II. Anatomy: Common Esophageal Foreign Body sites

  1. Patient localization of foreign body sensation typically correlates with the actual foreign body location
  2. Cricopharynx (C6)
    1. Location where cricoid cartilage abuts the esophagus
    2. Most common site in children
  3. Aortic arch (T4)
    1. Where aortic arch contacts and indents the esophagus
  4. Tracheal bifurcation (T6)
  5. Gastroesophageal Junction (T11)
    1. Most common site in adults

III. Risk Factors: High risk foreign bodies

  1. Sharp objects
  2. Objects in esophagus >24 hours
    1. Risk of fistula, stricture, or erosion through wall
  3. Large items (risk of Intestinal Obstruction)
    1. Size >2 to 3 cm in infants under age 1 year
    2. Size >3 to 5 cm in children over age 1 year
  4. Button Batteries (disc batteries, especially Lithium batteries)
    1. Appear similar to 2 stacked coins (stack sign) on XRay
    2. Risk of voltage burn or corrosive injury
      1. Serious esophageal burns occur within 2 hours (even within 30 min)
      2. High risk of Esophageal Perforation in first 6 hours
      3. Tomaszewski (2016) Household Toxins Lecture, ACEP PEM Conference, attended 3/8/2016
    3. Requires emergent upper endoscopy for removal (typically gastroenterology)
    4. Asymptomatic button batteries below the esophagus (e.g. Stomach) may be followed with serial XRay
      1. Expect to pass through pylorus within 48 hours and out with stool by 72 hours

IV. Imaging

  1. Radiopaque Foreign Body (e.g. coins, some medications, bones)
    1. Soft tissue neck (PA and lateral)
    2. Chest XRay (PA and lateral) - as indicated
  2. Other measures to localize foreign body
    1. Hand-held metal detector (from security) may be used to select best initial XRay location

V. Management: Endoscopy for radiopaque objects

  1. Preferred method in most cases of ingestion
  2. Indications: Radiopaque objects
    1. Object (e.g. coin) in proximal two thirds esophagus
      1. Conners (1995) Pediatr Adolesc Med 149:36-9 [PubMed]
    2. Symptomatic object beyond esophagus
    3. Object not past the pylorus
      1. Small blunt object not past pylorus in 3-4 weeks
      2. Button battery not past pylorus in 48 hours
    4. Object before duodenal sweep
      1. Object without progress in 1 week
      2. Large object (see above for definition of large)
      3. Sharp object

VI. Management: Observation of Radiopaque Objects

  1. Indications (Radiopaque Objects)
    1. Small blunt objects
    2. Object beyond duodenal sweep that is making progress
      1. Large object (see definition of large as above)
      2. Sharp objects
  2. Observation protocol (Radiopaque objects)
    1. XRay weekly: small or large items past duodenal sweep
    2. XRay q3-4 days: Button or disc batteries
    3. XRay daily: Sharp objects beyond duodenal sweep
    4. Monitor stool for passed foreign body
      1. Misses 2/3 of ingested foreign bodies

VII. Management: Surgical Excision Indications (Radiopaque)

  1. Radiopaque object below duodenal sweep
    1. Large object with no progress in 1 week
    2. Sharp object with no progress in 3 days
    3. Small blunt object with no progress in 1 week

VIII. Management: Radiolucent objects

  1. Esophageal radiolucent object suspected
    1. Upper endoscopy and/or Laryngoscopy: preferred method
    2. Barium esophagogram: if endoscopy not available
      1. Consult with gastroenterology first
  2. Radiolucent object suspected below esophagus
    1. Observe for symptoms
    2. Check stool for foreign body
    3. Consider contrast radiograph if not passed in 2 weeks
    4. Consider CT Abdomen
      1. Do not use Oral Contrast if risk of aspiration such as in high grade obstructive symptoms

IX. Management: Other methods for inert, blunt foreign body such as coin from esophagus

  1. Indications (endoscopy is preferred over these methods)
    1. Single coin (or similar flat, blunt object) lodged less than 24 hours (some use 72 hours as cut-off)
    2. No prior foreign body, normal esophagus, no Dyspnea
  2. Anxiolysis (adjunct to measures below)
    1. Consider Lorazepam or similar Benzodiazepine in low dose
    2. Consider lower dose Propofol
  3. Carbonated beverage (e.g. sugar soda pop such as coca cola, EZ-Gas)
    1. Increases gas pressure in the esophagus which may push a food bolus into the Stomach
    2. Do not use if risk of aspiration
  4. Relax Lower esophageal tone (typically ineffective methods, but may work on lower/distal esophageal foreign bodies)
    1. Glucagon 1 mg IV (May repeat in 15-30 minutes)
      1. Most commonly used agents of the esophageal relaxants
      2. Marginally better than Placebo (14% versus 10% success rate)
        1. Bodkin (2016) Am J Emerg Med 34(6): 1049-52 +PMID: 27038694 [PubMed]
    2. Diazepam 2-10 mg IV
    3. Nifedipine 5-10 mg SL
    4. Nitroglycerin 0.6 mg SL
  5. Mechanical measures (endoscopy is preferred)
    1. Bougienage
      1. Weighted Nasogastric Tube to push coin into Stomach
    2. Foley Catheter (requires experienced clinician)
      1. Foley Catheter (8-12 french) inserted through nose or mouth
      2. Catheter passed beyond coin (estimate insertion distance externally)
      3. Balloon inflated with radiocontrast (barium)
      4. Reposition patient in slight Trendeleburg, in left lateral decubitus position
      5. Balloon pulled out under xray or fluoroscopy, then sweep the mouth for coin
      6. May require multiple attempts (deflate balloon prior to re-insertion or removal)

X. References

  1. Mason and Sacchetti in Herbert (2017) EM:Rap 17(4): 13
  2. Birnbaumer (2013) Upper Abdominal Disorders, EM Bootcamp, CEME
  3. Chen (2001) Pediatr Ann 30:736-42 [PubMed]
  4. Uyemura (2005) Am Fam Physician 72:287-92 [PubMed]

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