Morning Report: 4/2/2015

Here’s Dr. Wang with today’s Morning Report!

Ingested Foreign Body

• Foreign bodies can be anywhere in the entire GI tract.
• The esophagus has three areas of narrowing where foreign bodies are most likely to become entrapped
  • upper esophageal sphincter (UES)
  • crossover of the aorta
  • lower esophageal sphincter (LES)
  • certain structural abnormalities (strictures, webs, diverticula, or tumors) of the esophagus can increase the risk of foreign body entrapment
• If the foreign body reaches the stomach, it has > 90% of chance of passing
  • If the foreign body is > 2cm in diameter it is less likely to pass the pylorus.
  • Objects >6cm can be entrapped at the pylorus or duodenal sweep. Once the foreign body gets into the small bowel it can be struck at the ileocecal valve.

Presentation:

Oropharyngeal foreign bodies

• Typically patients will endorse foreign body sensation due to the well-innervated area.
• Patients can have airway compromise, which is only seen with delayed presentation with resulting infection or perforation.

Esophageal foreign bodies

• Dysphagia and inability to tolerate secretions are typical complaints.
• Children presents with gagging, vomiting, and neck or throat pain.
• Chronic esophageal foreign bodies in children can present with poor feeding, failure to thrive, stridor, or repetitive pneumonias from aspiration.

Stomach/small intestine foreign bodies

• Typically presents with abdominal pain, vomiting or fever.

Imaging:

• Plain radiographs are done to localize known or suspected radiopaque foreign bodies in the GI tract.
• X-rays are typically done for patients who have swallowed bones even though the yield is low.
• CT is considered the imaging modality of choice to locate radiopaque foreign objects.
  • CT with IV contrast is also indicated if suspicious for perforation or abscess.

Endoscopy Indications:

• Airway compromise
  • Patients who swallowed toothpicks or other sharp objects that are not visible on x-rays but have high rates of complications (possible esophageal injuries).
• Multiple magnets: as they can cause perforation, necrosis, fistula, volvulus, infection or obstruction.
• Button battery
  • In esophagus: URGENT endoscopy due to esophageal wall necrosis within 2 hours. Noted to be round radiopaque density with “double-contour” configuration.
  • In stomach: endoscopy is typically not indicated. Patients have to be monitored for disruption of the battery. Button batteries contain electrolyte solution and heavy metal, and if they break in the GI tract can cause heavy metal poisoning. REPEAT x-rays are indicated in 24-48 hours. If the battery is still in the stomach, endoscopy removal is necessary.
• If foreign body in the stomach or proximal duodenum is >2cm in diameter or longer than 5-7cm or oddly shaped foreign object – due to high risk of perforation.

Disposition

• Oropharngeal foreign bodies: if evaluation is negative in ED, discharge with follow up with ENT
• Esophageal foreign bodies: If foreign body noted in esophagus refer to GI for endoscopy
  • In stable children: if the coin is at the LES – return for repeat x-ray in 12-24 hours. If there is no advancement, refer for endoscopy.
• Stomach/small intestine: if objects are <2cm in width or <6cm in length, can be discharged home.
  • Serial radiographs are generally not indicated.
  • Discharge instructions should include return precautions for fever, vomiting or abdominal pain.
  • Serial radiographs are indicated for sharp or large foreign bodies in the duodenum or small intestine – follow up in 24 hours for repeat x-ray.

References:

• http://emedicine.medscape.com/article/776566-overview
• http://www.uptodate.com/contents/ingested-foreign-bodies-and-food-impactions-inadultssource=search_result&search=ingested+foreign+body&selectedTitle=2~150

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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital

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