Ingestions

The majority (80%) of foreign body ingestions occur in children, most of whom are between 6 mo and 3 yr of age. Youngsters with developmental delays and those with psychiatric disorders are also at increased risk. Coins and small toy items are the most commonly ingested foreign bodies. Food impactions are less common in children than in adults and usually occur in children with an underlying structural anomaly or motility disorder, such as repair of esophageal atresia or eosinophilic esophagitis. Most esophageal foreign bodies lodge at the level of the cricopharyngeus (upper esophageal sphincter [UES]), the aortic arch, or just superior to the diaphragm at the gastroesophageal junction (lower esophageal sphincter [LES]).

At least 30% of children with esophageal foreign bodies may be totally asymptomatic, so any history of foreign body ingestion should be taken seriously and investigated. An initial bout of choking, gagging, and coughing may be followed by excessive salivation, dysphagia, food refusal, emesis, or pain in the neck, throat, or sternal notch regions. Respiratory symptoms such as stridor, wheezing, cyanosis, or dyspnea may be encountered if the esophageal foreign body impinges on the larynx or membranous posterior tracheal wall. Cervical swelling, erythema, or subcutaneous crepitations suggest perforation of the oropharynx or proximal esophagus.

Evaluation of the child with a history of foreign body ingestion starts with plain anteroposterior (AP) radiographs of the neck, chest, and abdomen, along with lateral views of the neck and chest. The flat surface of a coin in the esophagus is seen on the AP view and the edge on the lateral view (Fig. 319-1). The reverse is true for coins lodged in the trachea; here, the edge is seen anteroposteriorly and the flat side is seen laterally. Disk batteries can look like coins (Fig. 319-2) and have a much higher risk of burns and necrosis (Fig. 319-3). Materials such as plastic, wood, glass, aluminum, and bones may be radiolucent; failure to visualize the object with plain films in a symptomatic patient warrants urgent endoscopy. Although barium contrast studies may be helpful in the occasional asymptomatic patient with negative plain films, their use is to be discouraged because of the potential of aspiration as well as making subsequent visualization and object removal more difficult.

Figure 319-1 Radiographs of a coin in the esophagus. When foreign bodies lodge in the esophagus, the flat surface of the object is seen in the anteroposterior view (A) and the edge is seen in the lateral view (B). The reverse is true for objects in the trachea.

(Courtesy of Beverley Newman, MD.)

Figure 319-2 Disk battery impacted in esophagus. Note the double rim.

(From Wyllie R, Hyams JS, editors: Pediatric gastrointestinal and liver disease, ed 3, Philadelphia, 2006, Saunders.)

Figure 319-3 A, Disk battery in esophagus with necrotic debris at burn sites. B, Typical bilateral esophageal burn after removal of disk battery.

(From Wyllie R, Hyams JS, editors: Pediatric gastrointestinal and liver disease, ed 3, Philadelphia, 2006, Saunders.)

Treatment of esophageal foreign bodies usually merits endoscopic visualization of the object and underlying mucosa and removal of the object; therapeutic endoscopy is most conservatively done with an endotracheal tube protecting the airway. Sharp objects in the esophagus, disk button batteries, or foreign bodies associated with respiratory symptoms mandate urgent removal. Button batteries, in particular, must be expediently removed because they can induce mucosal injury in as little as 1 hr of contact time and involve all esophageal layers within 4 hr (see Fig. 319-3