Pediatric Gastrointestinal Foreign Bodies

Foreign bodies in the air and food passages are the sixth most common cause of accidental death in the United States. In the pediatric population, toddlers younger than 5 years are most commonly affected because of their increased mobility and natural propensity for experimentation. Although children younger than 6 months are rarely able to get a foreign object into the oropharynx, infants can ingest foreign bodies with the assistance of a sibling. Although any child can swallow a foreign body, most incidents result in minor annoyance; however, some can become a challenging problem and have serious life-threatening complications.

Endoscopy is a valuable tool in the armentarium of removing foreign bodies from the upper aerodigestive tract. As such, the history of the development of endoscopic technique dates back to early physicians such as the Arabian Albukasim (936-1013 AD); later, in 1805, Bozzini also developed methods to examine body orifices. Bozzini is credited with creating the first endoscope in 1806 by constructing the lichtleiter, which used concave mirrors to reflect candlelight through an open tube into the esophagus, bladder, or rectum. Maximilian Carl-Friedrich Nitze, another German urologist, produced the first usable cystoscope in 1877 by using series of lenses to increase magnification. He was also the first to place light inside the organ of interest to aid visualization. In 1880, Mikulicz made the first gastroscope using a system similar to Nitze’s cystoscope.

Modern endoscopy was born with the introduction of the fiberoptic endoscope in the late 1950s. Diagnostic and therapeutic endoscopy flourished in the 1960s, with endoscopic interventions first described in the 1970s. Technical refinements of endoscopy in the 1980s, including the introduction of a GI endoscope with a small videocamera and a charge-coupled device (CCD), facilitated storage of data and documentation. ^[1] Advanced endoscopic techniques in the 1990s and further improvements in the 2000s have introduced endoscopic procedures that are less invasive alternatives to traditional operative procedures. ^{[2, 3]}

Foreign bodies that enter the oropharynx can exit through the route they entered, they can be hidden in the mouth by the child, or they can travel down either the trachea or the esophagus. Although children commonly aspirate food items, small children rarely present with impacted food. Foreign bodies that lodge in the airway are discussed in Airway Foreign Body and are less common than GI foreign bodies. Children with a retained or impacted GI foreign body are commonly referred for urgent surgical consultation and should be appropriately treated. ^[4]

Frequency

Although exact figures are unavailable, foreign body ingestion is relatively common among children. In the United States, approximately 1,500 deaths per year are attributed to the ingestion of foreign bodies. In 2006, the American Association of Poison Control documented 90,906 incidents of foreign body ingestion by patients younger than 5 years. ^[5] Many children who swallow foreign bodies are likely to be undiagnosed (because the ingestion of foreign bodies in children is unwitnessed and unreported in about 40% of cases) and experience no untoward consequences. Alternatively, GI foreign bodies that come to the attention of the physician should not be dismissed. ^[6]

Most parents would attest that toddlers put whatever they get their hands on into their mouths. GI obstruction from bezoars are more common in teens with emotional disturbances or mental retardation. See the image below.

A trichobezoar within the stomach of a 14-year-old girl with trichotillomania. This intraoperative photograph demonstrates the bezoar being delivered through a longitudinal gastrotomy made along the body of the stomach.

View Media Gallery

Finally, any child with a congenital or anastomotic narrowing of the GI tract is more susceptible to foreign body impaction. See the image below.

A 4-year-old child presented with an impacted coin in the mid jejunum. A mini laparotomy revealed evidence of a dilated jejunum with decompressed distal bowel. An eroded coin (penny) was found just proximal to an incomplete intestinal web.

View Media Gallery

For the sake of simplicity, objects are characterized based on size, shape, and radiolucency.

Perhaps the most common regularly shaped smooth foreign body in the GI tract is a coin. See the images below.

Impacted esophageal coin in the thoracic inlet in a 2-year-old child. Note the coronal alignment on this posteroanterior (PA) radiograph that is suggestive of an esophageal location.

View Media Gallery

Lateral radiograph of impacted esophageal coin in the thoracic inlet of a 2-year-old child.

View Media Gallery

Other objects include buttons, pen or bottle caps, rubber or plastic materials, marbles, seeds, and disk batteries, which present a special problem. ^{[7, 8]} In general, regularly shaped smooth foreign bodies cause the least difficulty and commonly pass through the GI tract with little concern once they are past the lower esophageal sphincter (LES). Disk batteries are small coin-shaped batteries used in watches, calculators, hearing aids, and other similar products; disk batteries may not cause problems unless they become lodged in the GI tract. When a disk battery is lodged in the esophagus, esophageal damage can occur in a relatively short period, and perforation has occurred as few as 6 hours after ingestion.

Irregularly shaped objects, such as keys, toys, tools, and jewelry, may have smooth or sharp edges. See the image below.

A 3-year-old girl with a buffalo-shaped pendant lodged in the esophagus at the thoracic inlet.

View Media Gallery

Sharp objects, such as pins, needles, bones, screws, razor blades, or nails, are of special concern because of their propensity for causing perforation. See the image below.

A 7-month-old child with broken razor blade (yellow arrow) lodged at the thoracic inlet of the esophagus.

View Media Gallery

Additionally, objects are classified as either radiopaque (eg, metallic objects) or radiolucent (eg, plastic objects, bones).

Rectal foreign bodies are rare in children. They are most commonly inserted, but they can be impacted in the rectum after swallowing. Improperly inserted rectal thermometers or enema tips are the most commonly seen rectal foreign bodies in children. Other impacted rectal foreign bodies should alert the examiner to consider the possibility of sexual abuse or autoeroticism (in the teenage population).

Although body packers (ie, individuals who ingest or insert wrapped packets of drugs such as heroin or cocaine into the GI tract) are often adults, teenagers have also been perpetrators of this crime. These patients require vigilant management and admission to the hospital because rupture of the packets can lead to devastating consequences. ^[9]

An event that is witnessed by a parent, guardian, or sibling offers the best hope of early intervention because up to 35% of pediatric patients with esophageal foreign bodies are asymptomatic. Note the exact nature of the object, if known, and the time of ingestion. If the event is unwitnessed, establish the nature, onset, and progression of symptoms. These include choking, gagging, drooling, coughing, wheezing, dysphagia, dyspnea, dysphonia, fever, hematochezia, or neck, chest, or abdominal pain. Children with chronic esophageal foreign bodies may also present with poor feeding, irritability, fever, or stridor. Note a history of previous GI surgery or functional or anatomical abnormalities of the GI tract. ^[10]

For older children and teenagers, specific questioning regarding bizarre eating habits and psychosocial behavior may help to diagnose a bezoar, a conglomeration of hair (trichobezoar), or a conglomeration of vegetable matter (phytobezoar). Additionally, always remain unbiased with regard to the number of foreign bodies ingested because some children have swallowed more than 1 item.

When a child has ingested a button battery, symptoms may include refusal to take fluids, drooling with black flecks in the saliva, dysphagia, vomiting, and hematemesis. Nevertheless, as many as 35% of patients with a battery impacted in the esophagus are asymptomatic. Rashes following disk battery ingestion have been reported and may be a manifestation of nickel hypersensitivity.

Patients with a rectal foreign body may present with abdominal or rectal pain, pruritus, or bleeding. In the case of suspected or known sexual assault, the appropriate legal authority or child protective services should be notified immediately. ^[11]

In general, foreign bodies in the esophagus should be removed or manipulated into the stomach, as described in Surgical Therapy. Accepted indications for endoscopic or surgical exploration and removal of ingested foreign bodies include the following: ^[12]

• Retention in the same location of esophagus for more than 12 hours

• Signs of airway compromise

• Complete esophageal obstruction

• A diseased esophagus obstructed by food boluses

• Sharp or pointed objects longer than 4 cm in length, 2 cm in diameter, or with no movement at 3 days after ingestion

• Button batteries in the esophagus

• Symptomatic patient at any time

• Objects causing acute abdominal findings (perforation or obstruction)

The vast majority of foreign bodies that pass the level of the lower esophageal sphincter (LES) proceed through the remainder of the gut without complication. Nevertheless, sharp objects may lead to perforation at any level of the GI tract. The corrosive nature of an alkaline battery can also lead to GI erosion or perforation.

Objects that are retained in the esophagus are typically upheld at one of the following 3 normal anatomic esophageal narrowings: the level of the cricopharyngeus muscle (ie, thoracic inlet, area between the clavicles on chest radiography), the level of the aortic arch, and the LES. Other physiologic narrowings or angulations where foreign bodies may become impacted include the pyloris, duodenal sweep, ileocecal valve, and anus. Congenital or acquired narrowings at any point within the GI tract also serve as barriers to free passage of a foreign body.

Relative contraindications to Foley catheter or bougienage removal include children who have swallowed more than a single coin and children who do not have a clear history of symptoms of less than 24 hours' duration. Absolute contraindications to these techniques include children who have a known esophageal abnormality or have undergone previous esophageal surgery and children who have evidence of respiratory distress. Bougienage and Foley catheter removal are not indicated in an unstable patient.