Esophageal Foreign Body

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

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II. Anatomy: Common Esophageal Foreign Body Sites

  1. Patient localization of foreign body Sensation typically correlates with the actual foreign body location
  2. Cricopharyngeal Muscle (C6)
    1. Location where cricoid cartilage abuts the Esophagus
    2. Most common site in children age <4 years old
  3. Aortic arch (T4)
    1. Where aortic arch contacts and indents the Esophagus
  4. Tracheal bifurcation (T6)
  5. Gastroesophageal Junction, Diaphragmatic Hiatus and lower esophageal sphincter (T10 to T11)
    1. Most common site in adults
  6. Pyloric sphincter (pylorus)
    1. Non-sharp, non-magnetic objects will typically be excreted in the stool if past the pylorus
    2. Objects >5 cm diameter (e.g. coins) are less likely to pass without intervention
    3. Objects <2.5 cm diameter in smallest dimension are likely to pass without intervention
  7. Aberrant Obstruction Sites (congenital vascular abnormalities)
    1. Aberrant right subclavian artery (Bayford-Autenrieth Syndrome)
    2. Double aortic arch (T4)

III. History

  1. Object swallowed
  2. How long ago was the ingestion?
  3. Symptoms (red flags)
    1. Difficulty Swallowing or Dysphagia
    2. Abdominal Pain
    3. Constipation

IV. Precautions

  1. Symptomatic patients with ingestion require emergent evaluation
  2. Sharp objects regardless of size or location, require Consultation for removal

V. Symptoms

  1. Upper or Proximal Esophageal Obstructions (esp. age <16 years old)
    1. Vomiting
    2. Gagging
    3. Choking
    4. Neck or throat pain
  2. Lower or Distal Esophageal Obstruction (esp. age >16 years old)
    1. Foreign body Sensation
    2. Substernal Chest Pain
    3. Progressive Dysphagia
    4. Excessive secretions that are difficult to manage
    5. Anxiety

VI. Exam

  1. Vital Signs including Temperature
  2. Lung Exam
    1. Stridor or Wheezing
    2. Respiratory distress
    3. Decreased breath sounds
  3. Abdominal Exam
    1. Peritoneal signs

VII. Risk Factors: Patients

  1. Young children (toddlers and preschool children)
  2. Psychiatric patients (e.g. Major Depression, Psychosis)
  3. Jail inmates
  4. Developmental Delay
  5. Autism
  6. Neurocognitive disabilities

VIII. Risk Factors: High Risk Foreign Bodies

  1. Objects resulting in airway compromise
    1. Complete esophageal obstruction (pooling of secretions with aspiration risk)
  2. Sharp objects (cause perforation in 35% of cases)
    1. Screws
    2. Straightened paper clips
    3. Sewing needles
    4. Thumb tacks
    5. Razor blades
      1. Common in mental health patients and jail inmates
      2. Razor blades are often taped at the sharp edge prior to ingestion
  3. Multiple magnets
    1. Risk of one magnet attracting another with intervening Small Bowel resulting in pressure necrosis
    2. Pressure necrosis results in bowel perforation and fistula formation
  4. Objects in Esophagus >24 hours
    1. Risk of fistula, stricture, or erosion through wall
  5. Large or Long 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
  6. Button Batteries (disc batteries, especially Lithium batteries)
    1. See Button Battery Ingestion
    2. Appear similar to 2 stacked coins (stack sign or poker chip) on XRay
    3. Risk of voltage burn or corrosive injury
      1. Serious esophageal burns occur within 2 hours (even within 30 min)
      2. High risk of Esophageal Perforation in first 6 hours
      3. Tomaszewski (2016) Household Toxins Lecture, ACEP PEM Conference, attended 3/8/2016
    4. Requires emergent upper endoscopy for removal (typically gastroenterology)
    5. Asymptomatic button batteries below the Esophagus (e.g. Stomach) may be followed with serial XRay
      1. Expect to pass through pylorus within 48 hours and out with stool by 72 hours
  7. Water Beads
    1. Small, gelatinous polymers that absorb large amounts of water and can expand more than 100 fold their original size
    2. Colorful, decorative beads with a similar appearance to candy, and that have been sold as toys
    3. On ingestion, their expansion can lead to Bowel Obstruction and perforation (deaths have occurred)
    4. Mehmetoglu (2018) Emerg Med Int 2018:5910527 +PMID: 29854461 [PubMed]

IX. Imaging

  1. Precautions
    1. Image as soon as possible to allow for opportunity for endoscopic retrieval of high risk objects
    2. Remove all external objects (e.g. jewelry) that may cause confusion on interpretation
  2. XRay: Radiopaque Foreign Body (e.g. coins, some medications, bones)
    1. General
      1. Esophageal foreign bodies orient to the frontal plane (coronal plane)
        1. Coins appear as a circle on anterior-posterior films
      2. Tracheal foreign bodies orient to the median plane (midsagittal plane)
        1. Coins appear as a circle on lateral films
    2. Soft tissue neck PA and lateral (as indicated)
    3. Upright Chest XRay PA and lateral (as indicated)
      1. Foreign body location
      2. Free air under diaphragm
      3. Pneumomediastinum
      4. Pleural Effusion
    4. Abdominal XRay (as indicated)
      1. Foreign body location and orientation
      2. Small Bowel Obstruction
  3. CT Abdomen and Pelvis Indications
    1. Radiolucent Foreign Body (esp. sharp or other dangerous radiolucent objects)
      1. Consider with Oral Contrast (however risk of aspiration, more difficult endoscopic evaluation)
    2. Suspected foreign body related complications (e.g. bowel perforation)
  4. Other measures to localize foreign body
    1. Hand-held metal detector (from security) may be used to select best initial XRay location

X. Management: Endoscopy for Radiopaque Objects

  1. Preferred method in most cases of ingestion
  2. Indications: Radiopaque objects
    1. Button Batteries need removal!
      1. See Button Battery Ingestion
    2. Cylindrical batteries (non-button batteries)
      1. Remove from Esophagus within 24 hours
      2. Remove if not past Stomach within 48 hours
    3. Object (e.g. coin) in proximal two thirds Esophagus
      1. Esophageal Coin Bougienage (Esophageal Bougie) has become first-line management (see below)
      2. Removal by Upper endoscopy
        1. Conners (1995) Pediatr Adolesc Med 149:36-9 [PubMed]
    4. Symptomatic object beyond Esophagus
    5. 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
    6. Object before duodenal sweep
      1. Object without progress in 1 week
      2. Large object (see above for definition of large)
      3. Sharp object (e.g. screw, straightened paper clip)

XI. 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 (consider hospital observation, discuss with general surgery)
  2. Observation protocol (Radiopaque objects)
    1. XRay weekly: small or large items past duodenal sweep
    2. XRay every 3-4 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

XII. Management: Surgical Excision (laparotomy) Indications (Radiopaque)

  1. See Button Battery Ingestion
  2. Radiopaque object below duodenal sweep
    1. Symptomatic object
    2. Large object with no progress in 1 week
    3. Sharp object with no progress in 3 days
    4. Small blunt object with no progress in 1 week

XIII. 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
    4. Consider CT Abdomen (may be needed serially in some cases, esp.if symptomatic)
      1. Do not use Oral Contrast if risk of aspiration such as in high grade obstructive symptoms

XIV. Management: Other methods for inert, blunt foreign body such as coin from Esophagus

  1. Indications (endoscopy is preferred over these methods)
    1. Single coin (or similar flat, blunt object) lodged less than 24 hours (some use 72 hours as cut-off)
    2. No prior foreign body, normal Esophagus, no Dyspnea
  2. Anxiolysis (adjunct to measures below)
    1. Intranasal Versed
    2. Other Anesthetic options
      1. Consider Lorazepam or similar Benzodiazepine in low dose
      2. Consider lower dose Propofol
  3. Esophageal Coin Bougienage (Esophageal Bougie)
    1. Weighted Nasogastric Tube to push coin into Stomach
    2. Preferred option for single coins in Esophagus of children without contraindication
  4. Carbonated or Effervescent beverage (e.g. sugar soda pop such as coca cola, EZ-Gas)
    1. Effective in up to 80% of patients
    2. Increases Gas Pressure in the Esophagus which may push a food bolus into the Stomach
    3. Do not use if risk of aspiration
    4. Risk of Esophageal Perforation if obstructive mass (consider Chest XRay first)
  5. Mechanical Dislodgement Maneuver
    1. Patient jumps up and firmly lands on their heels
    2. Ko (1996) Am J Emerg Med 14(6):604-5 +PMID: 8857816 [PubMed]
  6. Relax Lower esophageal tone (typically ineffective methods, but may work on lower/distal esophageal foreign bodies)
    1. Glucagon 1 mg IV or IM (May repeat in 15-30 minutes)
      1. Most commonly used agents of the esophageal relaxants
      2. Marginally better than Placebo (14% versus 10% success rate)
        1. Bodkin (2016) Am J Emerg Med 34(6): 1049-52 +PMID: 27038694 [PubMed]
      3. No benefit in later studies, and Vomiting is common
        1. Long (2020) Ann Emerg Med 75(2): 299-301 [PubMed]
    2. Other low efficacy agents that are not recommended
      1. Diazepam 2-10 mg IV
      2. Nifedipine 5-10 mg SL
      3. Nitroglycerin 0.6 mg SL
      4. Hyoscine butylbromide or Methscopolamine Bromide
        1. Anticholinergic used in low resource regions
        2. Low efficacy and not recommended if alternatives are available
  7. Mechanical measures (endoscopy is preferred, although Bougienage is now commonly performed in pediatric EDs)
    1. Foley Catheter (requires experienced clinician or consultant)
      1. Most experts recommend intubation for airway protection first (risk of airway obstruction)
      2. Foley Catheter (8-12 french) inserted through nose or mouth
      3. Catheter passed beyond coin (estimate insertion distance externally)
      4. Balloon inflated with radiocontrast (barium)
      5. Reposition patient in slight Trendeleburg, in left lateral decubitus position
      6. Balloon pulled out under xray or fluoroscopy, then sweep the mouth for coin
      7. May require multiple attempts (deflate balloon prior to re-insertion or removal)

XV. Complications

  1. Esophagus
    1. Esophageal Obstruction
    2. Esophageal Laceration or Esophageal Tear
    3. Mass effect with airway compromise
  2. Bowel
    1. Bowel injury or Small Bowel perforation
    2. Small Bowel Obstruction
    3. Bowel wall necrosis

XVI. References

  1. Birnbaumer (2013) Upper Abdominal Disorders, EM Bootcamp, CEME
  2. Claudius and Brown (2017) Crit Dec Emerg Med 31(12): 13-20
  3. Hagen and Pickle (2023) Crit Dec Emerg Med 37(6): 24-9
  4. Mason and Sacchetti in Herbert (2017) EM:Rap 17(4): 13
  5. Sperandeo and Barata (2021) Crit Dec Emerg Med 35(6): 14-5
  6. Chen (2001) Pediatr Ann 30:736-42 [PubMed]
  7. Leopard (2011) Ann R Coll Surg Engl 93(6): 441-4 [PubMed]
  8. Uyemura (2005) Am Fam Physician 72:287-92 [PubMed]

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