Ingested foreign bodies

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7.6 Ingested foreign bodies

Scott Pearson

Essentials

1 Foreign bodies in the stomach or intestines are expected to pass spontaneously about 99% of the time if the child has normal anatomy.
2 Most complications occur when a foreign body is lodged in the oesophagus but a significant number of these will pass spontaneously.
3 Children who ingest a metallic foreign body and attend an ED should have X-ray localisation of the object. For coin ingestions, an alternative is localisation with a hand held metal detector.
4 Removal of disc batteries lodged in the oesophagus should occur urgently as mucosal injury can occur within a few hours.

Introduction

Ingestion of foreign (non-food) material is common in early childhood and often goes undetected whilst the child is playing and may not prompt a physician visit. The exact frequency of reported foreign body ingestions is uncertain. The literature in this field can be divided into three areas: descriptive studies of fairly large numbers of ingestion cases; studies primarily or exclusively about coin ingestion; and studies about disc batteries.1 Common foreign bodies ingested that come to medical attention include coins, bones (fish, chicken), other metallic objects (pins, screws, keys, batteries), and plastic and rubber foreign bodies. In one large series of 1265 reported cases of foreign-body ingestions, age ranged from 7 months to 16 years with a mean of 5.2 years.2 Most foreign bodies pass through the gastrointestinal tract without complications. The emergency physician should be aware of the few instances when emergent or semi-urgent intervention is indicated. Parents need to have clear guidelines regarding the treatment plan for children who are discharged to outpatient follow up.

History

In most instances, a thorough history can be obtained from parents or caregivers before a requirement for intervention. The nature of the ingested item is obviously imperative, as is the time of ingestion. The ingestion may have been witnessed or may have been reported (by an older child) or implied by the child’s environment at the onset of symptomatology. It can be extremely useful if a replica of the foreign body can be easily obtained, especially in determining the type and size of disc batteries. Determining the immediate environment of the child at the time of ingestion can assist in revealing the possibility of any likely co-ingestants.

The symptoms experienced by the child since ingestion help determine the likely site of the foreign body but this has limitations. Many children are asymptomatic at presentation, which usually (but not always) suggests that the foreign body is lying in the stomach or more distal part of the gastrointestinal tract. Symptoms of vomiting, pain or discomfort on swallowing, drooling, irritability and refusal to take food or fluids may occur and suggest oesophageal foreign body. Several reports note that some children will be asymptomatic with foreign bodies lodged in the oesophagus, especially the distal oesophagus.3,4 Even in the context of sharp fishbones, a prospective study found that symptoms were a poor predictor of the presence of fishbones, except for a sharp pricking sensation on swallowing.5 Reports of abdominal pain or blood in the bowel motions should be noted. A history of previous oesophageal or other gastrointestinal disease is significant in determining a management plan and alerting one to potential complications. Significant developmental/intellectual delay has been associated with major morbidity and mortality after foreign body ingestion.2,6 This is often due to the vague symptomatology and delay in presentation.

Examination

For the majority of children the foreign body will have negotiated the oesophagus and general examination will be unremarkable. Vital signs should be recorded but once again are unlikely to be abnormal unless there is delayed presentation and the development of a complication.

Palpation of the abdomen will usually be normal. If the history alerts one to abdominal symptoms, the examiner may find localised tenderness or peritonism suggestive of intestinal perforation. This is rare.

Some children will have symptoms of proximal oesophageal or pharyngeal foreign body. In the older child or adolescent where this is due to bony ingestion (e.g. fish or chicken) there should be a careful examination of the oral cavity and pharynx by either indirect or direct laryngoscopy. Younger children are unlikely to co-operate with these procedures without sedation and an experienced examiner.

Investigations

All children with a history of ingestion of coins or batteries (or other radio-opaque foreign bodies) should have an X-ray performed to localise the foreign body. There is some controversy on this issue in relation to the need for X-rays in children who have ingested coins. Some authors (mainly hospital-based) note that even previously healthy children can be asymptomatic with an oesophageal coin and advocate early removal of oesophageal coins to prevent serious sequelae.3,4 Other authors (notably in primary care) believe that routine X-rays in children having ingested a coin are unnecessary given that asymptomatic coin ingestion is rarely, if ever, associated with complications in otherwise healthy children.7 It has been recognised that those patients presenting to an emergency department (ED) are a selected group and would be expected to have greater severity of symptoms and higher frequency of complications.8 Hence the recommendation that all children with a history of coin ingestion who attend an ED, should have X-ray localisation of the coin performed. An alternative approach for coin ingestions is the use of a handheld metal detector for localisation of the coin. Several authors have confirmed the safety of this approach following a clear algorithm. Handheld metal detectors are not reliable at detecting metal foreign bodies other than coins.9,10 If the ingestion is unwitnessed and the object looks like a coin on anteroposterior X-ray, be aware that a disc battery may have a similar appearance. In this situation, an additional lateral view will reveal an asymmetry, as the two sides of the disc battery have slightly different diameters. On the anteroposterior view one may also see the ‘double ring’ of both circumferences of the battery.

Treatment

Coins

Coins that reach the stomach almost always pass through the gastrointestinal tract without incident and further management is unnecessary unless symptoms arise. Coins that lodge in the oesophagus and have been unrecognised can cause complications such as oesophageal perforation, mediastinitis, acquired tracheo-oesophageal or aorto-oesophageal fistula formation – and death has been reported.11 All children who are symptomatic should have a procedure to remove the coin. Asymptomatic children with proximal or middle-oesophageal coins should also have the coin removed as it is unlikely to pass spontaneously (20–30% in one series).3 If there is a significant delay before the procedure (of more than a few hours) the X-ray should be repeated to ensure that spontaneous passage into the stomach has not occurred or a metal detector should be used to check if the position has clearly changed. Asymptomatic children with distal oesophageal coins can safely be observed as outpatients (depending on social circumstances) for 12–24 hours. The chance of spontaneous passage into the stomach has been reported to occur in 37–60% of patients.3,4

Glucagon has been found to be ineffective when studied prospectively in the management of oesophageal coins. Children should be referred to a specialist with expertise in paediatric endoscopy for endoscopic removal under appropriate sedation or anaesthesia. This may require transfer of the child to another institution, as local resources dictate. Other techniques have been described, such as oesophageal bougienage or Foley catheter extraction, but most emergency physicians will not manage sufficient children with this problem to develop expertise and appropriate safety of the procedure.

Disc batteries

Disc batteries are used for hearing aids, electronic devices and children’s toys and cause tissue destruction due to their alkaline nature when in contact with moist membranes. Two deaths have been reported in the literature in situations of oesophageal batteries in children with delayed presentations.12 Children with a history of possible ingestion of a disc battery should have an urgent X-ray performed. If the battery is lodged in the oesophagus, removal should be performed on an emergent basis because mucosal injury can occur in a few hours. Litovitz and Schmitz studied 2382 cases of battery ingestion over 7 years (97% were disc batteries) which were reported to a national registry.13 There were only two major adverse outcomes, both occurring in children with oesophageal batteries. There were no deaths. There were 16 children with oesophageal disc batteries. In 88.3% the battery passed through the gastrointestinal tract with no symptoms or minor symptoms only. In 8.4% there were unrelated or unknown symptoms. As few as 3.1% of patients suffered moderate symptoms (defined as more pronounced or multiple episodes of nausea, vomiting, fever, bloody stools or emesis or changes in vital signs). Forty-four patients had arrested transit defined as identical non-oesophageal site on successive X-rays 48 hours apart: 17 in stomach; two in small intestine; 16 in the colon; and in nine at unidentified sites. Although more patients had minor or moderate symptoms in this group, none had major adverse effects. Outcome was more severe when there was arrested transit in the stomach. Battery transit time was known for 1366 patients. For the great majority (86.4%) the battery passed through the gastrointestinal tract in 96 hours.

Recommendations for ingested disc batteries are:

• All oesophageal batteries to be removed urgently by endoscopy.
• Asymptomatic children with subdiaphragmatic batteries can be observed at home with appropriate instructions to return if symptoms develop. It would seem reasonable to repeat an X-ray at 4 days and thereafter as required to detect the small group where arrested transit has occurred.
• Symptomatic children with subdiaphragmatic batteries should have surgical consultation to consider surgical or endoscopic removal of the battery, particularly if the battery case has split open or is not progressing along the gastrointestinal tract on sequential X-rays.1

Other metallic foreign bodies

Foreign bodies should be localised by X-ray and removed if lodged in the oesophagus. Other objects, including pins, needles and other sharp objects can be safely observed on an outpatient basis, with intervention occurring only if symptoms develop. In certain situations, where the object is lodged in the stomach, it may be appropriate to repeat an X-ray to ensure passage into the intestine. In many situations repeat X-rays are unnecessary unless symptoms develop. A more cautious approach is advisable when there is abnormal gastrointestinal anatomy.

Non-metallic foreign bodies

Sharp foreign material such as fish or chicken bones will usually impact in the pharynx or oral cavity and are considered elsewhere. X-rays may assist in localisation but many foreign bodies are not radio-opaque. Intervention is dictated by the presence or persistence of symptoms. The vast majority of other objects pass through uneventfully. Plastic bread-bag tags have been associated with small bowel obstruction and perforation. If there are symptoms of lodgement in the oesophagus the foreign body should be removed by gastroscopy, otherwise an observant approach is adequate, with the parents or caregiver receiving clear advice on when to return to the hospital.

Disposition

Most children will be managed in the ED and discharged. Some will be asked to return for further X-ray imaging but many will be advised to return only if symptoms or complications develop. Where admission is required this should be to a facility that is skilled in the endoscopic and surgical management of these children.

Prevention

Together with child-proofing the home to ensure that children are protected from access to potential poisons, this should extend to protection from small items that pre-school-age children can ingest. Great care should be exercised in relation to disc (button) batteries.

Controversies

Methods of removal of oesophageal coins/batteries. There are some advocates of Foley catheter removal or oesophageal bougienage by emergency physicians or surgeons. Most centres utilise endoscopic removal by trained endoscopists.

References

1 Brown L., Dannenberg B. A literature-based approach to the identification and management of paediatric foreign bodies. Pediatr Emerg Med Rep. 2002;7:19.

2 Cheng W., Tam P.K.H. Foreign body ingestion in children: experience with 1265 cases. J Pediatr Surg. 1999;34:1472-1476.

3 Soprano J.V., Fleisher G.R., Mandl K.D. The spontaneous passage of esophageal coins in children. Arch Pediatr Adolesc Med. 1999;153:1073-1076.

4 Connors G.P., Chamberlain J.M., Ochsenschlager D.W. Symptoms and spontaneous passage of esophageal coins. Arch Pediatr Adolesc Med. 1995;149:36-39.

5 Ngan J.H., Fok P.J., Lai E.C., et al. A prospective study on fishbone ingestion. Experience of 358 patients. Ann Surg. 1990;211:459-462.

6 Gilchrist B.F., Valerie E.P., Nguyen M., et al. Pearls and perils in the management of prolonged, peculiar penetrating esophageal foreign bodies in children. J Pediatr Surg. 1977;32:1429-1431.

7 Connors G.P., Chamberlain J.M., Weiner P.R. Paediatric coin ingestion: a home based survey. Am J Emerg Med. 1995;13:638-640.

8 Paul R.I., Christoffel K.K., Binns H.J., et al. Foreign body ingestions in children: risk of complication varies with site of initial health care contact. Paediatrics. 1993;91:121-127.

9 Seikel K., Primm P.A., Elizondo B.J., et al. Handheld metal detector localisation of ingested metallic foreign bodies. Arch Pediatr Adolesc Med. 1999;153:853-857.

10 Lee J.B., Ahmad S., Gale C.P. Detection of coins ingested by children using a handheld metal detector: a systematic review. Emerg Med J. 2005;22:839-844.

11 Byard R.W., Moore L., Bourne A.J. Sudden and unexpected death: a late effect of occult intraesophageal foreign body. Pediatr Pathol. 1990;10:837-841.

12 Blatnik D.S., Toohill R.J., Lehman R.H. Fatal complication from an alkaline battery foreign body in the esophagus. Ann Otol Rhinol Laryngol. 1977;86:611-615.

13 Litovitz T., Schmitz B.F. Ingestion of cylindrical and button batteries: an analysis of 2382 cases. Paediatrics. 1992;89:747-757.

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