Foreign Body Ingestion
90 - 95% of ingested foreign bodies pass without difficulty.
Who is at risk of ingesting FBs?
- children: 80% of cases.
- elderly: especially oesophageal pathology and dentures
- prisoners and psychiatric patients: intentional ingestion.
Where do FBs get caught?
- cricopharyngeus (C6)
- thoracic inlet (T1)
- aortic arch (T4)
- tracheal bifurcation (T5)
- lower sphincter (T10)
- if an fb passes the pylorus it will usually pass without further difficulty.
- Ileocaecal valve
- Meckel's diverticulum
What are high risk FBs?
- sharp or pointed objects eg. open safety pins
- objects longer than 5 cm or wider than 2 cm rarely traverse the pylorus
- packaged drug ingestion
Symptoms and Signs
- Symptoms relate to complications
- Obstruction: coughing, choking, drooling, vomiting, pain in throat, neck, chest,
- Bleeding: haemoptysis, H & M
- Perforation: s/c emphysema, fever
- Airway impairment: stridor, respiratory compromise
- Leakage: from batteries causing bums and perforations.
- In children: refusal to eat, drooling, stridor.
Usually a single AP CXR is all that is necessary to:
- establish the diagnosis
- determine the location
Asymptomatic children with a history of FB ingestion should be X-rayed.
NB: Coins in the oesophagus lie in the coronal plane (ie. in face in AP film), whereas
those in the trachea lie in the sagittal plane.
Who can be sent home ?
- Asymptomatic patient in whom the FB has passed the oesophagus. Weekly follow up X-ray
- Most FBs pass within 3 - 5 days.
Who should be observed ?
- Asymptomatic oesophageal FBs can be observed for several hours before re X-ray. If
movement has not occurred removal is indicated.
- High risk FBs including packaged drug ingestion.
Who requires intervention?
- Symptomatic oesophageal FBs
- Those with meat impaction can be observed for up to 12 hours awaiting spontaneous
movement if the patient can manage their secretions.
- Oesophageal button batteries even if asymptomatic
- Gastric button batteries if no movement in 2 - 3 days
- Gastric coins if no movement in 2 - 3 weeks.
- Those with obstruction, perforation, haemorrhage.
Special cases and manoeuvres
Oesophageal meat impaction
- Gas forming agents which propel the bolus eg. coke
- glucagon l mg IV followed by 2 mg if no movement has occurred in 20 minutes (smooth
- papain (proteolytic enzyme)
- nifedipine 10 mg. S/L to reduce lower oesophageal pressure
- NB: all patients should have follow-up oesophageal Ix.
Paediatric coin ingestion
- All should be X-rayed in case oesophageal.
- Only complications are from coins in the oesophagus >24 hrs.
Button Battery ingestion
- Can contain: KOH, Hg/Mn/Zn oxide
- 4 mechanisms of injury: corrosion, low voltage bums, pressure necrosis, Hg poisoning.
- All oesophageal batteries need immediate removal
- If oesophageal, need removal
- If intragastric consult with surgeon: 15 - 35% will cause intestinal perforation.
- Manual removal is safest
- Post removal should have X-ray to exclude presence of free gas
- Cocaine packets: danger of perforation if removed endoscopically
Summary of Do's and Dont's:
- always secure the airway
- always evaluate for complications
- always X-ray asymptomatic patients
- always admit asymptomatic but high risk patients
- always provide follow-up.
- don't use ipecac
- don't leave objects in the oesophagus
- don't admit low risk patients
- don't admit non-oesophageal button batteries
Adapted from the
SCGH Emergency Manual