Epidemiology

According to the most recent Annual Report from the American Association of Poison Control Centers (AAPCC), there were 2,334,004 human exposures in the year 2011. Of these exposures, 49% of them occurred in children 5 years of age or younger. Although it is difficult to extrapolate how many of these were true caustic ingestions, 11.9% of children 6 years of age or younger (277,746 patients) sought medical attention for their exposure. The most frequently ingested substances in children younger than 5 years of age in the United States were cosmetics/personal care products (14%), analgesics (9.9%), and household cleaning substances (9.2%), A male predominance of ingestion was found in children younger than 12 years of age and younger, whereas a female predominance occurred in teens older than 13 years. In children 12 years or younger, the majority of exposures were unintentional. This, however, changes in teens 13 years of age and older, with the majority of exposures done with the intent of self-harm or suicide.

The unintentional ingestion of corrosive substances has been declining in developed countries through education and safety measures such as warning labels and child safety caps. In stark contrast, caustic ingestion remains a major problem in developing countries, where it still remains a significant cause of morbidity and mortality in children. The method by which known caustic agents are stored and handled may have a significant impact on the accessibility of these products to young children. Countries that have established national prevention programs targeted at parents of young children have experienced a decline in accidental exposures and esophageal injuries. For example, the Poison Prevention Packaging Act of 1970 stated that caustic agents should have “special packaging” that is designed to be difficult for children younger than 5 years of age to open, and that the amount of the caustic agent should be limited to 10% of the product. In developing countries, where prevention campaigns are not as widespread, children continue to have high rates of caustic ingestion and may come to medical attention later with more severe injuries. One of the mechanisms that leads to caustic exposure in developing countries is the use of secondary containers. Secondary containers that are unlabeled may be used to store household products or even sold in open marketplaces with serious consequences when consumed.

Alkaline agents account for most caustic ingestions in the developed world, with bleach being a common household ingestion. Table 18-1 lists many of the common alkaline and acidic household agents that are implicated in caustic ingestions. In a published series evaluating 473 pediatric caustic ingestions, the most common agents consumed were household bleach (36.6% of patients) and oven cleaner (23% of patients). Other common agents include dishwashing liquids, drain cleaners, and cosmetic products.

Household bleach usually contains sodium hypochlorite at a concentration between 5% and 10%, with a pH ranging from 10.8 to 11.4, when manufactured in the United States. Therefore, unintentional ingestion produces minimal injury to the gastrointestinal tract; how­ever, ingestion of large quantities of bleach has been associated with serious damage. Sodium hydroxide (NaOH) or lye is found in drain and oven cleaners as well as dishwasher detergent. Lye can produce severe injury to the gastrointestinal tract, such as perforation and strictures (see Figure 18-1 ). Hair relaxer is another common household liquid. The ingestion of hair relaxers, which are alkali products, does not typically result in significant injury, although pain and minor erythema of the mouth may occur.

(A) Esophagram of a 5-year-old boy demonstrating a long stricture after lye ingestion. (B) Endoscopic view of the same patient in the proximal esophagus looking at the top of the stricture. The arrow is pointing to the area of the stricture.

Acid ingestion accounts for less than 5% of all caustic ingestions in the United States, but is much more common in countries like India and Surinam where hydrochloric acid, glacial acetic acid, and sulfuric acid are easily accessible. In the United States, acids are commonly found in toilet bowel cleaners (sulfuric, hydrochloric), anti-rust compounds (hydrochloric, oxalic, hydrofluoric), battery fluids (sulfuric), and swimming pool cleaners (hydrochloric).

Pathophysiology

The severity of injury to the gastrointestinal tract is dependent on the agent’s pH, concentration, tissue contact time, amount ingested, and the ingested form of the agent (liquid, gel, or solid). Acidic suspensions with a pH of less than 2 and alkaline suspensions with a pH greater than 12 are considered highly caustic agents. The solution concentration is a significant predictor of esophageal injury. In a rat model investigating the concentration and tissue contact time of lye, or NaOH, on a rat esophagus, concentrations of 1.83% were sufficient to cause epithelial necrosis, concentrations of 7.33% induced submucosal damage, and concentrations of 14.33% resulted in muscle and adventitial damage. In this same study, 10 minutes of contact time was sufficient to stimulate necrosis, even at the lowest concentration of 1.83%. At higher concentrations, a 22.5% solution of NaOH in contact with the esophagus for 10 seconds or 30% NaOH for 1 second can produce a full-thickness injury.

The physical state of the ingested agent also plays a role in the type of tissue injury. Solid agents are more likely to affect the supraglottic and oropharynx area. Powdered or crystalized particles are more likely to affect the airways, pharynx, and upper esophagus. Crystals tend to adhere to mucosa and thus may lead to more injury due to increased contact time. Liquid agents have increased surface area exposure, thereby leading to more circumferential injury. In addition, liquids can pass through the esophagus reaching the stomach and small bowel, which leads to injury that is more extensive. In animal studies of liquid alkaline ingestion, reflux of the agent into the esophagus was found to occur and cause more extensive damage of the esophagus and stomach prior to passage into the small bowel. Finally, the amount of caustic agent ingested affects injury. Alkaline agents are tasteless, which usually results in larger quantities being ingested. Alternatively, the unpleasant taste of acids tends to limit the amount of acid ingested in unintentional cases.

Acids produce tissue injury because of coagulation necrosis. The formation of eschar has been hypothesized to limit further acid penetration and lessen depth of injury. The development of eschar may also lead to preferential damage of the stomach; these beliefs have been questioned with recent reports of serious esophageal injury caused by acid ingestion. In addition, the low viscosity and specific gravity of acids result in rapid transit to the stomach, and gastric injury is more common than esophageal injury, especially in the prepyloric area. Alkaline agents bind with tissue proteins producing liquefactive necrosis and saponification, resulting in increased depth of tissue injury. Alkali ingestion produces thrombosis in blood vessels, thereby impeding blood flow to already damaged tissue. Free radical damage with consequent lipid peroxidation may also contribute to esophageal damage.

The timeline for esophageal injury begins within minutes after ingestion, and persists for hours afterward. Initial tissue injury begins with eosinophilic necrosis with accompanied swelling and hemorrhagic congestion. Marked mucosal sloughing and ulceration of the esophagus occurs 4 to 7 days after ingestion, which leads to bacterial infiltration. Fibroblasts appear at injury sites around day 4 or 5 after ingestion, and this window of time is characterized by further inflammation and the initial appearance of granulation tissue. The ulcerated tissue develops a fibrinous layer. Deep ulceration into the muscle layer may lead to perforation at this time. By day 10 postingestion, esophageal repair begins. Epithelialization of denuded tissue begins one month after initial exposure. The tensile strength of the injured tissue is low during the first 3 weeks after injury. Starting in week 3, scar retraction occurs. The result of this phase, which lasts for several months, is stricture formation and shortening of the involved segment of tissue.

Clinical Presentation

Common features on presentation after caustic ingestion include drooling, vomiting, refusal of intake by mouth, and abdominal pain. The patient may also experience visible mouth lesions such as erythema and or ulceration of the lips and oral mucosa. Hoarseness and stridor suggest upper airway and or epiglottic involvement; dysphagia and odynophagia point toward esophageal injury, whereas epigastric pain and bleeding are suggestive of stomach involvement.

The relationship between symptoms and severity of injury is uncertain. There have been conflicting studies in the literature, correlating symptoms with extent of gastrointestinal injury. Crain et al. demonstrated that the presence of two or more signs or symptoms, including vomiting, drooling, or stridor, predicted serious esophageal injury. Nuttitnen et al. suggested that the combination of drooling and dysphagia correlated well with esophageal injury. A subsequent study by Chen et al. supported that children with three or more signs and symptoms tended to have severe esophageal injury ( p = 0.027) and esophageal stricture ( p = 0.05). These studies have been refuted by several others that have shown that the presence or absence of symptoms does not predict the likelihood or extent of gastrointestinal injury. In a review of 378 pediatric ingestions by Gaudreault et al., 12% of asymptomatic children had severe esophageal burns, whereas 82% of symptomatic children had no esophageal burns. Dogan et al. illustrated that the presence or absence of oral lesions is a poor indicator of esophageal injury. In this study of 473 pediatric caustic ingestions, primarily of alkaline agents, 240 (61%) of 389 patients without oral cavity burns had esophageal lesions found at endoscopy; 80% of patients had an esophageal injury; and 17% of patients had gastric injury. Additional studies have demonstrated the discordance between oral and esophageal injury.

Clinical Assessment

The clinical assessment of a patient after a caustic ingestion involves a thorough physical examination and care­ful history. The physical examination should include an airway assessment and evaluation of the mouth for oral lesions. The history should involve obtaining the identity of the ingested material, its pH and estimated volume, and the approximate timing of the ingestion. It is also important to determine if the ingestion was accidental or intentional, since suicide attempts are more likely to involve larger volumes compared with patients who ingested the agent accidentally.

Patients with caustic ingestion are at risk for hemolysis, disseminated intravascular coagulation, renal failure, and liver failure; therefore, laboratory studies may be useful in guiding patient management, but not in predicting morbidity or mortality. There have been attempts to correlate laboratory values with ingestion of severity. Rigo et al. found a white blood cell count greater than 20,000 cells/mm ³ to be a predictor of mortality. A later study refuted this and found no correlation between C-reactive protein or white blood cell count with esophageal injury morbidity or mortality.

A plain radiograph of the chest may reveal air in the mediastinum, suggesting esophageal perforation, as well as free air under the diaphragm, indicating gastric perforation. An upper gastrointestinal contrast study is generally not indicated. If it is deemed necessary, then a water-soluble contrast agent is preferred over barium. A computed tomography (CT) scan can be done to get a detailed evaluation about the transmural damage of esophageal and gastric walls and the extent of necrosis. It has been suggested that CT may be an equal or superior alternative to endoscopy to predict extent of injury and esophageal stricture.

Role of Endoscopy

Esophagogastroduodenoscopy (EGD) is a vital tool in the initial evaluation of patients who have had a caustic ingestion. The recommended timing of endoscopy is 12 to 48 hours after caustic ingestion, although it has been reported safe to perform endoscopy up until 96 hours. Endoscopy is generally avoided 5 to 15 days after caustic ingestion, since this is when the esophagus is at its weakest integrity and highest risk of perforation. EGD should be performed with anesthesia present to provide adequate airway protection via orotracheal or nasotracheal intubation. Once the degree of injury is known, treatment and prognosis can be determined. In the past, endoscopists usually stopped at the first evidence of severe injury, but some centers now consider it appropriate to identify the full extent of injury, at least to the level of the duodenum. Air insufflation should be minimized to decrease the risk of a perforation through a deeply ulcerated area. The procedure should be terminated if a perforation is suspected or encountered.

The purpose of endoscopy is to categorize the extent and grade of injury according to Zargar’s classification (see Table 18-2 ). Grade 0 and 1 lesions usually do not develop delayed esophageal complication, such as strictures or gastric outlet obstruction. As lesion grade severity increases, the likelihood of stricture formation also increases. The incidence of stricture for a grade 2b burn may be as high as 71%, and anywhere from 75% to 100% stricture rate after grade 3 caustic burns. Furthermore, the degree of esophageal injury at endoscopy is an accurate predictor of systemic complications and death, with each increased injury grade correlated with a ninefold increase in morbidity and mortality. In a large study of 473 patients who underwent endoscopy after caustic ingestion, 379 patients sustained esophageal lesions (80%), whereas 81 children sustained gastric damage (17%). The majority of children were diagnosed with mild lesions, Zargar’s stage 1 to 2a.

Acute Management

The most important initial factors in management include determining whether the patient is at risk for respiratory compromise or impending shock. Initial management includes an airway assessment, with possible endotracheal, nasotracheal, or surgical airway, when necessary. The presence of supraglottic or epiglottic burns with erythema and edema may be a sign of airway obstruction and is an indication for early endotracheal intubation. Fluid resuscitation should be started in patients who demonstrate hemodynamic instability.

A conservative watch and observe approach can be taken after ingestion of certain products, in patients who are asymptomatic, and in patients without oral lesions. It is important that patients discharged after observation have follow-up to ensure no long-term complications and to provide preventive teaching. Symptomatic patients and/or patients with oral lesions should be admitted to the hospital, designated as nil per os (NPO), and started on intravenous fluids.

If there are concerns regarding severe esophageal and gastric necrosis, antibiotic therapy should be initiated and emergency esophagogastrectomy may be required to avoid extension of corrosion to nearby organs. The presence of shock, fever, or prostration indicates profound tissue damage and requires immediate surgical consultation. Gastric perforation is almost invariably fatal as a result of toxic and septic effects of acute hemorrhagic pancreatitis, multiple bowel perforations, and peritonitis. Urgent and aggressive surgical debridement of all necrotic tissue in the chest and abdomen has been shown to significantly improve survival. Endoscopy in the setting of a suspected perforation should be performed only in concert with the surgeon, and only if required for planning the surgical approach.

Induced vomiting is contraindicated after caustic ingestion, to avoid re-exposing the esophagus and airway to the caustic material. Charcoal administration is not recommended, since it does not absorb caustic agents. Consuming either a weak acid or base to induce pH neutralization has been shown effective in animal studies. There is a concern of potentially compounding injury by inducing an exothermic reaction. There are no human data to support pH neutralization, and it is currently not recommended. Consuming milk or water as a dilution therapy has been suggested for patients with caustic agents. An animal model demonstrated that the consumption of milk and water after 50% sodium hydrochloride ingestion decreased esophageal injury. Because of the risk of vomiting with dilution therapy and the lack of human data, there is no evidence to support this kind of therapy in patients.

To minimize the reflux of gastric contents into the esophagus, thereby minimizing esophageal injury, initiation of proton pump inhibitors and H2 blockers is recommended 24 hours after caustic ingestion. This recommendation is based on one study that demonstrated increased gastric injury when H2 blockers were administered immediately following corrosive ingestion. The study’s hypothesis was that decreased acid led to decreased neutralization of the caustic agent, thereby leading to more injury. There has been no human data proving or disproving this study. Once acid-blocking therapy is instituted, it is generally recommended that treatment is continued in order to reduce the risk of accelerating stricture formation by gastroesophageal reflux.

Prevention of Strictures

A chronic long-term complication of caustic ingestions is stricture formation. The overall rate of stricture development after a caustic ingestion has been reported to be from 26% to 55%. The risk for stricture formation may be as high as 77% in patients with grade IIb lesions, and the risk may reach 100% in patients with grade III lesions. Stricture formation can occur as early as 3 weeks following ingestion and is usually confirmed in 80% of the patients by 8 weeks.

Corticosteroids have been proposed as a treatment to reduce stricture formation after caustic ingestion. The rationale for corticosteroid use in this setting is due to their ability to attenuate inflammation, granulation, and fibrous tissue formation. In a prospective study, Anderson et al. showed no benefit from systemic steroid administration in children after caustic ingestion, and that the development of strictures was related only to the severity of injury. Conversely, a study by Boukthir et al. found that high doses of methylprednisolone were beneficial in patients with grade 2b esophageal lesions, with a decreased incidence of stricture formation and decreased need for bougienage after stricture formation. An early meta-analysis by Howell et al. showed a benefit to steroids in stricture prevention. However, two more recent meta-analyses have shown that corticosteroids are of no benefit and do not significantly decrease the incidence of strictures after corrosive ingestion and therefore recommend the abandonment of this practice. Corticosteroids remain a controversial treatment for stricture prevention but in general are no longer recommended.

The use of antibiotics is recommended in the setting of caustic ingestion with associated signs of infection, peritonitis, or mediastinitis. Antibiotics are also warranted in patients with full-thickness injury, since they are at a high risk for perforation because of the loss of the mucosal and muscular barriers. The role of antibiotics in stricture prevention is less clear. In theory, antibiotics reduce the bacterial count in the wound, thereby decreasing inflammation and reducing scar tissue formation. Currently there are not sufficient human data to support the global use of antibiotics in patients with caustic ingestion. Patients treated with steroids should also be treated with antibiotics, since steroids may mask signs of perforation and infection, but prophylactic antibiotics to prevent strictures, in the absence of steroid therapy, has not been advocated.

Stricture Management

First-line treatment for strictures is dilation. Balloon or mechanical (bougienage) dilators can both carry out dilation. The most common type of mechanical dilators are Savary-Gilliard dilators, which are passed over a guidewire and deliver both radial and longitudinal force to the stricture. Balloons deliver equal radial force simultaneously across the entire length of the stricture. Balloon dilation can be performed through the endoscope or over a guidewire. There is no clear difference in effectiveness and safety between balloon and mechanical dilation. The method of choice depends on operator experience and comfort with the equipment.

Timely evaluation and dilation of the stricture is crucial in obtaining a good outcome. Likewise, the late onset of treatment has been shown to be a strong predictor of future esophageal replacement. Dilation should be avoided from 7 to 21 days post ingestion to minimize risk of perforation. Although early prophylactic dilation with bougienage has been reported to be safe and effective in this period, it is generally recommended to start dilations after 21 days postingestion. The interval between dilations varies from weekly to every 2 to 3 weeks. The total number of dilations required to maintain lumen patency is highly variable. Intralesional corticosteroid (triamcinolone acetonide) injections into the stricture site have been shown to reduce the total number of dilations needed in small case studies. However, intralesional steroid injections can be difficult to place and are less effective in long strictures. In addition, there is no standard dose or frequency of steroid used to treat strictures.

Mitomycin C is an anti-neoplastic agent that disrupts base paring of DNA molecules, inhibits fibroblast proliferation, and induces apoptosis at higher doses. It has been proposed as an adjunct therapy for management of caustic strictures. Mitomycin C is mainly placed topically ( Figure 18-2 ); however, there are reports of injection of mitomycin C. The dose of mitomycin C is also variable, ranging from 0.004 mg/mL to 1 mg/mL. A systematic review of the literature suggests promising long-term benefits of mitomycin C, but prospective studies are needed to determine the most effective concentration, duration, and frequency of application. There is a hypothetical risk of secondary malignancy with mitomycin C, so this must be taken into account and discussed with the patient before use.

Application of mitomycin C to dilated, stenotic lesion in the esophagus. (A) Dry pledget is advanced from clear plastic hood on endoscope. (B) Mitomycin C is injected down forceps sheath onto pledget. (C) Pledget is held on mucosa at site of dilation. (D) Pledget is withdrawn into hood for safe removal.

The use of self-expanding plastic stents (SEPS) and fully covered self-expanding metal stents (FCSEMS) has been reported to provide an alternative or adjunctive means of preventing stricture formation by providing continuous dilation of the esophagus for prolonged periods. Broto et al. showed a 50% success rate with SEPS and Zhang et al. reported a 75% success rate using FCSEMS. Both studies are limited by their small sample size and retrospective design. The use of “dynamic stents,” which are custom silicon stents attached to a nasogastric tube, has been proposed as a useful treatment for caustic strictures. In several published series the reported healing of the strictures with intraluminal stents was 96%, 72%, and 69%, respectively. These authors hypothesize that the dynamic effect of food passage between the stent and the esophageal wall allows for the long-term improvement of esophageal patency.

Biodegradable stents (poly-L-lactide or polydioxanone) are a newer technology that has been under evaluation for benign strictures. In the largest study to date, 9 (45%) of 20 patients were dysphagia free at 6-month follow-up. A pediatric study of seven patients with caustic ingestion reported complete or partial benefit in three patients. The reported stent migration rate is approximately 10%, and with stent degradation there is also a significant hyperplastic tissue response. Biodegradable stents along with the other above-mentioned stents show promise but still require further investigation before more widespread use.

Strictures often develop after caustic ingestion, and repeated dilations may be required over a period of years to maintain adequate esophageal diameter. Symptoms that indicate the need for stricture dilation include odynophagia, dysphagia, or decreased oral intake with weight loss. Kukkady et al. described a case series of 10 patients with known esophageal stricture after caustic injuries that were followed over time. They reported that a total of 424 dilations were performed in these patients over the course of 9 months to 4 years, with esophageal perforation occurring in two patients. In developing countries, children may present later with caustic injury and esophageal strictures, which leads to the development of more severe, fibrotic esophageal stenotic lesions. Esophageal perforation rates at the time of endoscopy in these regions have been reported to be as high as 18%. Other severe complications such as mediastinitis, pneumothorax, peritoneal soiling, or brain abscess have been reported at the time of stricture dilation.

Surgery may be necessary in cases where dilation fails to produce adequate lumen size to permit only minimal dysphagia symptoms. Surgical procedures performed include partial esophagectomy, local resection of the stricture, and esophageal replacement. Types of esophageal replacement include gastric pull-up, gastric tube, colon interposition, and jejunal interposition. The most common operations are gastric pull-up and colon interposition. In a study of 173 patients with gastric pull-up over a 21-year period, Spitz et al. overall reported good functional outcome with no graft failures. Postoperative complications included 9 deaths (5.2%); anastomotic leaks occurred in 21 patients (12%) of which 11 resolved spontaneously, and anastomotic strictures requiring dilation occurred in 19.6%. Long-term morbidities in another study included significant gastroesophageal reflux and delayed gastric emptying.

Colon interposition is a common esophageal-replacement surgery. Accepted disadvantages with this approach include the need for three anastomoses, increased risk of anastomotic leak, and strictures at the proximal esophagocolic anastomosis due to poor vascularity. Hamza et al. reported a 30-year experience of 775 patients with colonic interposition, mainly in patients with caustic strictures. Reported complications included a 10% cervical leak rate, 5% proximal strictures, 2% postoperative obstruction, and 1% mortality. Other studies have reported a cervical leak rate ranging from 30% to 60%. In addition, long-term complications include redundancy, tortuosity, and dilation of the colonic conduit in 3% to 12% of patients. These long-term complications can lead to dysphagia, early satiety, respiratory difficulties, and gastroesophageal reflux. The native esophagus can be left in and bypassed, or removed. It has been shown that the affected esophagus can be resected without a substantial increase in morbidity and mortality compared to bypass. Given the 13% incidence of esophageal cancer after bypass, the risk of infected esophageal mucocele in 50% of the patients after 5 years, and the impossibility of endoscopic follow-up for cancer, the preferred option for children is esophageal resection.

Dysmotility

Esophageal and gastric dysmotility can occur when the lower third of the esophagus is involved in the burn. Depending on the depth of the scar, the myenteric plexus may be damaged and the normal syncytium of smooth muscle cells may be interrupted. Dysmotility is also caused by auto-vagotomy secondary to nerve entrapment secondary to scar formation. Impaired vagal cholinergic transmission may also affect gallbladder and gastric emptying, especially in patients for whom caustic ingestion affects the lower esophagus.

Cancer Risk

A late complication of caustic ingestion is esophageal cancer. Both adenocarcinoma and squamous cell carcinoma have been reported at a rate of 1000 to 3000 times higher than the normal population. The incidence of esophageal carcinoma ranges from 2% to 30%. The time to presentation of esophageal carcinoma has been reported to be 10 to 30 years from the time of caustic ingestion. The most common location for carcinoma is at an area of stenosis. There is controversy regarding the need for cancer surveillance in this patient population. It has been suggested that periodic endoscopy should be considered starting 20 years after the initial ingestion; however, there are no formal recommendations.

Gastric Injury

Gastric outlet obstruction can occur after both alkali and acid ingestion. Early surgery has been reported to decrease mortality and morbidity. Endoscopic gastric dilation has been considered an alternative to surgery, but dilations have a less than 50% success rate in preventing surgery. In the setting of severe gastric adhesions and significant duodenal injury, gastrojejunostomy should be considered as an alternative to gastric resection. Partial gastric resection has been proposed as prophylaxis for gastric malignancy. However, previous reports of gastric carcinomas after acid ingestion are limited. Regular follow-up and surveillance endoscopy is the more preferred approach, although, as for the esophagus, there are no standard guidelines.

Epidemiology

The 2011 Annual Report from the American Association of Poison Control Centers (AAPCC) reported 112,562 foreign body ingestions representing all age groups. Of these, 73% occurred in children younger than 5 years of age and more than 85% occurred within the pediatric population. These numbers are an underrepresentation of the total number of foreign bodies, since up to 40% of foreign body ingestions in children go unwitnessed. Because many foreign body ingestions are asymptomatic, the true incidence of foreign body ingestions in children is likely higher than the reported data. The peak incidence age range of foreign body ingestion in children is between 6 months and 6 years. There is equal incidence among boys and girls.

It is estimated that 98% of foreign body ingestions in children are accidental. The majority of children who swallow a foreign body are healthy; however, some children may have a condition that predisposes them to retain a swallowed object. Diseases such as strictures, rings, achalasia, esophagitis (including eosinophilic esophagitis), and a tight Nissen fundoplication should all be considered when a patient presents with a foreign body.

Types of Foreign Body ingestion

The most common foreign body ingested by children in the United States is a coin. Other common objects ingested by children include small toys, game pieces, batteries, magnets, marbles, and small earrings ( Figures 18-3 and 18-4 ). In other countries, the types of foreign bodies ingested by children may differ based on cultural practices. For example, in Asian countries where fish (without removal of bones) is a dietary staple, fish bones are the most common type of foreign body identified. Pork bones and chicken bones are also frequent offending agents in these cultures.

A small collection of objects removed endoscopically in a single practice.

Trigonometry compass in the stomach of a teenage boy, swallowed while in class. The compass was removed endoscopically.

In adolescents and adults, the most common type of foreign body reported is food impaction, with meat being the most likely item found at endoscopy. Often, underlying pathology exists that predisposes these patients to impaction. Unlike children, intentional ingestions occur often in adolescents and adults. Intentional ingestions are most commonly identified in patients with psychiatric problems, eating disorders, or impairment by alcohol or drugs. It is not unusual to find repeated episodes or multiple objects ingested by these patients.

Initial Assessment

The American Society for Gastrointestinal Endoscopy has published guidelines for the management of ingested foreign bodies in both adults and children. Controlled trials are mostly absent, so guidelines rely on best evidence with careful review of the literature. The acuity of management of ingested foreign bodies is dependent on the presenting signs and symptoms and the duration of time since ingestion, as well as the type of object ingested. A brief medical history should be obtained immediately to determine any underlying medical problems, regular medications, recent drug or alcohol exposure, medication allergies, or previous reaction to anesthetic agents. Physical examination should be performed to further determine the patient’s respiratory status and severity of abdominal symptoms. Whether the foreign body ingestion is witnessed or unwitnessed may also play a role in the outcome for the patient. Several large, retrospective pediatric series of children presenting to the emergency setting with esophageal foreign body have reported that between 16% and 25% of patients have unwitnessed ingestions. For unwitnessed patients younger than 2 years of age, wheeze and fever are more commonly found than in patients with witnessed foreign body aspirations.

A patient with obvious respiratory symptoms, difficulty controlling secretions, or repeated episodes of emesis should be managed emergently. Patients with signs and symptoms of acute abdomen require emergency surgical consultation. Likewise, patients with respiratory distress necessitate emergency consultation with otolaryngology. In 2006, in a series of 555 children presenting to the emergency room setting with a foreign body lodged in the esophagus, the most common clinical symptoms included dysphagia in 37% of patients, drooling in 31% of patients, and choking in 17% of patients. Other common symptoms included cough, abdominal pain, fever, chest pain, wheezing, stridor, vomiting, and refusal to eat. Patients with objects retained at the upper esophageal sphincter typically present with drooling, vomiting, and dysphagia, whereas objects retained at the lower esophageal sphincter typically present with pain. In large pediatric series, cases of asymptomatic foreign body ingestion have been reported to range from approximately 10% to 50% of all cases.

Radiologic Evaluation

Because many children presenting to the emergency department can be asymptomatic, a radiograph of the chest with frontal and lateral views should be obtained in all patients with suspected foreign body ingestion. It is also recommended that additional radiographs of the neck and abdomen are obtained, since objects above the thoracic inlet, or distal to the stomach, will be missed on a chest radiograph.

In a review of 325 consecutive cases of pediatric foreign body ingestions, 64% of patients ingested a radiopaque object, with a high prevalence of coin ingestion, whereas 35% of patients ingested a radiolucent object. Common radiolucent ingestions include food bolus, plastics, glass, or aluminum. Sharp and thin objects such as a pin or a needle, may not be easily visualized by radiograph. Lateral films, a computed tomography (CT) scan, or, less often, a barium swallow may be helpful in the setting of radiolucent foreign body ingestions. Features that can be suggestive of a radiolucent foreign body on a lateral plain film include tracheal compression, tracheal deviation, or air trapped within the esophagus. The use of CT scan in these patients has also been described. Applegate et al. reported successful use of rapid, low-dose spiral CT scanning of the neck and chest in the detection of plastic Lego toys. Ultrasonography, in general, is not helpful for detecting foreign bodies in the gastrointestinal tract, since the object may be hidden by bowel gas.

Caution should be taken when performing a contrast study in patients with suspected foreign body. In symptomatic patients, a contrast study is absolutely contraindicated because of risk of aspiration or barium entering the mediastinum. If the patient is symptomatic but radiologic evidence of a foreign body and its location cannot be determined, it is generally recommended that the patient undergo diagnostic endoscopy, since if the item is visualized, it can be removed at that time. If a contrast study is performed before endoscopy, it must be done with water-soluble contrast in order to minimize lung injury in the event of aspiration.

Specific Radiologic Consideration

Coins and Magnets

Coin ingestion is a common foreign body seen on X-ray. However, it is important to remember that button batteries can be mistaken for coins on X-ray, and mistaking a button battery for a coin can lead to disastrous outcomes. Therefore a coin-shaped foreign body on X-ray requires careful attention. A 20-mm button battery looks similar in size to a penny (19 mm) or a nickel (21 mm). Button batteries appear to have a double ring or halo on radiographs. This is due to the bilaminar structure of the button battery. United States coins do not produce a double ring. Figure 18-5 shows a chest X-ray of a disk battery impacted in the esophagus, with the “double rim” sign that is useful in differentiating a disk battery from a coin. On a lateral view, a button battery has much more rounded edges, with a step-off at the junction of the cathode and anode. This appearance can be mimicked by multiple coins stacked together.

Disk battery impacted in the esophagus. Note the “double rim.”

The location of a coin can be determined with frontal and lateral radiographs of the chest. Conventional teaching maintains that a coin located in the esophagus presents in the coronal plane on a front view chest radiograph, and that a coin located in the trachea presents in the sagittal plane on a lateral view. However, there are numerous reports of esophageal coins presenting in the sagittal plane on frontal view. This is why lateral views of the chest are recommended to properly locate the coin position. In addition, a lateral view can help to determine if there are multiple coins stacked in the esophagus. In some centers, metal detectors have also been used to identify metallic foreign bodies successfully; however, this practice is not widespread.

Common Sites for Foreign Body Impaction

Preexisting Conditions Associated With Foreign Body Ingestion

It is now widely accepted that several preexisting esophageal disorders place patients at risk for foreign body impaction in the esophagus and significant mucosal damage. In a published series of 484 occurrences of pediatric esophageal foreign body impaction, 14% of patients had an underlying esophageal abnormality, with many patients experiencing more than one impaction over the period of 15 years. Preexisting conditions that place patients at risk for esophageal impaction include Schatzki’s ring, eosinophilic esophagitis, severe gastroesophageal reflux disease with peptic stricture, tracheoesophageal fistula with previous surgical intervention, esophageal motility disorders, and previous caustic ingestion with subsequent esophageal narrowing.

Management

The type, location, and length of time the item ingested play a key role in determining management. Generally, most swallowed objects pass through the gastrointestinal tract without intervention. Between 50% and 90% of foreign objects pass spontaneously, 10% to 20% require removal, and less than 1% require surgical intervention. Therefore, many objects can be observed once they have made it to the stomach, since they will likely traverse the remainder of the gastrointestinal tract without difficulty. When a conservative observation approach is taken, the stool can be inspected for passage of these objects, with follow-up radiographs every 2 weeks if the object did not pass. A majority of ingested foreign bodies pass within 4 to 6 days, although some objects can take up to a month to pass.

There are objects in the stomach that should be removed more urgently. These objects include magnets, button batteries, sharp objects, and long objects. We discuss these items in more depth in subsequent text, but in general, these objects should be removed if they remain in the stomach for four or more days or if the patient becomes symptomatic. In addition, no foreign body should be left in the esophagus for more than 24 hours under any circumstance. Box 18-1 lists indications for urgent foreign body removal.

Methods of Foreign Body Removal

Endoscopic Methods

Foreign bodies retained in the esophagus may be removed in a number of different ways. Objects have routinely been removed by gastroenterologists, otolaryngologists, or general pediatric surgeons using flexible endoscopy or rigid endoscopy. Endoscopic foreign body removal can be performed under general anesthesia with endotracheal intubation, monitored anesthesia care with propofol, or conscious sedation. If there is a concern regarding aspiration of gastric contents or food material lodged above a foreign body in the esophagus, then endotracheal intubation is recommended. Endoscopic removal is recommended if there is a history of previous foreign body ingestion, esophageal surgery, or evidence of esophageal disease.

Under suitable sedation, the endoscope is passed to the level of the upper esophageal sphincter. A careful examination of these tissues should be performed to ensure no damage from the ingestion and no foreign body affected in this area. Most objects are identified immediately below the upper esophageal sphincter and can be grasped and removed with a rat tooth forceps or similar forceps. If the object is located in the upper esophagus near the cricopharyngeus, clearly sharp, impacted, and likely to perforate the esophagus, rigid endoscopy under general anesthesia with a wide-diameter tube may be required. In adult-sized patients, an endoscopic overtube can be used for sharp objects. The use of an overtube has not been useful in children because of the smaller size of the pharynx and upper esophageal sphincter, which are rarely of sufficient size to accept an overtube.

Objects that reach the stomach can usually be left to pass spontaneously through the bowel. The exception would be a large or long object that cannot negotiate the pylorus, duodenal C loop, or ileocecal valve. Nails and pins usually pass easily into the stomach and onward down the bowel with the blunt end forward. Objects longer than 2 inches (5 cm), such as nails, pencils, or pens, should be removed from the stomach or duodenum, if possible, because they will have difficulty passing the angulated portions of the bowel. Irregularly shaped objects that may adhere to the cardia of the stomach during removal can be pulled up into a “hood,” a device of thick latex that fits over the end of the endoscope ( Figure 18-6 ). If unavailable, a hood can be made from a portion of thick latex surgical glove. Table 18-3 lists some of the tools commonly used for foreign body removal during endoscopy. Figure 18-7 displays various devices that can be used to remove foreign bodies in the upper gastrointestinal tract. In the case of irregularly shaped foreign bodies, attempts should be made outside of the patient to find a similar-shaped object in order to determine the appropriate instrument for extracting the foreign body. In case of doubt or difficulty with extraction, the endoscopist should consult a general surgeon with regard to gastrostomy to remove the object.

Latex hood fits over the endoscope tip. (A) Fitted. (B) Inverted before oral insertion and passed into the stomach. (C) Foreign body withdrawn into hood. (D) Hood flips over foreign body as endoscope is pulled back through lower esophageal sphincter.

TABLE 18-3

FOREIGN BODY REMOVAL TECHNIQUES

Object	Retrieval Tools
Coin and other blunt objects	Rat tooth or alligator forceps, retrieval net
Food bolus	Retrieval net, tripod or pentapod forceps, friction fit adapter
Sharp objects	Polypectomy snare, rat tooth or alligator forceps
Smooth objects	Retrieval net or basket
Long objects	Polypectomy snare, double snare (consider rigid endoscopy)
Batteries	Retrieval net or basket
Safety pin	Combined forceps-snare technique
Objects with a hole	Suture technique

 

Various devices that can be used to remove foreign bodies. (A) Retrieval basket. (B) Three-pronged grasping forceps. (C) Polypectomy snare.

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