Foreign body in the esophagus

Notes

## Basic introduction

  • Coins are the most common foreign bodies (FBs) in children while fish bones and meat are the most common FBs in adultsc
  • Various FBs can be found in psychiatric patients.
  • When an object has passed the pylorus, it will generally be excreted without much problem unless it has either irregular or sharp edges or it is wide (>2.5cm), long (>6cm) or corrosivea
  • 75% of cases of FBs in esophagus occur in cricopharyngeus (near C6) muscle. Other sites include aortic cross over the esophagus and lower esophageal sphinctera
  • Most of the fish bone FBs are in the posterior pharynx, from where they can be removed using Magill forceps

## Some common FBs in esophagus

  • Coins
  • Fish bones
  • Chicken bones
  • Meat
  • Safety pins
  • Sewing needles
  • Toys
  • Erasers
  • Beans
  • Peas

## FBs in esophagus that requires emergency removal

  • Bone fragments
  • Button batteries
  • Coins
  • Cases of FBs with esophageal perforation
  • High complete obstruction
  • Potentially corrosive agents
  • Sharp objects

## Risk factors

  • High-risk foods such as fish and sometimes chicken
  • Illicit drugs
  • Psychiatric illness
  • Altered level of consciousness
  • Developmental immaturity
  • Structural dental abnormalities
  • Abnormal process of swallowing (deglutition)

## Complications of FBs in esophagus

  • Airway compromise
  • Aortic perforation
  • Perforation of esophagus
  • Aspiration pneumonia
  • Bowel necrosis
  • Fistulas
  • Infections
  • Mediastinitis (inflammation of the mediastinum i.e. the chest cavity)
  • Obstruction Stricture
  • Vocal cord paralysis
Symptoms
  • Feeling of the presence of FB in the esophagus
  • Pain in retrosternal area and/or in the back
  • Choking
  • Stridor
  • Vomiting
  • Dysphagia
  • Coughing
  • Drooling
  • Spitting
  • Gagging
  • Regurgitation of food
  • Painful swallowing (odynophagia)
  • (About 30% of children with coins lodged in the esophagus may not display any symptom)
Diagnosis
  • Clinical review, including history of the meals taken before
  • Chest X-ray with dilute barium or gastrografin swallow (care must be taken to avoid aspiration)
  • For the fish bone FBs, endoscopy is the preferred method of diagnosis as only 33-50% of cases are detectable by X-ray
Differential
  • Achalasia
  • Schatzki Ring
  • Esophageal web
  • Esophageal irritation (globus sensation)
Prevention
  • Proper child training and care by parents/caretakers
Reference

a. Leopard, D., Fishpool, S., & Winter, S. (2011). The management of esophageal soft food bolus obstruction: a systematic review. The Annals of the Royal College of Surgeons of England, 93(6), 441-444.

b. Ikenberry, S. O., Jue, T. L., Anderson, M. A., Appalaneni, V., Banerjee, S., Ben-Menachem, T., ... & Harrison, M. E. (2011). Management of ingested foreign bodies and food impactions. Gastrointestinal endoscopy, 73(6), 1085-1091.

c. Kenyan Ministry of Health. Clinical guidelines for management and referral of common conditions at levels 4-6. Hospitals. 2009; 3:259-261.http://apps.who.int/medicinedocs/documents/s21000en/s21000en.pdf

d. Ministry of Health, Kenya. Kenya Essential Medicine List (2016). http://publications.universalhealth2030.org/uploads/KEML-2016Final-1.pdf

Management

## In most cases, the goal of treatment is to manage the patient medically to encourage resolution of the obstruction

## For soft food bolus obstruction, conservative (non-surgical) treatment may include administration of:

  • Fizzy drinks that release gas and dislodge the food

OR/AND

  • IV/IM Glucagon 0.5- 2.0mg STAT (normal dose 1.0 mg) – it relaxes the lower esophageal sphincter

OR

  • IV Diazepam 5 -10mg STAT – it relaxes the lower esophageal sphincter

OR

  • IV/IM Atropine 5 to 1.0mg STAT

OR

  • Sublingual Nitroglycerin 0.4mg STAT

OR

  • Sublingual Nifedipine 10mg

## Sharp objects and objects with a corrosive capacity (e.g. batteries) require urgent removal

## Surgical management

  • Flexible fiberoptic endoscopy

_This is the most preferred method

_Impacted food may be pushed into the stomach instead of removing it

  • Nasogastric suction (a magnet may be used to remove metallic objects such as batteries)
  • Foley catheter extraction that is suitable for upper esophageal impactions
  • Follow-up reviews are required with endoscopy
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