Introduction
Background
Prompt treatment of an infant or child with a suspected esophageal foreign body is crucial because of the potential for severe complications. Radiographic evaluation of the esophageal foreign body is warranted in both symptomatic and asymptomatic patients. Ingestions that are witnessed are generally managed without problems. Conversely, diagnosis of nonwitnessed ingestions can often be difficult and delayed. This delay in diagnosis can result in severe morbidity and mortality.1,2,3,4,5,6,7,8,9
Nonenhanced axial CT scan demonstrates a retained esophageal foreign body. Its attenuation is similar to that of adjacent bone. Note the adjacent soft-tissue swelling and tracheal narrowing. At esophagoscopy, a metal-coated plastic disk was retrieved.
Anteroposterior chest radiograph depicts a penny at the thoracic inlet of a 13-month-old infant who refused to eat.
For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education article Battery Ingestion.
Related eMedicine topics:
Pediatrics, Foreign Body Ingestion
Foreign Bodies, Gastrointestinal
Gastrointestinal Foreign Bodies
Airway Foreign Body
Foreign Bodies, Trachea
Presentation
Demographics
In the United States, thousands of children per year have a foreign body in the esophagus. Evaluation of the esophageal foreign body remains relevant given the prevalence of the condition. Most patients with an esophageal foreign body are younger than 5 years. However, cases involving teenagers have been reported. Most patients with a chronically retained foreign body are nonverbal. Boys account for a slight majority of patients who ingest foreign bodies.
Mortality and morbidity
High morbidity rates are associated with the chronic retention of esophageal foreign bodies. Complications of retained esophageal foreign bodies are primarily related to perforation of the esophagus, but they may also result in intrinsic esophageal stenosis.
Esophageal diverticula are less common complications of prolonged retention of esophageal foreign bodies such as plastic disks (eg, tiddlywinks, bingo chips) and coins. Both true and false diverticula can result. True diverticula result from esophageal dilatation proximal to a long-term obstruction, whereas false diverticula result from a contained esophageal perforation with a persistent communication to the contained encapsulated area involved with a paraesophageal inflammatory process.
Foreign bodies that migrate outside the esophagus into the mediastinum or soft tissues usually cause respiratory symptoms. Complete foreign body migration outside the esophagus is occult on esophagoscopic images, but it may be depicted on chest radiographs. Also, esophageal foreign body granulomas that cause tracheal stenosis, lobar atelectasis, and bronchoesophageal fistulas are reported as complications. Foreign bodies can become lodged above esophageal strictures, and chronically embedded esophageal foreign bodies can induce stricture formation, although these are less common. Although esophageal-vascular fistulas are rare, one fatality has been reported; this involved an infant who exsanguinated through an aorto-esophageal fistula caused by an open safety pin.
Natural history and presentation
The inherent curiosity of children may lead them to ingest many types of objects other than appropriately sized foodstuffs. Most esophageal foreign bodies are radiopaque; the most common ones are coins. Other frequently ingested items include small metal and plastic toys, buttons, bones, batteries, safety pins, thumbtacks, and wood or glass objects. Fortunately, the vast majority of ingested objects pass through the gastrointestinal tract without problems.10 Some of these foreign bodies, however, become lodged in the esophagus because of normal physiologic narrowings, and others may become lodged at the site of underlying pathology. A foreign body that is retained for a long period can serve as a nidus for a local tissue reaction and result in chronic inflammatory change.
The most common locations of foreign body lodgment are the 3 areas of normal physiologic esophageal narrowing. The first and most common location is the proximal esophagus at the level of the thoracic inlet. The thoracic inlet is the junction between the neck and the thorax. This is delineated by the Sibson fascia, which extends bilaterally from the transverse process of C7 to the medial border of the first rib. Because the posterior attachment is more cranial, the plane of the thoracic inlet is oblique and higher posteriorly than anteriorly. The second location is the mid esophagus at the level of the carina and aortic arch. The third location is the distal esophagus, slightly proximal to the gastroesophageal junction.
Prior conditions such as the ingestion of a caustic substance, tracheoesophageal fistula repair, a vascular ring, or other esophageal pathology also may cause esophageal strictures above which a foreign body may lodge.
Most patients with an esophageal foreign body present several hours after ingestion, usually to a medical facility in the early-to-late evening. A variety of signs and symptoms are observed on initial presentation. Infants and children with a retained foreign body may be asymptomatic. In some instances, the ingested foreign body is incidentally discovered in an asymptomatic patient who undergoes radiographic examination for reasons other than the evaluation of the foreign body. Alternatively, depending on the time the foreign body has been lodged, advanced vague signs and symptoms, including weight loss or an altered level of consciousness, may be present.Common signs and symptoms in patients with a foreign body that has been retained for less than 24 hours tend to be gastrointestinal and include dysphagia, drooling, vomiting, gagging, and/or anorexia. Significant respiratory symptoms, such as coughing, stridor, fever, chest pain, wheezing, chronic upper respiratory tract infections (eg, persistent croup), pneumonia, and hemoptysis, are more common weeks or months after ingestion. Patients may also have acute respiratory distress with choking and cyanosis.
Obtaining a history from the child or caretaker is important in determining the amount of time that the foreign body has been present. A foreign body lodged longer than 24 hours poses a greater risk of esophageal perforation, mediastinal abscess formation, and airway compromise. The removal procedure depends on the features of this history as much as on the findings at initial radiographic examination.
Treatment
A variety of methods can be used to remove an esophageal foreign body. Careful patient selection aids in determining the method of choice. The chosen strategy depends on the type and location of foreign body, the length of time it has been in the esophagus, and the relative degree of experience with the different techniques at a given facility. The success rate for the removal of foreign bodies from the esophagus is 95-100% regardless of the technique used. The cost of the procedures varies depending on the patient setting. All of the methods for esophageal foreign body removal are successful when chosen appropriately. Whichever technique is used, trained professionals with experience in pediatric resuscitation procedures must be available.2,6,8,11,12,13,14,15,16
Current strategies for the removal of retained foreign bodies include endoscopy or surgery; temporization, which allows the foreign body to pass into the stomach on its own; rigid or flexible esophagoscopy; balloon catheter extraction with radiographic guidance; and bougienage or a balloon catheter technique to push the foreign body into the stomach. The last technique is appropriate only when the object is lodged in the distal portion of the esophagus.
Absolute contraindications to fluoroscopic balloon catheter removal, esophageal bougienage, and temporization include chest radiographic findings of esophageal edema with airway compromise, esophageal perforation, and pneumomediastinum.
Endoscopy or surgery
In witnessed ingestions in asymptomatic patients, diagnosis and treatment are usually straightforward because foreign bodies in the mid or upper esophagus have little prospect of passing spontaneously, and instruments should be used immediately. Sharp objects and irregular or unknown foreign bodies always should be removed promptly with endoscopy or surgery. A battery lodged in the esophagus should be removed immediately, whereas a battery in the stomach can be observed initially. Repeat radiography should be performed 24 hours after presentation, and the battery should be removed if it remains in the stomach. Serial follow-up images should be obtained every 3 days until passage is verified.
Temporization
Temporization is an option if a child is examined within 24 hours after ingestion and if a single smooth object is depicted in the distal aspect of the esophagus on the chest radiograph. Temporization may be performed in an inpatient setting or outpatient setting if the child is tolerating the foreign body. Repeat radiography, performed 24 hours after ingestion, is recommended. The caretaker should look for the object in the patient's stool and must be instructed to notify a physician if the child has abdominal pain. If the object is still retained in the distal esophagus, it can be removed with an alternative method.
Rigid or flexible esophagoscopy
Most often, esophageal foreign bodies are retrieved with rigid esophagoscopy. Some advantages include a high success rate, direct visualization of the foreign body in the esophagus, the variety of objects that can be extracted, and direct visualization of the esophagus after removal of the object. The airway is protected because the procedure is performed with general anesthesia. Some disadvantages are the risks of general anesthesia and the higher cost compared with that of other methods. Complications are generally related to anesthesia, injury to the esophageal mucosa, bleeding, and perforation. Flexible esophagoscopy is performed with a child under sedation and without intubation. It is primarily limited to retrieval of objects from the mid esophagus to the duodenum.
Fluoroscopic balloon catheter extraction
Fluoroscopic balloon catheter extraction is another common technique. Advantages include its avoidance of the risk with general anesthesia, low cost, and time efficiency. Disadvantages include lack of direct visualization of the esophagus and lack of direct protection of the airway. Known abnormalities of the esophagus, such as repaired esophageal atresia, peptic stricture, a vascular ring, or esophagitis, are relative contraindications to balloon catheter removal. Under these conditions, only an experienced operator should perform the procedure.
Fluoroscopic balloon catheter extraction is performed in the radiology suite. An infant may be strapped to a board, whereas an older child rarely requires immobilization. Under fluoroscopic guidance, a 12F or 14F Foley catheter is inserted orally or nasally just beyond the radiopaque foreign body and inflated to the width of the esophagus with a water-soluble contrast material. The patient is placed in the prone-oblique steep Trendelenburg position. The catheter is withdrawn with gentle and steady traction as the balloon is used to pull the opaque foreign body ahead of it. The object is expectorated or removed from the mouth with the aid of forceps. Contrast-enhanced esophagography is indicated if examination is difficult or if blood is present on the catheter. In some cases, the balloon catheter technique is used to push the foreign body into the stomach, where it can be followed through the gastrointestinal tract.
Complications of the balloon catheter technique include epistaxis, vomiting, and mucosal injury or perforation. The most serious complication of balloon catheter removal is transient airway compromise caused by displacement of the foreign body from the esophagus into the airway. The reported complication rates with this technique vary; however, a potential risk does exist and must be avoided when this treatment method is used.
Bougienage
Esophageal bougienage with a Foley catheter balloon or bougienage dilator is a less frequently used method, but it may be a feasible option in patients whose ingestion was witnessed and the object has been lodged for less than 24 hours, in those with no history of previous esophageal disease or surgery, and in those without respiratory compromise at presentation.2,6
Preferred Examination
The radiographic evaluation begins with the acquisition of anteroposterior and lateral chest, lateral neck, and supine abdominal radiographs to complete the examination from the nasopharynx to the rectum.
If a child is referred from an outside institution, a repeat chest radiograph can be obtained to reconfirm the presence of the foreign body in the esophagus or confirm its passage beyond the esophagus, obviating a retrieval procedure.
If the presence of a nonradiopaque object is suspected after the initial series of radiographs is obtained, contrast-enhanced esophagography is indicated to rule out a radiolucent foreign body. Further evaluation with cross-sectional imaging may be required to determine the presence and extent of mediastinitis versus mediastinal abscess formation.4,17
Limitations of Techniques
The major limitation of the initial plain radiographic evaluation is the potential failure to visualize the nonradiopaque foreign body. Small esophageal foreign bodies may also be difficult to visualize on plain radiographs alone. Additional evaluation is required when the suspected foreign body is not radiopaque or when the presence of a retained object is highly suspected. The initial radiographic evaluation also can cause underestimation of the extent or degree of involvement, such as the amount of edema with foreign bodies that are retained for long periods.
Differential Diagnoses
Airway Foreign Body
Asthma
Atelectasis, Lobar
Child Abuse
Croup
Trachea, Stenosis
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References
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Further Reading
Related eMedicine topics:
Pediatrics, Foreign Body Ingestion
Foreign Bodies, Gastrointestinal
Gastrointestinal Foreign Bodies
Airway Foreign Body
Foreign Bodies, Trachea
Guidelines:
Modifications in Endoscopic Practice for Pediatric Patients
Clinical trial:
Thoracic Computed Tomography (CT) Scan for Diagnosis of Aspirated Foreign Bodies.
Keywords
esophageal foreign body, foreign body of the esophagus, foreign body, foreign body stricture, foreign body ingestion, retained foreign body, esophagogram, esophagraphy
