Pediatric Gastrointestinal Foreign Bodies 

Updated: Oct 20, 2017
Author: John A Sandoval, MD; Chief Editor: Carmen Cuffari, MD 

Overview

Background

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.

History of the Procedure

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]

Problem

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]

Epidemiology

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]

Etiology

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 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.

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 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.

Pathophysiology

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

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

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

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]

Presentation

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]

Indications

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)

Relevant Anatomy

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.

Contraindications

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.

 

Workup

Laboratory Studies

No laboratory studies are usually necessary for diagnostic or treatment purposes; however, blood and urine mercury levels are reasonable adjuncts to the workup in the case of a fragmented rectal thermometer.

Imaging Studies

Plain Radiography

Radiography is mandated for children with suspected GI foreign body ingestion.[14]  This assists in locating radiopaque foreign bodies in the hypopharynx and esophagus. In small children, a mouth-to-anus film (babygram) can be obtained. In older children, anteroposterior (AP) and lateral chest radiographs that include the neck help to locate radiopaque foreign bodies in the hypopharynx and esophagus.

Coins are usually observed in a coronal alignment on AP films. See the image below.

Impacted esophageal coin in the thoracic inlet in 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.

If the foreign body is in the trachea, they typically lie in a sagittal orientation. Disk batteries appear as a circular double density on radiography, representing the cell's cathode and anode.

Flat Plate Radiography of the Abdomen/Pelvis

This may be helpful to assess whether the object has slipped into the stomach in an older child or teenager.

A flat plate of the pelvis may be helpful when a rectal foreign body is suspected.

Barium Swallow or Upper GI Contrast Study

Contrast studies are helpful if the foreign body in question is radiolucent.

Barium is contraindicated in cases in which esophageal perforation is suspected.

Gastrografin may be used as the contrast agent if a study is necessary.

CT Scanning

CT scanning of the neck, chest, abdomen, and pelvis is highly reliable in localizing foreign bodies yet is necessary only in difficult or complicated cases.[15]

Other Tests

Although the use of metal detectors for location of ingested metallic objects has proven efficacious, this technique is not commonly used in clinical practice.

Diagnostic Procedures

No diagnostic procedures outside of the radiology suite are required.

 

Treatment

Medical Therapy

Foreign bodies in the esophagus that cause symptoms should be removed as is described in Surgical Therapy.

Parents of children who have swallowed a coin that has passed the gastroesophageal junction should be assured that the foreign body will probably pass through the GI tract unimpeded and without consequence. Other objects that are likely to pass without incident include small toys, buttons, and marbles. The results of one study concluded that the initial location of ingested foreign bodies is the main determining factor for spontaneous passage. When located below the esophagus, most ingested foreign bodies can be spontaneously passed without complication.[16] These patients can be sent home with instructions to return if abdominal pain, vomiting, or bloody stools occur. One exception to this general statement is in the case of toy magnet ingestion.[17, 18] Bowel perforation as a result of the attraction of 2 or more ingested magnets across loops if intestine has resulted in a more aggressive intervention via either endoscopy or surgery exploration.[19]

The transit time for an asymptomatic radiopaque foreign body varies and can normally take hours to weeks. Although rarely used from a clinical standpoint, serial weekly radiography may be used to monitor the transitory progress of the foreign body.[20] Some surgeons, after finding the foreign object in a fixed radiographic, note the location and use this as an indication to proceed with operative removal if the object has not moved in more than one week. Screening of the stool for foreign bodies is largely impractical and unnecessary in most cases.

Alkaline disk batteries or objects with sharp edges or points mandate more vigilant management. Batteries lodged in the esophagus should be immediately removed because of the propensity for erosion and perforation. Batteries that have passed the lower esophageal sphincter (LES) should be monitored with serial radiographs taken at 12-hour intervals. If no progress in transit occurs over 24 hours, the battery should be removed surgically. Their passage may be aided with cathartics, GI lavage, or enemas.[21]

Objects with sharp edges or points present a special problem because of the possibility for erosion or perforation. These include pins, needles, tacks, razor blades, pieces of glass, or open safety pins. Children who have swallowed such objects should be vigilantly observed. Esophageal impaction demands surgical removal; however, many of these objects also pass through the GI tract without incident once they are past the gastroesophageal junction. Obtain a daily radiograph (for radiopaque objects) and monitor closely for signs of peritonitis or GI bleeding. In these cases, stools are examined for the foreign body in question. GI hemorrhage or signs of peritonitis mandate surgical exploration and removal of the object.

Although smooth muscle relaxation agents (ie, glucagon, benzodiazepines) have been used in select circumstances in adults, these measures are generally unsuccessful in children; therefore, they are not recommended. The use of meat tenderizer (papain) to digest meat impacted in the esophagus is not recommended because the practice can result in severe esophageal injury. Patients with foreign bodies in the stomach should not be administered syrup of ipecac. Cases have been reported of the foreign body becoming lodged in the esophagus after ipecac administration.

Body packers are at risk of death if the packets of the illicit substance rupture. Such patients should be hospitalized and whole bowel irrigation (ie, Go-Lytley) considered. Consultation with a specialist from a poison control center is recommended.

Surgical Therapy

Because the diagnosis, decision to intervene, and management may be accompanied with difficulties in the treatment of foreign body ingestion, various methods have been described for removal of foreign bodies from the esophagus.[22]

Historically, the initial method of management of esophageal foreign bodies was extraction through the rigid esophagoscope. In 1966 Bigler reported on a new technique, using a Foley catheter; in the 1970s and 1980s, the flexible fiberoptic instrument became an option.[23] The Foley catheter has been used for extraction of large radiopaque foreign bodies but is of no use in most instances. Currently, flexible endoscopy and rigid endoscopy remain the two universally applicable methods.

The success rate with the use of rigid instrument is 94-100%. The estimated incidence of esophageal perforation is 0.34%, with a 0.05% mortality rate. The success rate with the flexible esophagoscopy is 76-98.5%, and the morbidity (perforation) rate 0-0.5%.[5] Although these success and morbidity rates are similar, the flexible endoscope is newer and thus more attractive, particularly to those physicians trained in its use, but with no training or experience in the rigid esophagoscopy. Nevertheless, some strongly advocate the use of the rigid endoscope as the criterion standard for extracting foreign bodies from the esophagus.[24]

Flexible Endoscopy

Endoscopic removal of esophageal foreign bodies is the usual treatment in many pediatric centers. As its safety and effectiveness are well demonstrated, it is more costly, requires the presence of a skilled pediatric endoscopist, necessitates sedation or general anesthesia, and may require the subsequent observation or hospitalization.

Foley catheter removal

Only experienced personnel should perform this procedure. For coins impacted in the esophagus above the LES, this technique has been shown to be safe and efficacious in patients without evidence of airway compromise or known preexisting anatomic abnormality.[25]

No postprocedure study is necessary. Parents are instructed to begin feeding with a clear liquid diet and advance as tolerated. No follow-up is necessary.

Esophageal Bougienage

Only experienced personnel should perform this procedure. A coin that is stuck in the esophagus can be pushed into the stomach with a bougie. Although this technique is a well-established for dislodging an esophageal coin into the stomach, this approach is not universally accepted. Nevertheless, bougienage is equally safe and is more efficient and cost-effective than endoscopy in properly selected patients. Children selected for this technique must have swallowed a single coin, have a clear history of symptoms of less than 24 hours' duration, have no previous esophageal abnormalities or previous esophageal surgery, and have no evidence of respiratory distress.

Laparotomy and Gastrotomy

GI foreign bodies may require laparotomy for definitive removal in select cases. Bezoars often require surgical removal, and, because most are in the stomach, this can be accomplished through a gastrotomy.[26] See the image below.

A trichobezoar within the stomach of a 14-year-old 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.

For rectal foreign bodies, objects that get stuck, perforate, bleed, or are proximal to the rectosigmoid junction (because of difficulty visualizing with proctosigmoidoscopy) usually necessitate surgical removal via laparotomy. Low-lying rectal foreign bodies are usually palpable with digital examination and are candidates for removal under conscious sedation, although mucosal edema and muscular spasms can hinder such an attempt if the foreign body has been in place for a long time.

Preoperative Details

The patient should be kept on nothing by mouth (NPO) status and kept well hydrated via intravenous dextrose-containing solution prior to proceeding to the operating room. In the case of an esophageal foreign body, a radiograph should be immediately obtained prior to endoscopic removal to confirm that the object has not migrated into the stomach. Additionally, do not wait for sufficient NPO interval for button batteries.

Intraoperative Details

Flexible Endoscopy

Occasionally, a retained gastric foreign body that fails to pass through the gastric outlet (pylorus) after a prolonged period of observation can be removed with flexible endoscopic techniques. Again, experienced personnel, such as a pediatric surgeon or gastroenterologist, should perform flexible endoscopy.

Esophagoscopy

Experienced personnel, such as a pediatric surgeon or gastroenterologist, should perform endoscopy.

Under general endotracheal anesthesia, the patient must first be properly positioned to allow for safe esophageal intubation. The head is extended on the neck.

Use a rigid telescopic endoscope that is connected to a fiberoptic light source and rod-lens telescope. This device accepts a grasping forceps within the lumen to allow for foreign body removal. Although a rigid endoscope is preferable, a flexible endoscope can also be used. Again, one should have ample experience with these techniques prior to unsupervised performance.

The operator manipulates the scope over the base of the tongue where the entrance to the cervical esophagus lies posterior to the vocal cords. Lifting the larynx gently forward often obviates this opening and allows for easier introduction of the scope into the esophagus. The scope is advanced under direct vision, and, once encountered, the foreign body is grasped with a forceps and withdrawn under direct vision.

In cases in which the foreign body is lodged in a direction that precludes retrograde removal through the esophagus (eg, an open safety pin that is oriented with the sharp end superiorly), the object may be carefully advanced into the stomach then turned around and removed or managed expectantly.

Batteries lodged in the esophagus should be removed immediately with esophagoscopy because of the risk for perforation and mediastinitis.

When an object is difficult to grasp with the forceps (eg, a marble, round toy), a Fogarty catheter can be advanced through the scope past the object and inflated. The Fogarty then can be pulled taught between the object and the endoscope, and the endoscope withdrawn to retrieve the foreign body.

One should always be ready to perform rigid bronchoscopy if erosion into the airway is suspected or if the location of the foreign body was mistakenly misidentified by preoperative radiographic evaluation.

Foley Catheter Removal

With a McGill forceps, pediatric laryngoscope, and resuscitation equipment at the bedside, the patient is immobilized; multiple bed sheets or a papoose is effective. The patient is positioned supine, and a Foley catheter is introduced via the intranasal or intraoral route. Under fluoroscopic guidance, the uninflated catheter tip is advanced distal to the object. The patient is then positioned in the oblique prone position, and the table is placed to a steep Trendelenburg position. The catheter is then inflated with dilute contrast material and gently withdrawn. When the coin reaches the oropharynx, the child can spit the coin out or the coin can be removed with a finger sweep of the oropharynx. A second look with fluoroscopy is taken to ensure that a second (or third) foreign body is not present.

Esophageal Bougienage

A blunt-tipped weighted bougie dilator is lubricated and passed into the stomach with a single pass, and a postprocedure upright chest radiograph is obtained. Confirmation of the coin in the stomach verifies success of the procedure. Failure to tolerate the procedure or failure to dislodge the coin mandates operative esophagoscopy and coin removal. Moreover, although endoscopic removal of foreign bodies offers advantages over simple bougienage treatment, this technique may provide a valuable intervention particularly when endoscopy is not readily available.[27]

Laparotomy

Under general anesthesia, most GI foreign bodies can be removed through a small enterotomy once the location of the object is identified. The most common areas for foreign body impaction in the GI tract include the pylorus, the second portion of the duodenum, the ligament of Treitz, the ileocecal valve, or a congenital narrowing.

A small enterotomy should be placed in the bowel or stomach either proximal or distal to the object, depending on its orientation. Once the object is removed, the enterostomy is closed in 2 layers and the laparotomy is closed in the standard fashion.

Laparoscopy

Under general anesthesia, laparoscopy can be used in select circumstances to remove GI foreign bodies. Again, once the foreign body is located, an enterotomy is created in an appropriate location and the foreign body removed. This allows for a smaller abdominal wound, but it may require lengthier operating room time, depending on the laparoscopic skill of the surgeon and the location of the object.

Proctosigmoidoscopy

Rectal foreign body removal in a child is accomplished best under conscious sedation or, preferably, general anesthesia. Under direct visualization with an anoscope or proctoscope, the object is grasped with forceps. In the case of broken thermometers, all mercury pellets should be removed when feasible. After removal, a repeat examination is indicated to evaluate for rectal injuries. In high-lying rectal foreign bodies, a manual transabdominal attempt to manipulate the foreign body into a low-lying position can be made. In rare cases, laparotomy is necessary to remove a high-lying rectal foreign body.

Postoperative Details

Following successful endoscopy, patients are admitted, observed, started on clear liquids as early as possible, and discharged when able to tolerate oral intake. Following rigid esophagoscopy, obtaining a postoperative chest radiograph to evaluate the mediastinum is a reasonable practice to assure that the procedure is without complication and no evidence of a retained (missed) additional foreign body is found. For those who require laparotomy or laparoscopy for foreign body removal, oral intake is advanced with the return of bowel function, and the patient is discharged when able to tolerate oral intake without difficulty. Patients who have had a rectal foreign body removed via an uncomplicated proctosigmoidoscopy are discharged after recovery.

Follow-up

Follow-up is not routinely necessary following esophagoscopy. Seeing patients following laparotomy or laparoscopy within 14 days following discharge is preferable.

Complications

A foreign body lodged in the GI tract may cause local inflammation that leads to pain, bleeding, fibrosis, and obstruction or may erode outside the GI tract. Migration from the esophagus can lead to mediastinitis but may evolve to aberrant communication to the upper respiratory tract (eg, acquired tracheoesophageal fistula) or great vessels (eg, aortoenteric fistulas). Migration from the lower GI tract may cause peritonitis.

The theoretical threat of heavy metal poisoning in the case of battery ingestion or from mercury with a broken rectal thermometer has not been borne out by clinical experience. The most common complications of rectal foreign bodies are rectal laceration and perforation.

Lastly, complications of the procedures required to remove a foreign body may lead to morbidity or mortality from the procedure itself or the necessary sedation or anesthesia. Nevertheless, mortality is exceedingly rare and occurs in less than 0.5% of infants who seek medical attention for a GI foreign body.

Outcome and Prognosis

After an esophageal foreign body is removed, children with uncomplicated courses need not undergo further evaluation. A healthy child with repeated foreign body impaction or impaction at an unusual site should be evaluated for an underlying esophageal or GI motility disorder or anatomic abnormality. The usual outcome of foreign body ingestions is uneventful passage. Most children who require foreign body removal via an intervention experience no untoward consequences.

For excellent patient education resources, visit eMedicineHealth's Digestive Disorders Center. Also, see eMedicineHealth's patient education articles Swallowed Object and Abdominal Pain in Children.

Future and Controversies

General agreement supports the emergent extraction of foreign bodies lodged in the esophagus. Less consistent practice are policies for objects that have reached the stomach. Some foreign bodies pass on their own, and many have adopted a "waiting policy" in such cases.[28] Which approach should be adopted depends on clinical status, the nature and number of objects ingested, as well as the location and transit time (most foreign bodies should be expelled within 4-6 d).