Esophageal Foreign Body

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

1. See Also
   1. Radiopaque Foreign Body
   2. Button Battery Ingestion
   3. Foreign Body Aspiration
   4. Nasal Foreign Body
   5. Ear Canal Foreign Body
2. Anatomy: Common Esophageal Foreign Body sites
   1. Patient localization of foreign body Sensation typically correlates with the actual foreign body location
   2. Cricopharynx (C6)
      1. Location where cricoid cartilage abuts the esophagus
      2. Most common site in children
   3. Aortic arch (T4)
      1. Where aortic arch contacts and indents the esophagus
   4. Tracheal bifurcation (T6)
   5. Gastroesophageal Junction and lower esophageal sphincter (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. 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
4. Precautions
   1. Symptomatic patients with ingestion require emergent evaluation
   2. Sharp objects regardless of size or location, require Consultation for removal
5. 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
6. 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
7. Risk Factors: High risk foreign bodies
   1. 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
   2. 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
   3. Objects in esophagus >24 hours
      1. Risk of fistula, stricture, or erosion through wall
   4. 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
   5. 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
8. Imaging
   1. 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
   2. Other measures to localize foreign body
      1. Hand-held metal detector (from security) may be used to select best initial XRay location
   3. Other imaging of Radiolucent Foreign Body
      1. CT Abdomen imaging may be needed for sharp radiolucent objects
9. 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)
10. 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
11. 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
12. 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
13. 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 beverage (e.g. sugar soda pop such as coca cola, EZ-Gas)
       1. Increases Gas Pressure in the esophagus which may push a food bolus into the Stomach
       2. Do not use if risk of aspiration
       3. Risk of Esophageal Perforation if obstructive mass
    5. Relax Lower esophageal tone (typically ineffective methods, but may work on lower/distal esophageal foreign bodies)
       1. Glucagon 1 mg IV (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. Diazepam 2-10 mg IV
       3. Nifedipine 5-10 mg SL
       4. Nitroglycerin 0.6 mg SL
    6. 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)
14. 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
15. References
    1. Birnbaumer (2013) Upper Abdominal Disorders, EM Bootcamp, CEME
    2. Claudius and Brown (2017) Crit Dec Emerg Med 31(12): 13-20
    3. Mason and Sacchetti in Herbert (2017) EM:Rap 17(4): 13
    4. Sperandeo and Barata (2021) Crit Dec Emerg Med 35(6): 14-5
    5. Chen (2001) Pediatr Ann 30:736-42 [PubMed]
    6. Uyemura (2005) Am Fam Physician 72:287-92 [PubMed]