Foreign Body Ingestion

Alexandra Murray, OMSIII

 January 06, 2014

Complications from foreign body ingestion affect thousands of people each year and are responsible for approximately 1,500 deaths annually. ^[1,2] Foreign bodies can create a unique set of problems depending on whether they become lodged in the airway or GI tract. The course of treatment varies depending on the type of object ingested, the size of the foreign body and the patient’s age.

Aspirated Objects

Of aspirated foreign bodies, 80-90% become lodged in the bronchi whereas larger objects tend to become lodged in the larynx or trachea. ^[3] The location of the obstruction can sometimes be deciphered by certain clinical cues. Laryngeal foreign bodies can present with hoarseness or aphonia, whereas tracheal obstructions may present with asthma-like wheezing. Patients with foreign bodies in the bronchus typically demonstrate cough, unilateral wheezing and/or decreased breath sounds.^[3]

GI Foreign Bodies

Foreign bodies that are swallowed may become lodged at any point in the GI tract. Most foreign bodies that are identified in the esophagus must be removed, as well as foreign bodies that are too large to pass through the pyloric sphincter. Objects that reach the stomach can usually pass through the rest of the GI tract spontaneously without further complication. Foreign bodies that require immediate removal include objects that are very sharp, toxic (batteries) or magnetic. Safety pins, needles and other piercing objects must be removed immediately due to risk of bowel perforation. ^[1-5] In the case of batteries, recent studies suggest that the real danger from batteries is not necessarily the leakage of alkaline material, but the development of a current through gastrointestinal tissues leading to hydrolysis of tissue fluids and production of hydroxide ions at the negative pole of the battery. ^[6] Magnetic objects can be dangerous due to formation of magnetic fields that create pressure necrosis, fistulas and bowel perforation. ^[4]

Children

Children under the age of four are the most common culprits of foreign body ingestion. Children may not present to the ED immediately if the event was unwitnessed since it may take time for complications to develop. Children with foreign body ingestion may appear asymptomatic or have vague symptoms such as dysphagia, weight loss, drooling, emesis, chest pain, sore throat, stridor, cough, altered mental status or fever. ^[1-5] Typically, ingested foreign bodies include bones (fish, chicken) and common household items such as small toys, beads, button batteries and erasers. Coins are the most common ingested object by children (70% of reported cases), whereas peanuts are the most common objects to be aspirated. ^[1-5]

Adults

Unlike children, adults tend to present to the ED immediately after foreign body ingestion since the majority of events are accidental. Obstructive lesions or motility disorders of the esophagus such as GERD, hiatal hernia, abnormal rings/strictures and eosinophilic esophagitis have been identified as risk factors for acute food impaction. ^[1,5] Individuals with these risk factors who develop obstruction have the predisposition to choke on poorly chewed meat, leading to the disorder known as “steakhouse syndrome.” ^[7] Accidental ingestion may occur in “body packers” or i“body stuffers” who have been known to ingest packaged illegal substances (heroin, cocaine) in order to avoid detection. If these packages rupture within the carrier, toxicity can occur rapidly. ^[8]

Diagnostic Testing and Treatment

Initial evaluation typically involves AP and lateral X-rays of the airway and chest. Radiopaque objects will readily appear, and radiolucent objects may be appreciated by looking for secondary signs of airway compression, atelectasis and hyperinflation. Ingestion of a small amount of contrast material may allow visualization of filling defects and confirm the presence of a radiolucent foreign body. However, this may increase the risk of aspiration and obscure endoscopy visualization and you should consult your GI specialist beforehand. Handheld metal detectors are sensitive and specific for identifying ingested metal objects. ^[1-5,9]

There are several techniques that are used to relieve obstructions. However, the most commonly used technique with the highest success rate is flexible endoscopy. The flexible endoscope has lower complication rates and higher patient comfort ratings compared to other instruments. ^[1-5] If the obstruction does not require emergent removal and a less invasive approach is desired, glucagon can be administered to promote passage of a bolus by reducing the resting pressure of the smooth muscle at the lower esophageal sphincter. ^[10]