Swallowed Foreign Body Case File
Eugene C. Toy, MD, Barry C. Simon, MD, Terrence H. Liu, MD, MHP, Katrin Y. Takenaka, MD, Adam J. Rosh, MD, MS
Case 19
A two-year-old boy is brought to the emergency department (ED) because of an episode of “choking.” The patient was playing with marbles when his mother left the room for a few minutes. She ran back in when she heard the patient gagging and coughing. She denies any recent fever, cough, or other upper respiratory infectious symptoms. When asked, she denies her son turning blue, having difficulty breathing or vomiting. The patient was a term baby without any significant past medical history. He is not taking any medications, and his immunizations are all up-to-date. He attends day care and has no recent sick contacts.
On examination, his temperature is 37.7°C (99.9°F), blood pressure is 93/55 mm Hg, heart rate is 105 beats per minute, respiratory rate is 24 breaths per minute, and the O2 saturation is 98% on room air. The patient is playful and alert. His examination is unremarkable except for intermittent gagging. He has no intercostal retractions or accessory muscle use.
⯈ What are the potential complications in this patient?
⯈ What is the most appropriate next step?
ANSWER TO CASE 19:
Swallowed Foreign Body
Summary: This is a two-year-old boy with probable ingestion of a foreign body (marble).
- Potential complications: Esophageal stricture, perforation, mediastinitis or peritonitis, paraesophageal abscess, cardiac tamponade, and aortotracheoesophageal fistula.
- Most appropriate next step: Because the child is stable, x-ray to localize the foreign body.
ANALYSIS
Objectives
- Recognize the clinical scenario, signs, and symptoms of swallowed foreign bodies.
- Learn the diagnostic and therapeutic approach to the various types of swallowed foreign bodies.
Considerations
Patients with swallowed foreign bodies may be asymptomatic or may present in extremis. Although most objects will pass through the gastrointestinal tract without problems, it is important to recognize which patients require observation and which will need intervention (Table 19–1).
Approach To:
Swallowed Foreign Body
CLINICAL APPROACH
Although children 18 to 48 months account for nearly 80% of cases, edentulous adults, psychiatric patients, and prisoners also commonly swallow foreign objects. Children most commonly ingest things they can pick up and place in their mouths, such as coins, buttons, toys, and crayons. Adults are more likely to have trouble swallowing meat and bones. Although objects can be located anywhere throughout the alimentary tract, there are several areas where they lodge more frequently. In the pediatric patient, most obstructions occur in the proximal esophagus at one of 5 areas: the cricopharyngeal narrowing (most common), thoracic inlet, aortic arch, tracheal bifurcation, and hiatal narrowing. In contrast, most adult patients have distal esophageal obstructions caused by a structural or motor abnormality (eg, stricture, malignancy, scleroderma, achalasia).
Most adult patients will be able to relate a history of ingesting a foreign object or of feeling food becoming lodged. They may complain of anxiety, foreign body sensation, chest or epigastric pain, retching, vomiting, wheezing, or difficulty swallowing.
Data from Tintinalli J, Judith E, and J S. Stapczynski. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide.
New York, NY: McGraw-Hill; 2011.
In children, the history may be less clear. Parents may have seen the child with an object in his or her mouth and suspect ingestion. Children can present with vomiting, gagging, choking, refusal to eat, or neck or chest pain. Increased salivation, drooling, or an inability to swallow suggests a complete obstruction. Patients with airway foreign bodies tend to present with more respiratory symptoms (Table 19–2).
The physical examination should focus on identifying patients with airway compromise, inability to tolerate fluids, or active bleeding. It should include a careful evaluation of the oropharynx, neck, chest, and abdomen. Findings such as fever, subcutaneous air, or peritoneal signs suggest perforation. In patients with a suspected oropharyngeal foreign body, direct or indirect laryngoscopy can be useful. Plain x-rays may help locate radiopaque foreign bodies throughout the gastrointestinal (GI) tract and be used to follow their progression (if repeated every 2-4 hours). Many foreign bodies are not radiopaque, including chicken and fish bones.
If plain films do not reveal the object, an esophagogram, computed tomography (CT), or endoscopy are other options. If perforation is suspected, the esophagogram should be performed with a water-soluble contrast agent. If aspiration is a concern, barium is the preferred contrast agent; however, barium can obscure the visual field if endoscopy is subsequently performed. CT can be useful to identify the location and orientation of swallowed foreign bodies as well as the presence of any complications such as perforations or fistulae. Endoscopy is usually the study of choice because the object may be removed once it is visualized. Some success has been reported using metal detectors to locate and follow metallic objects.
Eighty to ninety percent of patients with normal gastrointestinal anatomy will pass swallowed foreign bodies without complications. Thus most patients are treated expectantly at first. If symptomatic, in-hospital observation should be considered for serial examinations. In general, once a foreign object passes the pylorus, it will continue through the GI tract without incident. However, if it cannot pass the esophagus or pylorus, it must be removed. Again, endoscopy is usually the method of choice. However, surgery may be necessary if there is evidence of obstruction or perforation, if the object is too big to pass safely, or if it contains toxins.
There are several special considerations when dealing with certain types of swallowed foreign bodies such as button batteries, which generally need to be removed because of their toxic effects on mucosa (see Table 19–1).
COMPREHENSION QUESTIONS
19.1 The ED director embarks on a study to see the type of patient most likely to experience foreign-body ingestion. Which of the following groups of individuals is most likely to have foreign-body ingestion?
A. Children
B. Edentulous adults
C. Prisoners
D. Psychiatric patients
19.2 A 21-year-old woman accidentally swallowed a penny. At which of the following locations is the coin most likely to be lodged?
A. Aortic arch
B. Cricopharyngeal narrowing
C. Lower esophageal sphincter
D. Thoracic inlet
19.3 A 3-year-old girl accidentally swallowed a button battery from her mother’s camera. She does not appear to be in respiratory distress. She has normal vital signs and is afebrile. Plain x-ray shows the battery in the esophagus. Which of the following is the best management for this patient?
A. Avoidance of citrus drinks
B. Avoidance of magnets
C. Endoscopy
D. Expectant management
19.4 An 8-year-old girl presents to the ED having swallowed a penny as part of a bet with a friend. The abdominal radiograph reveals that the penny is in the stomach. Thirty-six hours later, it is still in the stomach. Which of the following is the best next step?
A. Endoscopy
B. Laparotomy
C. Lithotripsy
D. Observation
E. Rigid bronchoscopy
ANSWERS
19.1 A. Foreign-body ingestion is most common in children.
19.2 C. In adults, a swallowed object will most commonly lodge in the esophagus at the lower esophageal sphincter. In children, the most common location is the proximal esophagus at the cricopharyngeal narrowing.
19.3 C. Button battery ingestion is a true emergency with the potential for mucosal burns within 4 hours and esophageal perforation within 6 hours of ingestion. A button battery in the esophagus must be removed as soon as possible.
19.4 A. In general, the preferred method of swallowed foreign body removal is endoscopy (except in body packers due to the risk of packet rupture).
CLINICAL PEARLS
⯈ Children account for the vast majority of cases of swallowed foreign bodies.
⯈ In the pediatric patient, objects most commonly lodge in the p roximal esophagus, whereas most adult patients have distal esophageal obstructions.
⯈ Findings such as fever, subcutaneous air, or peritoneal signs suggest perforation and necessitate an emergent surgical consult.
⯈ Button batteries in the esophagus as well as sharp, pointed objects in the stomach must be removed as soon as possible. In general, the preferred method of swallowed foreign body removal is endoscopy (except in body packers because of the risk of packet rupture).
References
Aghababian, R. Essentials of Emergency Medicine. 2nd ed. Sudbury, Mass: Jones and Bartlett Publishers; 2011.
Harrigan R, and Ufberg JW , Tripp ML. Emergency Medicine Review: Preparing for the Boards. St. Louis, MO: Saunders/Elsevier; 2010.
Marx J A, Hockberger RS, Walls RM, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia, PA: Mosby/Elsevier; 2010.
Tintinalli Judith E, and Stapczynski JS. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. New York, NY: McGraw-Hill; 2011:Chapter 80.
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