FOREIGN BODY ESOPHAGUS PART 1

QnAs

What is the most common age group?

Children particularly between 6 months to 3 years of age (nelson- below 5yrs)

Children comprises of 80% cases of FB esophagus

Older children with developmental delay and Neuromuscular conditions can present

What are common objects of ingestion?

 Coin in children and food bolus in adults are most common objects of ingestion

 Other objects are :

 

  Button Battery

  Sharp objects – pins, needles , fish bones,

  magnets ,

  multicomponent objects—toys

  long objects

  Superadsorbent polymers 

  Lead containing objects

  Wireless endoscopy capsules

Is food impaction common in children?

Food bolus particularly meat is more common in adults

In children food impaction can occur in certain esophageal conditions like;

Eosinophilic esophagitis (92%)

Stenosis

Strictures

Achalasia

Motility disorders

What are the narrowest sites of esophagus?

  Cricopharyngeus (upper esophageal sphincter=UES) Narrowest

  Arch of aorta

  LES (lower esophageal sphincter)

What is the commonest site of FB impaction ?

The most frequent lodgment site in children is at the level of the cricopharyngeus muscle (which is the narrowest part of the esophagus), and in adults it is at the lower esophageal sphincter or at the site of any predisposing lesion.

Since most of the presentations are in children, the overall commonest site of FB presentation in the esophagus is in its upper third.

Does size determine the location of lodgement ?

YES

Large and rigid FBs tend to lodge in the pyriform fossa and esophagus.

While fish bones are usually found in the pharynx

Coins and impacted meat are usually in the proximal and distal parts of the esophagus respectively

What is the risk with sharp objects?

Cause perforation and when get lodged in hypopharynx can cause retropharyngeal abscess.

Why superadsorbent polymers dangerous?

These objects can absorb water and expand 30-60 times in volume predisposing to the risk of bowel obstruction

Anatomical consideration of FB impaction in esophagus.

What percentage of children require intervention?

Most of the fb pass spontaneously.

10- 20% require endoscopic intervention.

Less than 1% require surgical intervention.

How do the patients present ?

Smaller children are unable to provide history of ingestion thus many of the cases  may  be asymptomatic and presentation may get delayed (30% are without symptoms)

Parents may provide history of witnessing the event

Older children and adults are able to provide history

What are the common symptoms?

Dysphagia and odynophagia are the most common symptoms

Other include—drooling ,refusal to eat, globus(sensation sthg sticking in the throat)

Retrosternal chest pain

       Respiratory symptoms like stridor, choking, dyspnea, wheezing--- indicating compression of trachea by FB in esophagus

In case of perforation—neck swelling,pneumomediastinum, crepitus in neck
        

        Features of shock- tachycardia, cold extremities, poor pulse volume and hypotension in cases of perforation.

Long standing esophageal FB can present with

weight loss

recurrent aspiration pneumonia

esophageal strictures

tracheo esophageal fistula

erosion into aorta 

History is important for diagnosis and the nature of object ingested also provides better understanding of location of impaction

How can physical examination help ?

        For supracricoid FB-- adequate visualization of the oral cavity, nasal passages, pharynx                    and larynx is crucial for ruling out an FB in the upper aerodigestive tract.

Tongue depressor, transnasal flexible endoscopy, indirect laryngeal mirror, Mackintosh laryngoscope and flexible pharyngolaryngoscopy may subsequently be utilized.

       For infracricoid follow up and other diagnostic and therapeutic modalities are required.

How do we investigate ?

        X-rays
CT/MRI
USG

        Fluoroscopic study

What is the use of X ray?

Both AP and lateral view X rays are necessary
X ray of chest and abdomen is necessary

How to differentiate between tracheal and esophageal?

        Flat objects in esophagus orient in coronal plane and appear circular in AP view .

 In trachea they tend to orient in sagittal plane and appear circular in lateral view.
 

        These tendencies aren’t universal thus X rays are to be carefully evaluated.
         

         Lateral view also helps in identifying if multiple FBs are stacked over one another or not.

Are X rays useful in case of radiolucent FB?

It is better to do X ray even in cases of radiolucent FB as they can provide some information like

·     Air fluid level in esophagus.

·     Free air s/o perforation.

X rays of Toys with multiple components should be carefully interpreted as they contain both radioopaque and radiolucent components.

What is the use Computed tomography?

·       Symptomatic patients in whom  FB localization is difficult.

·       In cases of large FB i.e. more than 5 cm in length and 3 cm in width or in cases of sharp objects

·       Ct with 3 D reconstruction is useful.

Indications of MRI

MRI can be used for radiolucent FB but should be avoided in cases of metallic foreign body

USG- not used  often but can be useful in the presence of expert radiologist .

What is the use of fluoroscopic UGI study?

 It can be used for identification of location of radiolucent FB.

·      Water soluble contrast media is used

·      Avoid using barium as it can obscure the view in subsequent endoscopy.

What are the indications of urgent removal ?

  Symptoms of respiratory compromise

·       Evidence of near complete obstruction of esophagus

·       Ingestion of sharp or long(>5cm) or superadsorbent objects

·       Button batteries in esophagus

·       Ingestion of high powered magnet or magnets

·       Sign and symptoms of esophageal inflammation

ANY OBJECTS IN ESOPHAGUS FOR > 24 HOURS SHOULD BE REMOVED IRRESPECTIVE OF TYPE OF FB

Role of proteolytic enzymes like papain or glucagon ?

Not recommended

What is the role of proteolytic enzyme and why isn’t it recommended?

Particularly useful for food bolus/meat as it can cause digestion and breakdown of bolus

·      Reports of esophageal erosion, perforation , aspiration pneumonia and hypernatremia have prevented its use.

What is the role of glucagon?

 It relaxes the LES and helps in passage of food bolus.

·      2 small RCTS and a large case series have found that glucagon no more effective than placebo in FB

·      It is useful in people with history of solid food dysphagia.

SPECIFIC MANAGEMENT FOR SPECIFIC FB.

COINS

·         In asymptomatic patients expectant management for first 24 hrs as 20-30 % cases coin spontaneously passes to stomach.

·         In Asymptomatic cases if coin persists after 24 hrs in esophagus or if time of ingestion isn’t known removal is indicated

·         In symptomatic patients removal of FB is done as soon as possible.

What to do for coins in stomach?

If asymptomatic—follow up with weekly X rays as most of them pass but if the coin is in the stomach even after 4 weeks endoscopic removal.

·      Symptomatic cases require immediate removal.

How do we remove coin?

·      Rigid endoscopy for proximal FB and flexible for distal

·      Several case series have shown use of bougienage to push the coin into the stomach for selected patients as effective alternative.(TABLE 2)

·      Some radiologists use Foleys catheter for removal during fluoroscopy with patient in prone. (TABLE 1)

SHARP OBJECTS

·         Immediate endoscopic removal using retrivel forceps

·         Orient the object with the sharp end trailing behind or use a protective hood on the end of the endoscope.

·         Sharp objects in stomach and duodenum should be removed immediately

·         Some Sharp objects (closed safety pin) can be managed like coins

·         Sharp objects in small intestine can be followed up daily with radiographs in asymptomatic cases and surgical intervention is     warranted if no signs of elimination is found even after 3 days

·         Symptomatic cases with sharp objects in intestine warrant immediate intervention.

LONGER OBJECTS

·         Objects longer than 5 cm cannot pass the stomach and thus should be removed.

·         Also longer objects even if they pass stomach can get impacted in the ileocaecal jxn hence removal is ideal

FOOD IMPACTION

·         Same as coin

LEAD CONTAINING OBJECTS

·         As soon as possible

·         PPI/H2 blockers can be used as they prevent dissolution of lead

 TABLE 1

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 TABLE 2

Button battery and magnet is discussed in separate blog.

CLICK HERE TO READ ABOUT BUTTON BATTERY AND MAGNET INGESTION

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Button battery and magnet is discussed in separate blog.