Digestive Foreign Bodies: Diagnosis and Management

Hey there listeners, this is Rod from Cincinnati Children's. Have you downloaded the new version of the Stay Current app? We've got a brand new layout, new content, you're absolutely gonna love it. But the reason I bring it up here is because if you're listening to a podcast, we have images that our guests are going to talk about. You're gonna want to look at them in, in the app, you can open it up while you're listening to the podcast. Check it out, it's in the Apple App Store, it's in the Google Play Store, but until then, enjoy the episode. Last week we talked about Airwave Foreign bodies. It was one of my favorite episodes, so if you haven't heard it yet, jump out of this one, go listen to that one, but if you did listen to it, and you were thinking, Rod, this is great, but like, what if the foreign body goes down the esophagus? Well, that's what we're gonna talk about today, digestive foreign bodies. And to do that, we brought in one of our colleagues from Cincinnati Children's who is a pediatric gastroenterologist, to talk us through the diagnosis and management because these can be sometimes really complex and really scary situations and Even sometimes emergencies. So, sit back and enjoy our podcast on digestive foreign bodies. So in terms of pediatric patients who ingest a foreign body, that's Alex Gibbons. He's a general surgery resident at the Cleveland Clinic. Actually lodged somewhere in the digestive tract, uh, where does that usually happen? The majority of the foreign bodies will eventually make it into the stomach, um, but in terms of emergency removal. Um, we worry most about esophageal foreign bodies. That is Doctor Vince Mkotta. He's a pediatric gastroenterologist at Cincinnati Children's Hospital. Some that get lodged high at the cricopharyngeus. If it's high in the esophagus, it's going to be where the aorta crosses over. That's not too common, and even less common is Rare vascular anomalies like subclavians, but more commonly if it's in the esophagus, typically it's at the lower esophageal sphincter where we end up going in and retrieving most foreign bodies. Wait, Rod, hold up, hold up. Yeah, what's up, Todd? This is really different than what we're used to seeing, or at least I'm used to seeing. OK, go on. I would say that almost all of the foreign bodies that I go after are in the very proximal esophagus. And we can reach down and grab them with a rigid scope or even sometimes with the McGill forceps. So, I'm surprised to hear that he says most of his are in the lower esophageal sphincter. Yeah, but dude, think about it, he's a GI doc, so he's gonna get called when surgeons like you or I can't get it out with a McGill forceps. That means it's probably farther down, so maybe there's a selection bias going on here. Anyway, Ray's got a question, so listen up, Todd. What age groups do you tend to find ingested foreign bodies? That's Ray Hanke. She is a general surgery resident out at Penn State University. And what are they normally putting in their, their mouths? The most common age group is probably the just mobile. Infants through toddler age range, so maybe like 6 months to 6 years. Now with that being said, I think you have to have a high index of suspicion and be just aware that this can happen in very young infants. So think of the situation where a toddler is trying to Be a good big brother, big sister, and feed an infant, and then the infant could end up with a digestive foreign body. We absolutely have older kids or young adults, you have to worry about, um, psych issues, you know, the chronic swallowing patients, and lots of kids just instinctively put things in their mouth to hold it, and then something happens and they swallow. You know, like that rooster from Moana. But I'm sure there's more to hey hey than meets the eye. tends to be shiny things, right? That's Doctor Aaron Garrison. He's a pediatric surgeon at Cincinnati Children's. The coins and, and rings and batteries and yes, coins are, are by far the majority, you know, there's been a, a rash of issues with magnets where kids are older kids are, you know, pretending to get piercings and that kind of thing, and they put the magnet across their tongue and swallow it by accident. And then, like we mentioned earlier, the patients who are chronic swallowers, and then, you know, they show up in the ED with a toothbrush in their stomach, you got to keep those in mind as well. And out of everyone coming in with an ingested foreign body, uh, how often do they actually require some sort of intervention and what is that intervention typically? There's a fair number of patients who never make it to us, you know, that they call the pediatrician. The pediatrician appropriately realizes that it's a small object that is likely to pass, may give us a quick call, um, and in the asymptomatic child, they just, we let it go and then, and, uh, make sure that it comes out. And that's why it's kind of hard to tell a percent of patients who swallow something, and then how many go on to get an intervention, and then tack on institutional and practitioner differences, so it can get a little cloudy. How do children who may have aspirated or ingest reformed body typically present? So sometimes they're asymptomatic, and then it's a decision on, you know, how to, how to best address things. If, if it's an esophageal foreign body, we're still more likely than not to go after it, but, um, or at some point, or at least to, to watch them in-house. But if they do have symptoms, there's a wide range. Odynophagia or, or sensation of pain with swallowing, um, intolerance of secretions and drooling. Um, some kids will just point, uh, especially younger kids can point and tell you, oh, you know, they, they're just pointing at one spot on their throat. Um, some kids will, it can be, they were doing fine and then they tried to swallow something else and then started vomiting, you know, chest pain. The more chronic ones, sometimes it's just refusal to eat and that the parents notice. And in a similar vein, um, what are you likely to see on physical exam? Usually not much on physical, to be honest. I mean, we, we're looking for the same things I think that everyone else is. So stability of the patient, uh, you know, are they, are they breathing comfortably? Is there any suspicion that it went airway rather than GI tract? But I think frequently by the time we get a phone call, they've already been seen in the ER. They've already had a film done. If there's a concern for could there be a caustic or some sort of chemical issue, you know, certainly we can sometimes see things in the mouth or in the back of the throat, but there's not a lot that we're seeing most of the time. So for the patient that you're considering a possible um ingested foreign body, what type of imaging or other workup do you start? Um, and we would generally start with uh a two view abdomen and chest X-ray. Now if you remember the classic teaching of coins in the esophagus, you're going to see in coronal and then coins in the airway, you're going to see sagittal, well, there's good published evidence that says that that's not always the case, but that can sometimes help. Regardless, you're still going to want a lateral view, and then keep in mind that some objects are radiolucent. In the case of an asymptomatic patient where there is a strong suspicion for something being ingested, we will sometimes do a contrast study if we don't see something on, on a plain view. If, if, if the suspicion is high enough and the patient is symptomatic, I, I certainly wouldn't stop to to to do a contrast study, and the contrast can make it a little more difficult for us endoscopically. It's very rare that we'd ever think about doing anything like that. Cross-sectional imaging for this. And then as part of a kind of overall workup, and something that's being recognized more and more in children now, is eosinophilic esophagitis. Um, when would a workup for that be warranted? So things that would prompt us to think about it more before we ever go in are if we get a family history of mom and dad or grandpa and grandpa or brother either has a Confirmed diagnosis, or they give you a history of, oh yeah, they get food stuck all the time, they've been dilated multiple times. Um, our families or kids that have a strong atopic history, so food allergy, asthma, terrible eczema, bad rhinitis, or those kind of things, uh, certainly our suspicion is higher. Or if it's something that should have passed, but it doesn't, like this kid should have swallowed it, and now it's in their esophagus, that should raise your suspicion. And then think of things that. We really don't want them swallowing, like a button battery. That's a whole different story. Does your evaluation differ if the ingested body might be a button battery? So button batteries uh change our change our evaluation, um, pathway considerably. You know, that's, that's, that's probably the biggest and most common need for emergent removal. Classically on X-ray, when you look at the X-ray that you hopefully will be able to see the, the double edged sign where there's a step off. Especially on the lateral view, but you might not always see it, depending on how long the battery's been there. So if there is a strong concern, especially if it was a witness, uh, esophageal button battery, um, we treat those as emergencies and take them, you know, within 2 hours to the operating room for removal. I think every student and resident should be able to, or should look at an X-ray and try to be able to discern the difference between an esophageal coin and a, and a battery and really get to know what that ring looks like. And wouldn't you know, we got both. So if you're in the app, scroll down under the media player, we have 2 plain films. Look at the difference here. Um, sometimes you can see the lettering on the battery, so that you know even what voltage it is, not that that really changes what you're going to do at that time, but. Uh, you know, certain batteries are really likely to cause esophageal damage within 2 to 6 hours, just causing that liquefactive necrosis. I can't tell conclusively. I would rather err on the side of going and trying to get it out. If it, if we make the mistake and take out a coin too early, that's not gonna hurt anybody. I think when we were talking about X-rays earlier too, if you, if you are concerned about a button battery, um, you do want to make sure that you have the whole neck and chest. Um, visualized too. So often we'll get a chest X-ray and an abdominal X-ray. If you see a distal esophageal button battery, you also want to rule out that there's not something stuck more approximately that may have been cut off the film. But what if the battery keeps going and now it's gastric? The guidance is, is that you can, if a patient is asymptomatic, you can sometimes let them go. I think many of us don't feel comfortable with that, um, and I think unfortunately here we've had several of us have had fatal gastric button battery ingestion. So I think myself and many of my colleagues, if we can get it, we will go and go get it immediately. The poison control has a nice flow sheet or algorithm for button battery ingestion, and I've referred to that, uh, a few times, not, not sure whether, uh, to go or not. And, in, in general, if, if it can be reached, um, and it's a button battery, I think we all agree it's, it's worth going. If you want to read those further, I've also linked that below, so scroll down into the media player and open that up. Aside from button batteries, we talked about how kids often ingest other things. Great point, Ray. So let's backtrack to the esophageal coins. Can you manage those expectantly? If it's lodged in the esophagus, we would tend to go get it. Uh, it's, you know, there's, there may be an argument to be made in a, in a bigger kid who's asymptomatic, can you watch it expectantly for For a little bit. I mean, I think that the guidance is still, if it's, if it's in the esophagus for, you know, 24 hours, um, it can cause big problems. So I think esophageal foreign bodies, by and large, we go and get. So if it hasn't been lodged for very long and you kind of manage it. Expectantly, is there a particular protocol you should use to follow that patient to make sure it's moving where it needs to go? The one thing that we will do is frequently, if it's esophageal and it's been a short period of time and they're asymptomatic, we will admit them. You know this is typically the, do you do this in the middle of the night question. Um, we will frequently admit them and then repeat a film in the morning. If it's not moved, then we're going to go get it. Sometimes it will then have fallen in the stomach and you'll be OK. But If it's, if it's there persistently on, on more than one X-ray, you should just go get it. OK, another situation, you get your initial X-ray, and it's already in the stomach, then what do you do? Relatively large foreign bodies, you know, 4 or 5 centimeters. They may not make it past the pylorus, so we'd probably have a higher likelihood of going to try to get it. Um, in an asymptomatic child, if you think that the, that it's, that it's a, you know, round foreign body that's unlikely to cause injury, we usually would let them, we would let them pass and, and, uh, look for them in the stool. Now, if they're symptomatic, you're gonna go in there and get it anyway, but That was about round stuff. How about sharp stuff? Sharps are their own separate um kind of issue, and so, you know, I think typically for us, um, If it is a, you know, one side of an object is sharp, and it's made it into the stomach, generally speaking, they actually make it through the through the GI tract without too much injury. Uh, you know, the sort of classic thought is that it flips and goes blunt side down, um, which, and even if it sort of sticks, it'll kind of flip itself around. Um, double-headed things, so toothpicks, we, we tend to go and try to get, if at all humanly possible. Um, safety pins, if they're open, we will go and try to get if we can reach them. Um, but things like nails or pins and things, if it's in the stomach, and I think I can get it, I probably would try to go get it, but we don't spend a lot of effort once I get beyond there. We watch for symptoms. Wait, Rod, hold up, hold up. Yeah, what's up, Todd? I want to point out one thing. Well, who am I to stop you? If you do have a patient that ingested an open safety pin, yikes. One trick is to make sure that you always pull it out with the point. Facing downward or away, you never want to lead with a point. Makes sense, but how? If the point is facing towards the mouth, you push it down first into the stomach, then grab it and pull it backwards, so you're pulling the blunt side towards you. So what you're saying is with an open safety pin, you've got to put the thing down, flip it, and reverse it. I got that. Joking aside though, Ray's got a question, so listen up, Todd. If we were going to go in to remove an ingested foreign body, what is the preferred technique? Are you using rigid or flexible esophagoscopy? I think it does depend on the location of the foreign body, you know, so again, I think, um, proximal, very proximal, um, Esophageal foreign bodies are very difficult to get with a flexible scope. Um, and so having either surgery or ENT, um, go after it with a rigid scope is almost certainly preferable. Um. It, and, and then I think it depends on, on which specialty gets called, you know, I think for, for GI we will go after everything with a flexible scope. Yeah, I agree. Proximal esophageal foreign bodies can sometimes be removed quite easily just with a rigid scope, and sometimes even just the McGill, if you have a protected airway, you can reach in there and, and grab it without even, um, without even having to put an airway in. Um, so sometimes they're just reachable and you can get it. Um, but anything distals, um, and then it depends on the age of the child. So sometimes even two year olds, you can reach pretty distally with a, with a rigid, um, but everything depends on size and, and what the object is and where it is in the esophagus. Alright, let's summarize. So, if you have an esophageal button battery, that's an emergency, you gotta intervene on that within 2 hours. If it's a magnet, you gotta assume there's more than 1. If it's past the pylorus, you have to watch that patient to make sure that the magnets don't stick to each other in a way that's gonna compromise the bowel. Overall, esophageal form bodies should be intervened on sooner than later, but it kind of depends on how the patient presents. So what do you guys think? Did you love this podcast? Did you hate it? Well, if you're in the app, you can let us know by leaving a comment, start a discussion, or tell us about a podcast that you want to hear about. The app's available in the Apple App Store or the Google Play Store, so download it. But until next time, I'm Rod from Cincinnati Children's, and remember, knowledge should be free.