Esophageal Foreign Bodies

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Chapter 39

Esophageal Foreign Bodies

Patients with foreign bodies (FBs) lodged in the esophagus commonly go to the emergency department (ED) for evaluation and treatment. Though most commonly accidental, FBs may sometimes be swallowed purposefully. Patients may have a sensation of a recently passed FB, minor irritation, life-threatening airway obstruction, or other significant complications. Because of the anatomic and physiologic features of the esophagus, FBs in this area of the gastrointestinal (GI) tract present unique clinical issues to the clinician.

General Features

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.1,2,4,913 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 perforation2127 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 hours2,32,33 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 evaluation20,3436; 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.15,3739

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.18,38,4042

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.

Radiology of Esophageal FBs

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.4649 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.43,4853 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).

image

Figure 39-4 Posteroanterior radiograph of an esophageal foreign body (coin) lodged at the level of the lower esophageal sphincter. Coins in this area are most likely to pass and be favorably manipulated by medication (see Table 39-2). Note: The chance of spontaneous passage is about 25% to 60%; chances increase with prolonged observation. (From Waltzman ML, Baskin M, Wypij D, et al. A randomized clinical trial of the management of esophageal coins in children. Pediatrics. 2005;116:614; and Soprano JV, Fleisher GR, Mandl KD. The spontaneous passage of esophageal coins in children. Arch Pediatr Adolesc Med. 1999;153:1073.)

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%.43,48,50,52,5658 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

Background

A contrast-enhanced esophagogram is a test with limited utility in the ED as a routine intervention to evaluate for an esophageal FB. It may be considered when plain radiographs are negative, but esophagography has largely been replaced by CT and endoscopy for evaluation of FBs. This technique uses swallowed contrast material to help identify the presence and location of an impacted radiolucent FB, the degree of obstruction, any underlying anatomic abnormalities, and the presence of perforation. A variation of this technique is to have the patient swallow contrast-soaked cotton pledgets. This technique uses smaller contrast loads and may identify impacted FBs by the impeded progression of the cotton or by tagging sharp irregular objects with radiopaque cotton threads as the bolus passes. Theoretically, this variation might interfere less with follow-up endoscopy because of the attenuated contrast loads. Unfortunately, ingestion of liquid contrast agents yields overall results no better than those of plain film radiography. More importantly, contrast material may interfere with the detection and extraction of FBs at endoscopy (barium) and may increase the risk for aspiration pneumonitis (diatrizoate meglumine and diatrizoate sodium [Gastrografin]).40,61,62 Therefore, routine, serial contrast-enhanced esophagograms after negative plain radiography in patients with known or suspected FBs are unnecessary for diagnostic purposes in most cases. Selective use is reasonable, but CT or endoscopy is the intervention with the best and most cost-effective yield.63

Procedure

Esophagograms couple voluntary ingestion of an enteric contrast agent (Gastrografin or barium) and plain radiography. Immediately after ingestion, erect and horizontal radiographs are performed at right-angle projections (PA and lateral or right and left anterior oblique). In addition to anatomic abnormalities, radiolucent FBs may be identified by contrast delineation or filling defects within the contrast column (Fig. 39-6).

The initial choice of contrast agent is debated and should be individualized according to the threat of aspiration and perforation. Other logistic concerns, listed later, have relegated this test to minimal use in the ED. Water-soluble Gastrografin is indicated first in most cases of suspected perforation because it causes less mediastinal inflammation when extravasated; however, it can give rise to severe chemical pneumonitis if aspirated and is relatively contraindicated in patients with complete esophageal obstruction.12 Patients without evidence of complete esophageal obstruction are instructed to swallow progressively larger aliquots of contrast agent up to approximately 50 mL. If these films are normal, the procedure is repeated with half-strength and then full-strength barium to delineate small esophageal injuries. Note that water-soluble contrast material (Gastrografin) causes more pulmonary reaction than barium does when inadvertently aspirated and should be used in small aliquots if aspiration or complete esophageal obstruction is a concern. Contrast-enhanced esophagograms coupled with fluoroscopy are seldom used for acute esophageal FB impactions, although slowed progression or abnormal peristalsis may suggest a retained FB or an anatomic abnormality. Barium interferes with endoscopy and should not be used when endoscopy is anticipated.

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.6466 CT further excels at localization and characterization of the impacted FB and identification of associated complications such as perforation.49,64,6769

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

Visualization of Esophageal and Pharyngeal FBs

Patients with an FB sensation in their oropharynx typified by a “fish bone” or “chicken bone” sensation need to have some form of visualization of their oropharynx performed as part of the physical examination. The three procedures are direct pharyngoscopy, which is simply direct visualization or examination using a tongue blade with a light source that may be a pen light, wall light, or head light; indirect laryngoscopy, which involves using a handheld mirror reflecting a light to allow visualization of the epiglottis, vallecula, arytenoids, arytenoids folds, and vocal cords—a procedure that requires experience and a cooperative patient; or nasopharyngoscopy, a procedure using a flexible nasopharyngoscope. If an FB is visualized (Fig. 39-8), it should be removed with forceps and the oropharynx carefully reexamined for any injury or additional FB. All three of these procedures are discussed in detail in Chapter 63.

Esophagoscopy

Esophagoscopy is the definitive diagnostic and therapeutic procedure for impacted esophageal FBs.9,41 Although esophagoscopy is not a procedure performed by the emergency clinician, its proper role in the ED evaluation of FBs must be understood. With esophagoscopy, the clinician can document the presence and location of the FB along with any underlying lesion. The clinician can then remove the object and reevaluate the esophagus after removal of the FB to rule out perforation or underlying pathology. Esophagoscopy may be necessary even if a radiologic contrast-enhanced study does not reveal complete obstruction because x-ray studies are not always conclusive.8,70 Esophagoscopy may be necessary to exclude predisposing pathology or resultant perforation, even when symptoms presumed to be due to an esophageal FB have resolved.

Esophagoscopy is the preferred method for removal of sharp or pointed objects such as bones, open safety pins, and razors. In the case of sharp objects prone to causing esophageal perforation, intravenous antibiotics should be administered before the procedure. Endoscopy is the preferred way to remove an impacted meat bolus and to evaluate for possible esophageal pathology at the same time. Esophagoscopy is also indicated for an FB retained for more than 24 to 48 hours, both to remove it and to examine for esophageal wall erosion or perforation. Esophagoscopy is the only appropriate removal technique for multiple or large esophageal FBs. This technique is also indicated for patients with an FB proved to have passed into the stomach and for those who have persistent symptoms possibly caused by esophageal wall injury. Flexible endoscopic procedures can usually be performed without general anesthesia, even in most children.71 The success rate of flexible endoscopy in patients with retained esophageal FBs exceeds 96%.41,72

Traditionally, esophagoscopy is more expensive than other maneuvers such as Foley catheter removal or esophageal bougienage (described later),3,7,73,74 largely because of charges for the surgical suite, but it has a higher success rate than the other two techniques do. ED removal of esophageal FBs in children by experienced endoscopists, while the child is under ketamine sedation administered by the emergency clinician, has been reviewed.75 In selected cases this approach can shorten the interval to completion of the procedure and reduce expense.

Esophageal Pharmacologic Maneuvers

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.

Glucagon

Pharmacology

Glucagon has been a prototype for the spasmolytic agents.76–78 Glucagon theoretically relaxes esophageal smooth muscle and decreases LES resting pressure. One study of normal subjects found that glucagon significantly lowers mean LES resting pressure but causes no significant difference in the mean amplitude of contraction in the distal end of the esophagus.79 Glucagon has no effect on the upper third of the esophagus, a common site of coin impaction in children, where striated muscle is present and some voluntary control is operative. It only minimally affects the middle third of the esophagus. Peristalsis is not affected by glucagon. Results with glucagon have been mixed, and the only randomized study, done in children, showed no better results than those achieved with placebo.80 A nonrandomized study in adults showed that glucagon is about equivalent to placebo, with a 33% success rate, and that the addition of a benzodiazepine increases the success rate slightly.81 Its use, however, is still advocated by some authorities and has little downside. Glucagon may cause vomiting, and this action may be responsible for some of the drug’s success.82

Indications and Contraindications

Glucagon is most useful for smooth FBs or food impactions at the LES that are suspected because of a patient’s complaint of pain or “something stuck” in the lower part of the chest or epigastrium. The clinical diagnosis is usually straightforward, especially if complete esophageal obstruction is present and the patient is unable to tolerate oral secretions. Nevertheless, some clinicians recommend that the FB be localized first with radiographs (with or without contrast enhancement) to establish that the impaction is indeed there. The radiographs can then serve as the baseline study for comparison after administration of glucagon. However, with classic findings on the history and physical examination, most investigators agree that an initial contrast-enhanced study can be omitted. Glucagon is not effective in relieving upper and middle esophageal obstruction, and it is not widely recommended for use in children. In addition, glucagon is not usually effective in patients with fixed fibrotic strictures or rings at the gastroesophageal junction.77 Glucagon is contraindicated if the patient has an insulinoma, pheochromocytoma, Zollinger-Ellison syndrome, hypersensitivity to glucagon, or a sharp esophageal FB.

Administration of Glucagon

Some reports recommend a small test dose to check for hypersensitivity to glucagon. In practice, this is rarely done. The therapeutic dose is 0.25 to 2 mg administered intravenously over a period of 1 to 2 minutes in a seated patient, although one study found that in normal subjects, 1 mg of glucagon provides no significant additive benefit over 0.5 mg.79 The patient is given water orally within 1 minute after the injection of glucagon to stimulate normal esophageal peristalsis; this helps push the food through the relaxed LES into the stomach. Glucagon has a rapid onset and short duration of action: GI smooth muscle relaxes within 45 seconds, and its duration of action is about 25 minutes. If no results are seen within 10 to 20 minutes, a second administration of 0.25 to 2 mg may be tried. Success rates are higher when glucagon is combined with gas-forming agents or even carbonated beverages.83,84 It is recommended that a small volume of some oral fluid be routinely given to enhance the activity of glucagon.