Esophageal Foreign Body

Published on 06/08/2015 by admin

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Last modified 22/04/2025

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 Bones tend to lodge in cervical esophagus, just below level of cricopharyngeus muscle (C6 level)

image Ingested bone fragments: Linear or slightly curved
image Diffuse widening of retropharyngeal soft tissue
• Large food bolus; unchewed meat

image Above stricture, Schatzki ring, or tumor
image Barium-soaked cotton ball, marshmallow; helps identify nonopaque, small FB
• Follow-up esophagram after removal of FB

image Underlying disease, motor function, patency
image Check for injury to esophagus

TOP DIFFERENTIAL DIAGNOSES

• Esophageal carcinoma
• Esophagitis

CLINICAL ISSUES

• Majority occur in children
• High-risk adults include

image Mentally impaired
image Those with esophageal motility or morphologic abnormalities
image Those who habitually hold nails or pins with their lips
• Management depends on type, size, location of FB

image Most FB pass spontaneously
image Disk batteries are toxic and should be removed
• Endoscopic extraction: Flexible fiberoptic

image Successful removal rates as high as 92-98%, with uncommon complications
• Fluoroscopically guided: Balloon-tipped Foley or Fogarty catheter; Dormia-type wire basket
image
(Left) Barium esophagram shows complete obstruction of the esophageal lumen and a filling defect image representing an incompletely chewed piece of meat. Following removal, a Schatzki ring was found.

image
(Right) This 1-year-old child swallowed a watch battery image, which is lodged in the cervical esophagus. Note the smooth outer contour that distinguishes it from the serrated surface of a coin. The coin was removed, but resulted in a persistent stricture of the esophagus.
image
(Left) Esophagram demonstrates the outline of a plastic comb impacted in the distal esophagus and extending into the stomach. On first impression, this might be misinterpreted as an esophageal stent that had been placed across an obstructing esophageal lesion.

image
(Right) Oblique esophagram following endoscopic removal of a foreign body shows extravasation of contrast medium image and free air within the abdomen image. Surgical repair was required.

TERMINOLOGY

Abbreviations

• Esophageal foreign body (FB)

Definitions

• Ingested FB impacted within esophagus

IMAGING

General Features

• Best diagnostic clue

image History of ingestion followed by dysphagia or odynophagia
• Location

image Gastroesophageal junction: Area of indentation by aortic arch or left main bronchus
image Above preexisting stricture, Schatzki ring, or tumor
image Bones tend to lodge in cervical esophagus, just below level of cricopharyngeus muscle (C6 level)
• Size

image Smooth objects measuring < 1-2 cm in diameter usually pass uneventfully
• Morphology

image Radiolucent: Food, plastic, wood, medication, etc.
image Radiopaque: Coin, battery, pin, nail, needle, etc.
image Sharp or dull, pointed or blunt, toxic or nontoxic

Radiographic Findings

• Radiography

image Lateral neck radiograph: Radiopaque FB

– Ingested bone fragments: Linear or slightly curved densities with well-defined margins
– Radiolucent FB: Indirect evidence of mucosal trauma; localized soft tissue emphysema, lump
– Diffuse widening of retropharyngeal soft tissue
image Chest radiograph: Coins and flat objects orient in coronal plane if within esophagus

Fluoroscopic Findings

• Barium swallow: Performed early to determine presence of FB and obstruction

image Animal/fish bone: Easily obscured by barium
• Large food bolus, unchewed meat

image May cause complete esophageal obstruction
image Polypoid filling defect with irregular meniscus
image Barium outlining superior border of food bolus
image With incomplete obstruction, small amount of barium may trickle into distal esophagus, stomach
image May erroneously suggest stricture; esophagus incompletely distended below level of impaction
• Barium-soaked cotton ball/marshmallow helps identify nonopaque, small FB
• Follow-up esophagram after removal of FB

image Underlying disease, motor function, lumen patency, mucosal injury induced by FB or its removal

CT Findings

• May detect faintly opaque bone
• Localized soft tissue emphysema, edema, hematoma, or abscess; may see FB penetrating esophageal wall

Imaging Recommendations

• Protocol advice

image Lateral film of neck, upright position, neck well extended, phonation: More informative than anteroposterior view
image Water-soluble iodinated contrast if perforation suspected; if no leakage seen, repeat with barium

DIFFERENTIAL DIAGNOSIS

Esophageal Carcinoma

• May appear as filling defect in esophageal lumen

Esophagitis

• Candida infection or viral
• May cause fibrinous exudate (pseudotumor)

PATHOLOGY

General Features

• Etiology

image Children: Anything that will fit into mouth
image Adults: Animal/fish bones, or boluses of meat
• Associated abnormalities

image Underlying webs, rings, or strictures (adults)

CLINICAL ISSUES

Presentation

• High-risk adults include

image Mentally impaired
image Those with underlying esophageal motility or morphologic abnormality
image Those who habitually hold nails, needles, etc., with their lips
• Diagnosis: History (by patient or observer)

Demographics

• Epidemiology

image 80% of FB impactions occur in children

Natural History & Prognosis

• Most FB pass spontaneously through gastrointestinal tract without difficulty
• Sharp, pointed, elongated FB: Associated with greater risk of perforation, vascular penetration, fistula
• Successful removal rates as high as 92-98%, with uncommon complications

Treatment

• Management depends on type, size, and location of FB

image Disk batteries (e.g., watch batteries) are toxic and should be removed
• Endoscopic extraction: Flexible fiberoptic
• Fluoroscopically guided: Balloon-tipped Foley or Fogarty catheter, Dormia-type wire basket
• Surgical removal: Rarely indicated for complications
image
Esophagram shows an intramural mass effect in the distal esophagus due to an ingested chicken bone that was imbedded in the wall, causing an inflammatory reaction.

image
Esophagram shows complete obstruction of the mid esophagus with a meniscus of barium outlining a piece of ingested meat, impacted above a stricture in Barrett esophagus.
image
Esophagrams show a hiatal hernia with a peptic stricture image. The foreign body image, a walnut, is impacted above the stricture.
image
Esophagram shows complete obstruction of the esophagus with distal filling defect due to ingested meat. After endoscopic removal of the foreign body, a Schatzki ring was found.

SELECTED REFERENCES

1. Sahn, B, et al. Review of Foreign Body Ingestion and Esophageal Food Impaction Management in Adolescents. J Adolesc Health. 2014. [ePub].

 

Hamilton, JM, et al. Severe injuries from coin cell battery ingestions: 2 case reports. J Pediatr Surg. 2009; 44(3):644–647.

Kelly, SL, et al. Successful management of an aortoesophageal fistula caused by a fish bone—case report and review of literature. J Cardiothorac Surg. 2009; 4:21.

Raboei, EH, et al. Management of button battery stricture in 22-day-old neonate. Eur J Pediatr Surg. 2009; 19(2):130–131.

Arana, A, et al. Management of ingested foreign bodies in childhood and review of the literature. Eur J Pediatr. 2001; 160(8):468–472.

Harned, RK, 2nd., et al. Esophageal foreign bodies: safety and efficacy of Foley catheter extraction of coins. AJR Am J Roentgenol. 1997; 168(2):443–446.

Brady, PG. Esophageal foreign bodies. Gastroenterol Clin North Am. 1991; 20(4):691–701.

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