From
StayCurrentMD
Digestive Foreign Bodies: Diagnosis and Management
With Dr. Vince Mkotta · hosted by Dr. Rae Hanke
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Esophageal foreign bodies commonly lodge at three sites: high at the cricopharyngeus, where the aorta crosses over (less common), and most commonly at the lower esophageal sphincter.
The most common age group for foreign body ingestion is 6 months to 6 years (just mobile infants through toddler age range).
Foreign body ingestion can occur in very young infants, such as when a toddler tries to feed an infant.
Coins are by far the majority of ingested foreign bodies.
There has been a rash of issues with magnets where older kids pretend to get piercings by putting magnets across their tongue and swallow them by accident.
Many patients with small objects that are likely to pass never reach gastroenterology, as pediatricians appropriately manage them expectantly in asymptomatic children.
Symptoms of esophageal foreign bodies include odynophagia (pain with swallowing), intolerance of secretions and drooling, pointing to one spot on the throat (especially in younger children), vomiting after attempting to swallow, chest pain, and refusal to eat in chronic cases.
Physical examination findings are usually minimal in patients with digestive foreign bodies.
Initial imaging for suspected foreign body ingestion is a two-view abdomen and chest X-ray.
The classic teaching that coins in the esophagus appear coronal and coins in the airway appear sagittal is not always the case according to published evidence.
For asymptomatic patients with strong suspicion of radiolucent foreign body ingestion not visible on plain X-ray, a contrast study may be performed.
Contrast studies should not be performed if suspicion is high and the patient is symptomatic, and contrast can make endoscopic retrieval more difficult.
Cross-sectional imaging is very rarely considered for foreign body workup.
Eosinophilic esophagitis should be suspected with family history of the condition or frequent food impactions, strong atopic history (food allergy, asthma, severe eczema, rhinitis), or when an object that should have passed becomes lodged in the esophagus.
Button batteries are the biggest and most common need for emergent foreign body removal.
The double-edged sign (a step-off especially visible on lateral X-ray) is classic for button batteries, though it may not always be visible depending on how long the battery has been present.
Witnessed esophageal button batteries are treated as emergencies and taken to the operating room for removal within 2 hours.
When concerned about a button battery, imaging should include the whole neck and chest to rule out a more proximal battery that may have been cut off the film.
Guidance exists to let asymptomatic patients with gastric button batteries go home, but many practitioners are uncomfortable with this due to fatal gastric button battery ingestions and will retrieve them immediately if reachable.
Esophageal foreign bodies are generally retrieved, though there may be an argument for expectant management in bigger asymptomatic kids.
Guidance indicates that esophageal foreign bodies present for 24 hours can cause significant problems.
For esophageal foreign bodies present for a short time in asymptomatic patients, the patient may be admitted and a repeat X-ray obtained in the morning; if the object has not moved, it should be retrieved.
Relatively large foreign bodies (4 or 5 centimeters) in the stomach may not pass the pylorus and have a higher likelihood of requiring retrieval.
Round gastric foreign bodies unlikely to cause injury in asymptomatic children are typically allowed to pass and looked for in the stool.
Sharp objects with one sharp side that reach the stomach generally pass through the GI tract without significant injury, with the theory that they flip and go blunt side down.
Double-headed sharp objects like toothpicks are retrieved if at all possible.
Open safety pins are retrieved if reachable.
Objects like nails or pins in the stomach are retrieved if reachable, but significant effort is not expended once they pass beyond the stomach; patients are watched for symptoms.
When removing an open safety pin, always pull it out with the point facing downward or away; if the point faces the mouth, push it down into the stomach first, then grab and pull it backwards so the blunt side leads.
Very proximal esophageal foreign bodies are very difficult to retrieve with a flexible scope and are preferably removed by surgery or ENT with a rigid scope.
Gastroenterology typically uses flexible scopes for all foreign body retrievals.
Proximal esophageal foreign bodies can sometimes be removed with a rigid scope or McGill forceps with a protected airway, without needing to place an airway.
The ability to reach distal esophageal foreign bodies with a rigid scope depends on the age and size of the child.
The majority of ingested foreign bodies eventually make it into the stomach, but emergency removal is most concerning for esophageal foreign bodies.
Certain batteries are likely to cause esophageal damage within 2 to 6 hours by causing liquefactive necrosis.
If a magnet is ingested, assume there is more than one.
If magnets pass the pylorus, the patient must be watched to ensure the magnets do not stick to each other in a way that compromises the bowel.