leave it…. or heave it: indications for foreign body removal

LEAVE IT…. OR HEAVE IT:
INDICATIONS FOR FOREIGN BODY REMOVAL
Wendy Jeshion, MD
Co-Section Chief
Pediatric Gastroenterology & Nutrition
Joseph M. Sanzari Children’s Hospital
Hackensack University Medical Center
Foreign Bodies (FB)
• Responsible for 1500 deaths each year in the US
• 80% of all FB occur in the pediatric patient
• Most common gastrointestinal FB in children
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coins
button batteries
food impaction
toys
 pins
 crayons
 magnets
 pen caps
Foreign Bodies (FB)
• 80-90% of FB will pass spontaneously
with an average transit time of 4-7 days
• 10-20% will require endoscopic
intervention
• 1% will require surgery
Complications of FB
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Esophageal perforation
Airway obstruction
Aspiration
Intestinal perforation
Tracheoesophageal or esophagoaortic fistula
formation
• Volvulus
• Death
Symptoms
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Dysphagia
Odynophagia
Sensation of foreign body
Even if foreign body passes, many children
complain of pain referable to cervical
esophagus
• In children, symptoms more commonly
include drooling, vomiting or gagging
Types of Foreign Bodies (FB)
• Coins
• Magnets
• Button Batteries
• Sharp/Pointed objects
• Food Impaction
Coins
Coins – Evaluation Criteria
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Length of time since coin swallowed
Symptomatic
Previous Surgery
Age of the child and type/size of coin
Location of coin (AP and lat CXR)
X-ray Coin in Esophagus
Coins by Size
• Coins smaller than 20mm usually pass
• Dimes (17mm)
• Pennies (18mm)
usually pass easily
• Quarters (23mm)
• Nickels (21mm)
usually don’t pass
Coins by Location - Esophagus
• Most common sites of impaction are at the
thoracic inlet, aortic arch, and LES
• Lodged in the pharynx or at the level of the
cricopharyngeus- ENT/surgery - rigid scope
• Distal esophagus and asymptomatic- can wait
up to 24 hours to let it pass
• Consider glucagon (0.5-1.0 mg)
Coins by Location - Esophagus
• Remove within 24 hours secondary to
complications of ulceration, perforation, and
fistula formation
• Bougie vs. foley vs. metal detector. vs. endoscopy
• Endoscopy- alligator or rats tooth grasping forceps
• Must protect the airway
Esophageal
Coin Removal
Fifty Cents
Coins by Location - Stomach
• Asymptomatic- can allow 4-6 weeks to let
it pass before retrieving; follow with xrays and examination of stool
• Coins smaller than 20mm will pass
spontaneously
• Now must remove pennies secondary to
increased zinc in the pennies
• Atypical coins often corrosive
Chuck E. Cheese
Carousel Craze
Magnets
Case:
• 17 yr old male with autism and pica
who complained of 1 week h/o vague
abdominal pain. No other symptoms
present
• AXR with 14 radioopaque objects
scattered throughout GI tract
Magnets in the Stomach
Magnets
Magnets
Magnets
• Small and powerful magnets are being used
more commonly in children’s toys
• CPSC aware of numerous injuries and deaths
secondary to magnet ingestions
• Ingestion of multiple magnets or coingestion
with a metallic object can pose unique health
hazards to children
Magnets
 Intestinal obstruction, perforation, fistula formation,
volvulus, ischemia, death
 Multiple magnets should be endoscopically removed
if possible
 Ingestion of multiple magnets and signs of intestinal
obstruction need emergent surgical evaluation
 CPSC announced recalls of numerous magnetic sets
 Pediatricians should include the dangers of
detachable magnets in toddler safety discussions
Button
Batteries
Button Batteries (BB)
• 3,500 cases of BB ingestions reported to poison control
centers annually
• Batteries from watches, remote controls, hearing aides,
cameras, calculators, singing greeting cards, and toys
• 90% of the batteries pass spontaneously.
• Complications include perforation, mediastinitis, stricture,
tracheoesophageal fistula, and death
• Sevenfold increase in the number of severe complications
from BB ingestion in the past few years (from 0.5% to 3%)
Button Batteries
• Newer batteries stronger than the older
batteries.
• Lithium batteries starting with number 20 are
responsibly for 90% of serious injuries.
• Federal safety rules require toys with BB to
have battery compartments locked with screws
• Devices for adults often have simple plastic
cover
Button Batteries
• Can be true medical or surgical emergency
• BB contain 25- 45% solution of either potassium
or sodium hydroxide
• BB cause tissue injury by:
– Low-voltage electrical burns
– Pressure necrosis
– Corrosive injury due to liquefaction necrosis from
leakage of alkaline solution
Button Batteries - Management
• Tx depends on location- need immediate X-rays
• Ipecac not recommended
• Administration of charcoal or neutralizing
solution is not helpful
Management of Esophageal BB
• Urgent endoscopic removal if lodged in the
esophagus.
• Esophageal damage can occur within 2 hrs after
ingestion
• Once remove battery, must inspect for mucosal
damage
• If there is a tissue damage, Barium swallow
should be obtained 24-36 hrs later to r/o fistula
• Repeat Ba swallow 10-14 days later to r/o
stricture or fistula
Management- BB in the Stomach
• In the stomach- can be more conservative
• All but the largest (>20 mm) should pass
• May be treated as an outpatient.
( Parents to strain the stools)
• Repeat abdominal film in 48 hrs if doesn’t
pass. If still in stomach - remove
endoscopically.
Management- BB past the Pylorus
• Repeat films until battery passed
• Can get “hung up” in the ileocecal valve
• Surgical removal if BB fails to move after
5 days or pt develops abdominal pain or
peritoneal irritation
Sharp/Pointed
Objects
Case:
 2 yo girl swallowed a barrette two hours ago.
 No abdominal pain, vomiting, or respiratory symptoms.
 CXR confirms that the 5 cm barrette is located in the
stomach.
Barrette in Stomach
Sharp/Pointed Objects
 Account for 10% of FB ingestions, but responsible
for most # of GI complications
 Bones, pins, toothpicks, nails, razors, glass
 15-35% of perforations are from sharp objects
 Perforations usually occur in the duodenum,
ligament of Treitz, ileocecal valve
Sharp Objects in the Esophagus
 X-ray to document location.
 Esophageal sharp objects should be removed
immediately
 High risk objects often need to be removed with
an overtube (glass, open safety pin, razors, &
needles)
Overtube for endoscopic removal
Sharp Objects in the Stomach
 Longer than 5cm (3 cm for a toddler) or greater
than 2 cm in diameter unlikely to pass
 High risk objects (bones, long straight pins, razors,
& toothpicks)-remove immediately
 Can manage small nails, screws, pins, &
thumbtacks more conservatively
Pointed Objects
Sharp Objects past the Pylorus
 Bowel has a “mural withdrawal reflex”
 Bowel reflexively dilates in response to
contact with a sharp object
 Reflex turns sharp objects; leaving the sharp
end trailing and preventing perforation
Sharp Objects past the Pylorus
• High roughage diet
• Serial abdominal x-rays and evaluation for
symptoms
• If a sharp object stays in one place for 5
days or the patient develops symptoms
must be surgically removed.
Food
Impaction
Spaghetti
…and Meatball
Underlying Stricture
Food Impaction
 Hot dogs, chicken, and meat
 Consider underlying GI problem
 Strictures
 Eosinophilic esophagitis
 X-ray only helpful to check for bones
 Barium studies can lead to aspiration
Food Impaction
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If asymptomatic; can wait up to 12 hrs to remove
Can try glucagon if asymptomatic
Do not try papain/meat tenderizer
Drooling- urgent endoscopy required
Food should not be pushed into the stomachremove in fragments
 If the impaction passes, still needs an endoscopy in
the near future to evaluate for potential GI pathology
Case
• 11 yr old boy who began drooling after eating
chicken. Vomits after the introduction of any
liquids. In ER pt continues to drool or spit out
his secretions. Otherwise asymtomatic.
• PMHx is remarkable for seasonal allergies
• Upon review, the patient has had some mild
episodes of dysphagia in the past
Chicken Impaction
Eosinophilic Esophagitis
Normal Esophagus
Eosinophilic Esophagitis
Eosinophilic Esophagitis (EE)
• Marked rise in EE in pediatric and adult
population
• Pts with EE can have food impaction from
dysmotility, edema, or stricture formation
• School aged children and adults with EE often
present with food impaction as their initial
presentation of the disease
• Important to ask about dysphagia in pts with
reflux symptoms and h/o atopy
• Patients with feeding aversion should have a
work up for EE
The End