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Esophageal Foreign Bodies and Food Impaction

Mizuho Morrison, DO, Matthieu DeClerck, MD, and Jessica Osterman, MD
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27:39

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Dr. Jessica Osterman joins the show to discuss esophageal foreign bodies including patient presentation and disposition. She goes over tips and tricks to use at the bedside, diagnosis, and treatment options.

Pearls:

  • Esophageal foreign bodies are common. Kids usually ingest coins and adults tend to have food impactions.

  • Immediately send to ED those with symptoms of complete obstruction (hypersalivation, aspiration/coughing, inability to tolerate secretions). Also transfer if the ingestion was a button battery, magnet, coin at cricopharyngeal level, or sharp object.

  • Pediatric patients with suspected foreign bodies should first be evaluated with a PA and lateral chest x-ray. 

  • Well-appearing adults with a complete food obstruction can attempt a trial of therapy to promote passage (eg. effervescent agents, glucagon, sublingual medications which relax the lower esophageal sphincter).

 

Esophageal foreign bodies are common. If you haven’t seen one, you will. 

  • Food bolus impaction is a common cause in adults, but in kids coins make up >70% of foreign body ingestions.

  • While many foreign bodies pass on their own, there can be significant morbidity and mortality associated with occluding esophageal foreign bodies.

  • 75% of pediatric foreign body ingestions occur in kids under age 4.

  • In adults, food bolus is usually the cause: meat > fish > veggies. Tend to occur around events that involve heavy alcohol consumption and overeating.

Presentation

  • Unimpaired adults and older children

    • Usually can provide an accurate history and localize the site of discomfort

    • Patients who are edentulous are at higher risk due to impaired mastication

    • Retrosternal pain, dysphagia, odynophagia, nausea or vomiting

  • Younger children or impaired adults

    • Choking or gagging, vomiting, dysphagia or odynophagia, refusal to eat

    • Many children will look normal but have a history of ingestion from the parent.

  • Immediately send to ER any patients with symptoms of complete obstruction

    • Hypersalivation, aspiration/coughing, inability to tolerate secretions

    • Abnormal VS: hypoxemia, tachycardia, hypertension

    • Exam with signs of perforation:

      • Proximal rupture: neck swelling, tenderness, erythema, crepitance

      • Distal rupture: peritonitis, systemic sepsis

Diagnostic imaging

  • PA and lateral chest x-ray

    • Can be very helpful in coin ingestions

      • Coins lodge at the level of the cricopharyngeus

      • On PA CXR→ esophageal coins will appear round (en face), tracheal coins will be lateral

      • On lateral CXR→ tracheal coins will be round (en face) and esophageal coins will be lateral

    • Fish and chicken bones, food material, glass, wood, plastic and thin metal objects may not be seen on x-ray; over 50% of pts with FB can have a negative x-ray

    • One thing to look for is a round FB with an outer “halo” = red flag.  Coins should be solid but this outer halo indicates this is a button battery

  • The majority of foreign bodies that have passed the pylorus and are not visible on chest x-ray will pass without complication. 

    • Exceptions include magnets, plastic bread bag clips, button batteries, sharp objects. These patients should be referred to the ED.

Management

  • Send to ER for emergent intervention if:

    • Signs or symptoms of complete obstruction or evidence of perforation

    • Sharp objects in the esophagus

    • Bread bag plastic clips: have small pincers that can trap tissue leading to necrosis and perforation

    • Button batteries: cause liquefaction necrosis and mucosal injury

    • Magnets should always go to ER for removal

    • Child with a coin stuck at the cricopharyngeal level: these can be difficult to pass without endoscopic removal 

What’s the nuanced approach to a coin that isn’t at the cricopharyngeal level, yet hasn’t passed into the stomach?

  • Coins < 2.5 cm in diameter (a quarter sized or smaller) should pass through the pylorus and out in the stool. 

  • A watch and wait approach should be fine for coins in the esophagus.

Are serial x-rays indicated for coins in the esophagus or stomach?

  • If the kid looks good, is eating normally, is not having belly pain or vomiting, you don't need to expose them to any further imaging unless they develop any new symptoms.

  • Parents should be given good return precautions and advised that they may see a coin (or other foreign body) pass in the stool. 

Esophageal food impactions in adults:

  • Meat is the most common culprit. 

  • Food doesn’t usually show up on x-ray.

  • Patients with a true food bolus have a lot of difficulty continuing to eat, drink, or even swallow saliva. That's a good differentiator between a fish bone or something that scratched the esophageal mucosa on the way down.

  • Tools that might help the stable patient pass a food bolus:

    • Effervescent agents (eg. soda OR sodium bicarbonate + simethicone + citric acid in 30mL of water) produce CO2 which increases luminal pressure and helps force FB into the stomach.

    • Glucagon (0.5 to 1 mg IV) is a smooth muscle relaxant that relaxes the distal esophagus and may allow the object to pass into the stomach. Can cause vomiting, so consider pretreatment with an antiemetic. 

    • Others: hyoscyamine, benzos, CCBs and nitrates (reduce LES). Sublingual meds may be easiest in the UC (eg. nifedipine 10-20 mg SL, isosorbide dinitrate 5 mg SL, nitroglycerin 0.4mg SL)

  • If a food bolus successfully passes into the stomach in the UC,  you don't need to send the patient to the ED for endoscopy provided they're well-appearing, tolerating PO, and they have a good history of having a food bolus as their cause.  

  • Outpatient GI referral is indicated for history of recurrent impactions, odynophagia, or dysmotility symptoms.

 

References:

  1. Munter D.  Chapter 39: Esophageal Foreign Bodies.  In: Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. 7th ed. Elselvier; 2019:807-827.

  2. Anderson K, et al. Foreign bodies in the gastrointestinal tract and anorectal emergencies. Emerg Med Clin North Am. 2011;29(2):369-ix. PMID: 21515184

  3. Shatani N, et al. Chest Radiograph Alone Is Sufficient as the Foreign Body Survey for Children Presenting With Coin Ingestion [published online ahead of print, 2018 Nov 19]. Pediatr Emerg Care. 2018;10.1097/PEC.0000000000001688. PMID: 30461670

  4. Gilger M, et al. Foreign bodies of the esophagus and gastrointestinal tract in children.  UpToDate Website.  Updated Dec 10, 2020.  Accessed February 2, 2021.   https://www.uptodate.com/contents/foreign-bodies-of-the-esophagus-and-gastrointestinal-tract-in-children

  5. Conners, G.  What is the emergency department (ED) management for esophageal foreign body ingestion?  Medscape website.  Updated Oct 4, 2018.  Accessed Oct 22, 2020.  https://www.medscape.com/answers/801821-113915/what-is-the-emergency-department-ed-management-for-esophageal-foreign-body-ingestion

  6. Long B, et al. Esophageal Foreign Bodies and Obstruction in the Emergency Department Setting: An Evidence-Based Review. J Emerg Med. 2019;56(5):499-511. PMID: 30910368

  7. Link to REBEL EM episode on button battery ingestion

Robert H. -

Neither glucagon or NTG have been shown to work. Rarely carbonated liquids will but if not these patients need endoscopy.

Mike W., MD -

That has also been my experience... thx Robert for the comments!
M

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