Pediatric Gastrointestinal Foreign Bodies Treatment & Management

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.

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.

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.

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.

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.

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

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.

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.

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).