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Esophageal Foreign Body
Aka: Esophageal Foreign Body, Foreign Body Ingestion, Ingested Foreign Body, Gastrointestinal Foreign Body, Esophageal Food Impaction
- See Also
- Radiopaque Foreign Body
- Button Battery Ingestion
- Foreign Body Aspiration
- Nasal Foreign Body
- Ear Canal Foreign Body
- Anatomy: Common Esophageal Foreign Body sites
- Patient localization of foreign body Sensation typically correlates with the actual foreign body location
- Cricopharynx (C6)
- Location where cricoid cartilage abuts the esophagus
- Most common site in children
- Aortic arch (T4)
- Where aortic arch contacts and indents the esophagus
- Tracheal bifurcation (T6)
- Gastroesophageal Junction and lower esophageal sphincter (T11)
- Most common site in adults
- Pyloric sphincter (pylorus)
- Non-sharp, non-magnetic objects will typically be excreted in the stool if past the pylorus
- Objects >5 cm diameter (e.g. coins) are less likely to pass without intervention
- History
- Object swallowed
- How long ago was the ingestion
- Symptoms (red flags)
- Difficulty Swallowing or Dysphagia
- Abdominal Pain
- Constipation
- Precautions
- Symptomatic patients with ingestion require emergent evaluation
- Sharp objects regardless of size or location, require Consultation for removal
- Exam
- Vital Signs including Temperature
- Lung Exam
- Stridor or Wheezing
- Respiratory distress
- Decreased breath sounds
- Abdominal Exam
- Peritoneal signs
- Risk Factors: Patients
- Young children (toddlers and preschool children)
- Psychiatric patients (e.g. Major Depression, Psychosis)
- Jail inmates
- Developmental Delay
- Autism
- Neurocognitive disabilities
- Risk Factors: High risk foreign bodies
- Sharp objects (cause perforation in 35% of cases)
- Screws
- Straightened paper clips
- Sewing needles
- Thumb tacks
- Razor blades
- Common in mental health patients and jail inmates
- Razor blades are often taped at the sharp edge prior to ingestion
- Multiple magnets
- Risk of one magnet attracting another with intervening Small Bowel resulting in pressure necrosis
- Pressure necrosis results in bowel perforation and fistula formation
- Objects in esophagus >24 hours
- Risk of fistula, stricture, or erosion through wall
- Large items (risk of Intestinal Obstruction)
- Size >2 to 3 cm in infants under age 1 year
- Size >3 to 5 cm in children over age 1 year
- Button Batteries (disc batteries, especially Lithium batteries)
- See Button Battery Ingestion
- Appear similar to 2 stacked coins (stack sign or poker chip) on XRay
- Risk of voltage burn or corrosive injury
- Serious esophageal burns occur within 2 hours (even within 30 min)
- High risk of Esophageal Perforation in first 6 hours
- Tomaszewski (2016) Household Toxins Lecture, ACEP PEM Conference, attended 3/8/2016
- Requires emergent upper endoscopy for removal (typically gastroenterology)
- Asymptomatic button batteries below the esophagus (e.g. Stomach) may be followed with serial XRay
- Expect to pass through pylorus within 48 hours and out with stool by 72 hours
- Imaging
- Radiopaque Foreign Body (e.g. coins, some medications, bones)
- General
- Esophageal foreign bodies orient to the frontal plane (coronal plane)
- Coins appear as a circle on anterior-posterior films
- Tracheal foreign bodies orient to the median plane (midsagittal plane)
- Coins appear as a circle on lateral films
- Soft tissue neck PA and lateral (as indicated)
- Upright Chest XRay PA and lateral (as indicated)
- Foreign body location
- Free air under diaphragm
- Pneumomediastinum
- Pleural Effusion
- Abdominal XRay (as indicated)
- Foreign body location and orientation
- Small Bowel Obstruction
- Other measures to localize foreign body
- Hand-held metal detector (from security) may be used to select best initial XRay location
- Other imaging of Radiolucent Foreign Body
- CT Abdomen imaging may be needed for sharp radiolucent objects
- Management: Endoscopy for radiopaque objects
- Preferred method in most cases of ingestion
- Indications: Radiopaque objects
- Button Batteries need removal!
- See Button Battery Ingestion
- Cylindrical batteries (non-button batteries)
- Remove from esophagus within 24 hours
- Remove if not past Stomach within 48 hours
- Object (e.g. coin) in proximal two thirds esophagus
- Esophageal Coin Bougienage (Esophageal Bougie) has become first-line management (see below)
- Removal by Upper endoscopy
- Conners (1995) Pediatr Adolesc Med 149:36-9 [PubMed]
- Symptomatic object beyond esophagus
- Object not past the pylorus
- Small blunt object not past pylorus in 3-4 weeks
- Button Battery not past pylorus in 48 hours
- Object before duodenal sweep
- Object without progress in 1 week
- Large object (see above for definition of large)
- Sharp object (e.g. screw, straightened paper clip)
- Management: Observation of Radiopaque Objects
- Indications (Radiopaque Objects)
- Small blunt objects
- Object beyond duodenal sweep that is making progress
- Large object (see definition of large as above)
- Sharp objects (consider hospital observation, discuss with general surgery)
- Observation protocol (Radiopaque objects)
- XRay weekly: small or large items past duodenal sweep
- XRay every 3-4 days: Button or disc batteries
- XRay daily: Sharp objects beyond duodenal sweep
- Monitor stool for passed foreign body
- Misses 2/3 of ingested foreign bodies
- Management: Surgical Excision (laparotomy) Indications (Radiopaque)
- See Button Battery Ingestion
- Radiopaque object below duodenal sweep
- Symptomatic object
- Large object with no progress in 1 week
- Sharp object with no progress in 3 days
- Small blunt object with no progress in 1 week
- Management: Radiolucent objects
- Esophageal radiolucent object suspected
- Upper endoscopy and/or Laryngoscopy: preferred method
- Barium esophagogram: if endoscopy not available
- Consult with gastroenterology first
- Radiolucent object suspected below esophagus
- Observe for symptoms
- Check stool for foreign body
- Consider contrast radiograph if not passed in 2 weeks
- Consider CT Abdomen (may be needed serially in some cases, esp.if symptomatic)
- Do not use Oral Contrast if risk of aspiration such as in high grade obstructive symptoms
- Management: Other methods for inert, blunt foreign body such as coin from esophagus
- Indications (endoscopy is preferred over these methods)
- Single coin (or similar flat, blunt object) lodged less than 24 hours (some use 72 hours as cut-off)
- No prior foreign body, normal esophagus, no Dyspnea
- Anxiolysis (adjunct to measures below)
- Intranasal Versed
- Other Anesthetic options
- Consider Lorazepam or similar Benzodiazepine in low dose
- Consider lower dose Propofol
- Esophageal Coin Bougienage (Esophageal Bougie)
- Weighted Nasogastric Tube to push coin into Stomach
- Preferred option for single coins in esophagus of children without contraindication
- Carbonated beverage (e.g. sugar soda pop such as coca cola, EZ-Gas)
- Increases Gas Pressure in the esophagus which may push a food bolus into the Stomach
- Do not use if risk of aspiration
- Risk of Esophageal Perforation if obstructive mass
- Relax Lower esophageal tone (typically ineffective methods, but may work on lower/distal esophageal foreign bodies)
- Glucagon 1 mg IV (May repeat in 15-30 minutes)
- Most commonly used agents of the esophageal relaxants
- Marginally better than Placebo (14% versus 10% success rate)
- Bodkin (2016) Am J Emerg Med 34(6): 1049-52 +PMID: 27038694 [PubMed]
- No benefit in later studies, and Vomiting is common
- Long (2020) Ann Emerg Med 75(2): 299-301 [PubMed]
- Diazepam 2-10 mg IV
- Nifedipine 5-10 mg SL
- Nitroglycerin 0.6 mg SL
- Mechanical measures (endoscopy is preferred, although Bougienage is now commonly performed in pediatric EDs)
- Foley Catheter (requires experienced clinician or consultant)
- Most experts recommend intubation for airway protection first (risk of airway obstruction)
- Foley Catheter (8-12 french) inserted through nose or mouth
- Catheter passed beyond coin (estimate insertion distance externally)
- Balloon inflated with radiocontrast (barium)
- Reposition patient in slight Trendeleburg, in left lateral decubitus position
- Balloon pulled out under xray or fluoroscopy, then sweep the mouth for coin
- May require multiple attempts (deflate balloon prior to re-insertion or removal)
- Complications
- Esophagus
- Esophageal Obstruction
- Esophageal Laceration or Esophageal Tear
- Mass effect with airway compromise
- Bowel
- Bowel injury or Small Bowel perforation
- Small Bowel Obstruction
- Bowel wall necrosis
- References
- Birnbaumer (2013) Upper Abdominal Disorders, EM Bootcamp, CEME
- Claudius and Brown (2017) Crit Dec Emerg Med 31(12): 13-20
- Mason and Sacchetti in Herbert (2017) EM:Rap 17(4): 13
- Sperandeo and Barata (2021) Crit Dec Emerg Med 35(6): 14-5
- Chen (2001) Pediatr Ann 30:736-42 [PubMed]
- Uyemura (2005) Am Fam Physician 72:287-92 [PubMed]