Esophageal Foreign Body

Aka: Esophageal Foreign Body, Foreign Body Ingestion, Ingested Foreign Body, Gastrointestinal Foreign Body

1. High risk foreign bodies
   1. Sharp objects
   2. Objects in esophagus >24 hours
      1. Risk of fistula, stricture, or Erosion through wall
   3. Large items (risk of Intestinal Obstruction)
      1. Size >2 to 3 cm in infants under age 1 year
      2. Size >3 to 5 cm in children over age 1 year
   4. Button Batteries (disc batteries)
      1. Risk of voltage burn or corrosive injury
2. Management: Endoscopy for radiopaque objects
   1. Preferred method in most cases of ingestion
   2. Indications: Radiopaque objects
      1. Object (e.g. coin) in proximal two thirds esophagus
         1. Conners (1995) Pediatr Adolesc Med 149:36-9
      2. Symptomatic object beyond esophagus
      3. Object not past the pylorus
         1. Small blunt object not past pylorus in 3-4 weeks
         2. Button battery not past pylorus in 48 hours
      4. Object before duodenal sweep
         1. Object without progress in 1 week
         2. Large object (see above for definition of large)
         3. Sharp object
3. Management: Observation of Radiopaque Objects
   1. Indications (Radiopaque Objects)
      1. Small blunt objects
      2. Object beyond duodenal sweep that is making progress
         1. Large object (see definition of large as above)
         2. Sharp objects
   2. Observation protocol (Radiopaque objects)
      1. XRay weekly: small or large items past duodenal sweep
      2. XRay q3-4 days: Button or disc batteries
      3. XRay daily: Sharp objects beyond duodenal sweep
      4. Monitor stool for passed foreign body
         1. Misses 2/3 of ingested foreign bodies
4. Management: Surgical Excision Indications (Radiopaque)
   1. Radiopaque object below duodenal sweep
      1. Large object with no progress in 1 week
      2. Sharp object with no progress in 3 days
      3. Small blunt object with no progress in 1 week
5. Management: Radiolucent objects
   1. Esophageal radiolucent object suspected
      1. Upper endoscopy and/or laryngoscopy: preferred method
      2. Barium esophagogram: if endoscopy not available
         1. Consult with gastroenterology first
   2. Radiolucent object suspected below esophagus
      1. Observe for symptoms
      2. Check stool for foreign body
      3. Consider contrast radiograph if not passed in 2 weeks
6. Management: Other methods for coin removal from esophagus
   1. Indications (endoscopy is preferred over these methods)
      1. Single coin lodged less than 24 hours
      2. No prior foreign body, normal esophagus, no Dyspnea
   2. Bougienage
      1. Weighted Nasogastric Tube to push coin into Stomach
   3. Foley Catheter (requires experienced clinician)
      1. Catheter passed beyond coin
      2. Balloon inflated with radiocontrast
      3. Balloon pulled out under fluoroscopy
   4. Relax esophageal tone (ineffective methods)
      1. Glucagon 1 mg IV (May repeat in 15-30 minutes)
      2. Diazepam 2-10 mg IV
      3. Nifedipine 5-10 mg SL
      4. Nitroglycerin 0.6 mg SL
7. References
   1. Chen (2001) Pediatr Ann 30:736-42
   2. Uyemura (2005) Am Fam Physician 72:287-92