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Pediatrics, Foreign Body Ingestion: Differential Diagnoses & Workup

Author: Gregory P Conners, MD, MPH, MBA, Professor of Emergency Medicine and Pediatrics, Departments of Emergency Medicine and Pediatrics, University of Rochester School of Medicine and Dentistry
Contributor Information and Disclosures

Updated: Apr 21, 2009

Differential Diagnoses

Appendicitis, Acute
Pediatrics, Gastroenteritis
Disk Battery Ingestion
Pediatrics, Gastrointestinal Bleeding
Esophagitis
Pediatrics, Intussusception
Foreign Bodies, Trachea
Pediatrics, Pyloric Stenosis
Gastritis and Peptic Ulcer Disease
Pediatrics, Reactive Airway Disease
Gastroenteritis
Pharyngitis
Munchausen Syndrome
Pneumonia, Aspiration
Obstruction, Large Bowel
Pneumothorax, Iatrogenic, Spontaneous and Pneumomediastinum
Obstruction, Small Bowel
Pediatrics, Appendicitis

Other Problems to Be Considered

Foreign body aspiration
Gastrointestinal obstruction
Esophageal stricture
Failure to thrive
Meckel diverticulum
Psychiatric diseases - Autism, bulimia, mental retardation, personality disorders

Workup

Laboratory Studies

  • Children with foreign body ingestion typically do not require laboratory testing.
  • Laboratory studies may be indicated for workup of specific complications, such as potential infection.

Imaging Studies

  • Chest/abdominal radiography

    • Most foreign bodies ingested by children are radiopaque (in contrast to inhalation, in which most are radiolucent).
    • If the swallowed object may be radiopaque, a single frontal radiograph that includes the neck, chest, and entire abdomen is usually sufficient to locate the object.
    • If the object is below the diaphragm, further radiographs are generally unnecessary (in the absence of previous GI disorders, such as repaired pyloric stenosis).
    • If the object is in the esophagus, frontal and lateral chest radiographs are necessary to precisely locate and better identify the object and to be sure that the foreign body is not, in fact, two adherent objects. Lateral views of button (disk) batteries reveal a distinctive 2-step border, as opposed to the smooth borders of most coins. Frontal views may suggest a corresponding ring just inside the outermost ring of the battery.
    • Coins and similarly shaped objects may be localized to the esophagus or the airway by their position on a frontal radiograph.
    • With rare exceptions, coins in the esophagus appear in the coronal orientation (ie, coin seen as a disk on frontal view), while coins in the trachea appear in the sagittal orientation (ie, coin seen from the side on frontal view).
    • If the ingested object is radiolucent, the object's location may be inferred from effects (eg, airway compression) seen on plain radiographs. However, such findings are not reliable. 
    • Radiolucent objects in the esophagus may be better visualized by repeating the study after having the child drink a small amount of dilute contrast. This should not be done if endoscopy is planned.
    • Special care must be taken if the esophagus could possibly be obstructed or perforated.
    • When a foreign body is strongly suspected on clinical grounds, visualization by endoscopy, which has the added advantage of allowing removal of the object, may be the most efficient method of management.
  • CT scan or MRI is rarely indicated but may enhance the detection of foreign bodies or complications (eg, perforations) in special cases.

Other Tests

  • Metal detectors
    • The use of handheld metal detectors to identify the location of ingested metallic objects (especially coins) has proven sensitive and specific. In the case of aluminum (eg, flip top of a soda can), a metal detector may be more sensitive since aluminum is often radiolucent. The operator should have experience with this modality before using it for patient care.
    • Patients with coins localized to the abdomen may be safely observed. However, patients with coins localized in the esophagus probably should have the exact locations confirmed by plain radiography.

Procedures

  • Endoscopy
    • Endoscopy (esophagoscopy) may be diagnostic and therapeutic.
    • Children who require extensive radiologic investigation may be best served by referral to a pediatric gastroenterologist or surgeon for endoscopy, which is safe and highly effective.

More on Pediatrics, Foreign Body Ingestion

Overview: Pediatrics, Foreign Body Ingestion
Differential Diagnoses & Workup: Pediatrics, Foreign Body Ingestion
Treatment & Medication: Pediatrics, Foreign Body Ingestion
Follow-up: Pediatrics, Foreign Body Ingestion
Multimedia: Pediatrics, Foreign Body Ingestion
References
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References

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Further Reading

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Keywords

foreign body ingestion in children, swallowed object, battery ingestion, swallowed magnet, swallowed foreign bodies, coins, pins, screws, button batteries, disk batteries, toy parts, esophageal impaction, aortoenteric fistula, esophageal foreign body, stomach foreign body, lower GI foreign body, mucosal abrasion, intestinal obstruction, esophageal obstruction, retropharyngeal abscess, esophageal perforation

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Contributor Information and Disclosures

Author

Gregory P Conners, MD, MPH, MBA, Professor of Emergency Medicine and Pediatrics, Departments of Emergency Medicine and Pediatrics, University of Rochester School of Medicine and Dentistry
Gregory P Conners, MD, MPH, MBA is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Jerry Balentine, DO, Professor of Emergency Medicine, New York College of Osteopathic Medicine; Executive Vice President, Chief Medical Officer, Attending Physician in Department of Emergency Medicine, St. Barnabas Hospital
Jerry Balentine, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American College of Physician Executives, American Osteopathic Association, and New York Academy of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Wayne Wolfram, MD, MPH, Clinical Associate Professor, Departments of Pediatrics, Children's Hospital and University of Cincinnati
Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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