Fig. 26.1
Seven-year-old girl who has swallowed her mother’s earring that is easily recognized on this AP fluoroscopic view. There is no need for a plain radiograph
Fig. 26.2
Two-year-old girl ingestion of a small anchor well identified in the upper third of the esophagus: Fluoroscopic views. (a) AP fluoroscopic view. (b) Lateral fluoroscopic view
The decision to remove the FB is based on its type, shape, nature, and its progression.
Ingested coins, which are the most frequent FB, within the lower esophagus will pass through the stomach in the majority of cases. Those that are impacted will need extraction [1].
Absorbed cells, especially the button-cell types, may produce micro currents and cause digestive wall liquefaction necrosis and thermal lesions (Fig. 26.3).
Sharp objects increase the risk of gastric perforation from 1% to 35% [6]
Fig. 26.3
Ingestion of button cell battery in an 8-year-old girl. Endoscopy revealed a small posterior ulceration. Fluoroscopic views allowing recognition of the nature and the location of the FB. (a) AP fluoroscopic view. (b) Lateral fluoroscopic view
Sharp objects and button-cells need to be removed either endoscopically if accessible or surgically.
26.2.2 Delayed Presentation
The longer the FB remains, the higher the risk of release by the FB of toxic substances (lead, cadmium, mercury, silver, zinc, manganese, cadmium, lithium, sulfur oxide, copper, brass, or steel) [7]. Furthermore, the longer the FB is fixed, the higher the risk of ulceration by compression [8]. Associated structural abnormalities of the lower third of the esophagus (strictures, rings, fundoplication), inflammatory conditions (reflux esophagitis, eosinophilic esophagitis), and motor dysfunction (achalasia) render higher the risk of no progression [8].
In this context of delayed presentation, the FB ingestion is either unrecognized or the symptoms occur during follow-up or even after its retrieval (Fig. 26.4). Within the abdominal cavity, the clinical symptoms are related to obstruction, perforation, or infection. In case of such clinical presentation, abdominal US is the examination of choice and should be completed by an AP plain film of the abdomen looking for radio-opaque FB.
Esophagus, stomach and duodenum:
Substernal pain is classically related to mucosal esophageal ulceration and should be managed rapidly by endoscopy [8].
Exceptional deaths related to vasculo-esophageal fistulas induced by ingested button batteries have been reported. As a rule, all ingested batteries must beneficiate from an endoscopy. In case of severe endoscopic lesion, the option of further thoracic imaging must be considered in order to evaluate the peri-esophageal damage [9].
Gastric obstruction may be related to various large FB including different types of bezoars (lactobezoar, phytobezoar, trichobezoar, medication induced bezoar, mixed-food bezoar). Their US appearance varies demonstrating most commonly an overdistended stomach, in a patient supposedly npo, with a heterogeneous content that may appear too well organized and sometimes acoustic shadowing. Surgical treatment is often required to remove the bezoar.
Lactobezoar is a compact mass made of undigested milk and gastric secretion occurring in neonates. Prematurity, immaturity of gastric motility, discontinuous enteral feeding, treatment for gastro-esophageal reflux and milk with high casein concentration are predisposing factors. Gastric perforation may occur [10]
Other bezoars occur later in childhood and are related to psychiatric or neurological disabilities. A specific entity, the Rapunzel syndrome, includes a gastric trichobezoar extending far below the stomach up to the small intestine [11]; CT is recommended whenever such a pathology is suspected.
Persistence within the stomach even of a non-aggressive FB over 3 weeks will need extraction. On the other hand, flat cell-button may be responsible for electric and toxic burns, ulceration by compression, and general toxicity if their content is released. These risks increase in FB staying for more than 48 h in the stomach. Endoscopic removal is required if the patient is symptomatic or if fragmentation of the battery occurs. Follow-up plain films of the abdomen is recommended to evaluate progression.
Duodenal loop is a classic location prone to block long ingested FB.
Below the duodenum:
Obstruction: The ileo-cecal valve represents a natural obstacle to any kind of FB. Rarely magnets can also cause bowel obstruction, which may lead to volvulus [12, 13]. In this context, the association of abdominal plain film and US are the most adapted imaging explorations.
Perforation:
Earth magnets are typically made of iron, boron, and neodymium and are 5–10 times more powerful than traditional magnets [1]. When multiple, they may lead to perforation or bowel fistula when located on two adjacent bowel loops (Fig. 26.5). In case of suggestive clinical signs, rapid surgical removal is mandatory to suppress the risk of perforation.
Sharp FB, radio-opaque or not, may be responsible for perforation and secondary peritonitis.
Battery cells are rarely responsible for small or large bowel perforation by electric burns. Their transit time is generally too fast to generate such lesion.
US is most useful as it may demonstrate the FB itself (Fig. 26.6) as well as its consequences such as thickened bowel loop, adjacent increased echogenic fat, and eventually extraluminal gas bubbles. If the FB potentially contains metal, a plain film is also helpful (Fig. 26.7).
Interestingly enough, a perforation due to a FB has been described without peritonitis [14].
Infection:
FB within a Meckel’s diverticulum or within the appendix may be responsible for an acute infection. Depending on the local radiological expertise such diagnosis can either be achieved by US, MR imaging, or CT.
Fig. 26.4
Late complication of ingested FB—Same patient as in Fig. 26.3. Two months later the patient presented with unexplained neck stiffness. (a) MR imaging sagittal T2-weighted sequence: Chronic spondylodiscitis C7-Th1. (b) Sagittal reformatted CT: Chronic spondylodiscitis with anterior bone bridging
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