Foreign Body Ingestions

The majority of foreign body ingestions occur in children between the ages of six months and three years. Most cases are brought to medical attention by their parents because the ingestion was witnessed or reported to them. Many of patients are asymptomatic or have transient symptoms at the time of the ingestion. Accidental foreign body ingestion may also occur in adults with learning difficulties. Intentional foreign body ingestion may occur in patients with psychiatric history or in prison inmates.

Clinical management focuses on identifying and treating the cases at risk for complications, which depends on the location and type of foreign body. Commonly ingested objects include coins (most common), button batteries, toys, toy parts, magnets, safety pins, screws, marbles, bones, and food boluses. The majority of ingested foreign bodies (FBs) are low risk objects and can be managed without imaging or intervention.

Anatomical considerations

Most ingested foreign bodies pass spontaneously. Only 10 to 20 percent require endoscopic removal, and less than 1 percent require surgical intervention.

When foreign bodies are retained:

• Oesophageal foreign bodies tend to lodge in areas of physiologic narrowing, such as the upper oesophageal sphincter (cricopharyngeus muscle), the level of the aortic arch, and the lower oesophageal sphincter.
• Objects that become lodged in the middle portion of the oesophagus are more likely to represent oesophageal pathology, such as an oesophageal spasm or stricture.
• Sections of the oesophagus with prior surgery or congenital malformations (e.g. tracheoesophageal fistula) pose an increased risk as sites for obstruction.

Clinical features

• Most cases are brought to medical attention by their parents because the ingestion was witnessed or reported to them. Many of the children are asymptomatic or have transient symptoms at the time of the ingestion.
• Patients with an oesophageal foreign body may present with:
  • Refusal to eat or drink
  • Coughing
  • Dysphagia
  • Drooling
  • Respiratory symptoms due to tracheal/airway compression e.g. wheezing, stridor, choking
  • Sensation of something stuck in neck or lower chest
  • Retrosternal pain
• Objects that reach the stomach are typically asymptomatic, unless they are large enough to cause gastric outlet obstruction, which could present with vomiting and/or feeding refusal.
• Objects that pass beyond the pylorus and into the intestines are usually asymptomatic and pass spontaneously. Occasionally, foreign bodies may be retained in the distal gastrointestinal tract, where they can cause delayed complications. This may present with features such as abdominal pain, vomiting, GI bleeding, and signs of peritonitis or obstruction.

Diagnosis

A careful history and physical examination are the keystones in diagnosing an oesophageal foreign body and to the prevention of its complications. X-rays are unnecessary in an asymptomatic child, with no possibility of button battery or magnet ingestion, a reliable history and no significant past medical history. Imaging is required in: suspected or known button battery, magnet/s, other high-risk radio-opaque object, unknown object, high risk or unwell child.

Imaging can be used to localise the site of the foreign body. For all patients with suspected foreign body ingestion, the initial diagnostic test should be biplane radiographs (anteroposterior and lateral) of the neck, chest, and abdomen. This is to evaluate for radiopaque foreign bodies, for indirect evidence of the radiolucent foreign body (such as an air-fluid level in the oesophagus); and for free air representing a perforation.

Management

Management Approach:

Complications

Rare Earth Magnets

Food boluses