaluation of these complaints is beyond the scope of this chapter, but initial modalities available to the clinician to evaluate these complaints are barium swallow, CT, and pharyngoscopy or laryngoscopy. The need for consultation is based on the clinical scenario. Figure 39-22 is a suggested approach to patients with dysphagia without an FB found on evaluation.

If no cause is suspected by the history or examination, globus pharyngeus may be the etiology. This may be associated with anxiety or a panic attack. The sensation of a painless lump in the throat is called globus pharyngeus or globus hystericus. It has many causes other than FBs. Palpate, visualize, or review the anatomic structures in the area: the chin, laryngeal cartilage, cricothyroid cartilage, tracheal rings, sternum, and cricopharyngeal muscle.

FB sensation may be caused by infection, acid reflux, esophageal spasm, esophageal strictures, pill esophagitis, benign and malignant tumors, hiatal hernia, scleroderma, and many other causes. Globus sensations may also persist after an FB has been completely removed because of mucosal injury. Neurologic causes include botulism, myasthenia gravis, cerebrovascular accident, and amyotrophic lateral sclerosis. If the patient otherwise appears well and is able to drink liquids and keep hydrated, referral to a gastroenterologist as an outpatient is standard.

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