Continuing Education Activity

Most patients who present for evaluation of a foreign body in the esophagus do so after accidental ingestion of a known object, and the patient has mild symptoms and is in stable condition. The challenges come from patients who are unable or unwilling to provide a history of the object ingested or when it occurred. Examples are infants, children, mentally impaired, psychiatric, and prisoners. Also, the wide range of possible symptoms and clinical presentations, plus the wide range of potential complications, can make this a difficult condition to evaluate and manage. This activity reviews the etiology, presentation, evaluation, and management of esophageal foreign body ingestion and reviews the role of the interprofessional team in evaluating, diagnosing, and managing the condition.

Objectives:

• Describe the typical etiology of an esophageal foreign body.
• Discuss the pathophysiology of an esophageal foreign body.
• Review the management options available for a patient who presents with an esophageal foreign body.
• Explain the importance of improving coordination among the interprofessional team to enhance care for patients affected by foreign bodies lodged in the esophagus.

Introduction

Most patients who present for evaluation of a foreign body in the esophagus do so after accidental ingestion of a known object, and the patient has mild symptoms and is in stable condition. The challenges come from patients who are unable or unwilling, for example, infants, children, mentally impaired, psychiatric, prisoners, to provide a history of the object ingested or when it occurred. Also, the wide range of possible symptoms and clinical presentations, plus the wide range of potential complications, can make this a difficult condition to evaluate and manage.[1][2][3][4]

Etiology

In adults, the esophagus is approximately 20 to 25 cm in length, extending from the hypopharynx to the stomach. The esophagus has an inner mucosa layer and a muscle layer made up of inner circular muscles and outer longitudinal muscles. The upper third is voluntary striated muscles that allow initiation of swallowing, while muscles of the lower third are involuntary smooth muscles.

The esophagus is the most common site for an acute foreign body or food impaction in the gastrointestinal tract, and 80 to 90% of swallowed objects that reach the stomach will eventually pass without intervention.

While a wide variety of objects could be ingested, common accidental esophageal foreign body ingestions include food bolus (mostly meat), fish or chicken bones, dentures, and coins. The type of objects ingested varies between different regions and cultures. For example, in southern China, fish bones were the most common esophageal foreign body impaction.[4][5][6]

Epidemiology

Children make up roughly 80% of patients presenting to emergency departments with an esophageal foreign body.[1][7] These are typically accidental ingestions of small objects such as coins, sharp-pointed objects (pins, needles), batteries, toy parts, crayons, fish and chicken bones, large food bolus, jewelry, among others. Coins are the most common foreign body ingested by children. Most children have normal anatomy. However, there is an increased risk of impactions with abnormalities such as eosinophilic esophagitis, prior esophageal atresia repair, and prior Nissen fundoplication.[8]

Similarly, in adults, similar accidental foreign body ingestions occur; however, the most common cause of impaction in adults is a food (mostly meat) bolus. The estimated annual incidence of food impaction is 13.0 per 100,000. Eighty percent to 90% occur in the distal esophagus associated with anatomic or motor abnormalities. These abnormalities include diverticula, webs, rings, strictures, tumors, eosinophilic esophagitis, achalasia, scleroderma, or esophageal spasms. For this reason, it is recommended that adults with a history of food impaction, even if it resolves spontaneously, need follow-up evaluation of the esophagus.

Pathophysiology

The normal esophagus has 3 primary areas of physiologic narrowing: the upper esophageal sphincter (UES) which includes the cricopharyngeus muscle, the middle esophagus where the esophagus crosses over the aortic arch, and the lower esophageal sphincter (LES). In children, approximately 74% of foreign bodies are entrapped at the UES level. In adults, approximately 68% of obstructions occur at the distal esophagus associated with pathologic abnormalities.[9]

Possible complications include local injury to the mucosa, such as abrasion, lacerations, necrosis, and stricture formation. Other serious complications include injury beyond the esophagus, such as airway obstruction, esophageal perforation, tracheoesophageal fistula, vascular injury (e.g., aortoesophageal fistula), retropharyngeal abscess, mediastinitis, pericarditis, or vocal cord injury.[10]

Three special types of foreign body ingestions with a higher risk of complications are button batteries (also called “disc” or “coin” batteries), multiple magnets, and sharp-pointed objects.

If a button battery becomes impacted in the esophagus, an electrical current is created between the positive and negative poles. This current can cause thermal injury plus produce hydroxide ions with a rapid rise in the local pH resulting in a caustic alkaline injury. Injury begins within 15 minutes and can lead to a perforation in hours. Complications can include localized esophageal mucosal necrosis and chronic stricture formation. More serious complications involve esophageal perforation and erosion into adjacent structures such as the mediastinum, trachea, or vascular structures. Leinwand et al. reported 13 cases of serious complications, including 30.8% perforation, 23.1% stricture formation, and 23.1% mortality from aortoesophageal fistula formation and exsanguination. More than 90% of serious complications occurred in children 5 years old or younger, with batteries 20-mm diameter and greater and impactions for prolonged periods.[2][10]

While a single, small, smooth magnet will usually pass without complications, multiple magnets create complications. Tissue may become trapped between the magnets leading to pressure ischemia, perforation, fistula formation, obstruction, or volvulus.[11]

Sharp-pointed objects stuck in the esophagus also have a higher risk of perforation and need urgent removal.

History and Physical

Key factors to consider in assessing patients with ingested foreign bodies include type and number of objects, location, time since ingestion, and presenting signs and symptoms. These factors will help determine if the object needs to be retrieved emergently, urgently or if the patient can be safely managed with observation and follow-up.

Most adults and older children can give a history of foreign body ingestion and time of onset. The most common symptoms are foreign body sensation or difficulty swallowing (dysphagia). Symptoms typically develop in minutes to hours. Foreign bodies in the upper esophagus are more accurately localized by the patient. However, impactions in the mid or lower esophagus may be described as a vague discomfort, ache, or chest pain.  Other symptoms include hypersalivation, retrosternal fullness, regurgitation, gagging, choking, hiccups, and retching. If patients report painful swallowing (odynophagia), this may indicate more serious problems such as esophageal laceration or perforation.

On exam, the patient may appear anxious and uncomfortable with swallowing. If the patient is unable to swallow saliva, this indicates a complete obstruction is needing more urgent treatment.

Infants, younger children, the mentally impaired, or prisoners may be unable or unwilling to provide history. In these situations, a high index of suspicion is needed. For infants and young children, symptoms may include gagging, poor feeding, drooling, or irritability. An esophageal foreign body might also press on the trachea, causing respiratory symptoms such as wheezing, cough, dyspnea, or stridor. However, airway foreign bodies would also need to be considered.

The physical exam should initially focus on airway patency, vital signs, patient’s ability to handle secretions, and looking for signs of complications such as hematemesis, abnormal breath sounds, tenderness in the neck, chest, or abdomen, or subcutaneous air.

Evaluation

Routine x-rays are usually the first step if a radioopaque object is suspected. This will help determine the object, the location, and possible complications. Chest x-ray (posterior-anterior (PA) and lateral views) is usually adequate, but the neck and abdominal x-rays may be needed depending on clinical presentation. Flat objects like coins, bottle caps, or disc batteries are usually oriented in the coronal plane if they are lodged in the esophagus and appear round on the frontal (PA) view. However, if they are lodged in the trachea, they orient in the sagittal plane and appear round on the lateral view. If a circular “coin-like” object is seen on the x-ray, the object needs careful review looking for a “halo” or “double-ring” appearance, which identifies it as a button battery and the need for emergent removal. A chest x-ray can differentiate coins from button batteries with sensitivity, specificity, and accuracy of approximately 80%. Food, plastic, wood, and aluminum are not radioopaque, so they are not seen on routine x-rays. Bones and glass may or may not be seen on x-rays. If nothing is seen on routine x-rays, but suspicion of a foreign body remains high, then diagnostic endoscopy or CT scan may be indicated. CT scans have a high sensitivity for detecting foreign bodies plus are useful for detecting complications such as perforation.

Treatment / Management

Assuming a stable airway and no developing complications, the treatment and management are guided by the type of foreign body, the location, the degree of obstruction, and the duration. Endoscopic removal is the procedure of choice and is successful in more than 90% of cases with less than a 5% complication rate. Endoscopic management can be divided into emergency, urgent, and nonurgent.[12][13][14][15]

Emergency

• Esophageal obstruction: Inability to handle oral secretions
• Disk batteries in the esophagus
• Sharp-pointed objects in the esophagus

Urgent (within 12 to 24 hours)

• Esophageal objects that are not sharp-pointed
• Food impactions without complete obstruction
• Sharp-pointed objects in the stomach or duodenum
• Objects greater than 6 cm in length above the duodenum
• Multiple magnets (or single magnet plus another ferromagnetic object within endoscopic reach)
• Coins in esophagus

Nonurgent

• Objects in the stomach greater than 2.5 cm diameter
• Disk battery in stomach up to 48 hours if asymptomatic
• Blunt objects that fail to pass stomach in 3 to 4 weeks

Several types of medical management have been studied. In theory, medications that relax the smooth muscles of the LES might allow smooth, blunt objects to pass spontaneously into the stomach. Glucagon is the most commonly discussed agent; dose 0.25 mg to 2 mg intravenously (IV) over 1 to 2 minutes in a sitting patient. This is followed by oral water or carbonated beverage in 1 minute to promote esophagus distention along with LES relaxation. Glucagon can cause nausea and vomiting. Vomiting may dislodge the object but also may increase the risk of esophagus rupture. Unfortunately, most studies looking at glucagon have a variety of weaknesses, including small sample size, exclusion criteria making them non-generalizable, or are underpowered for evaluating side-effects, so most results show slight or no benefit over placebo.[8][16]

Papain (an ingredient in meat tenderizers) is not recommended for meat bolus impactions because of possible complications and a theoretical risk of damage to the esophagus.

A disc battery impacted in the esophagus is a true emergency and needs immediate removal. The greatest concern is the potentially fatal complication of an aortoesophageal fistula with the highest risk in children less than five years old, battery size 20 mm or greater, impaction at the aortic arch level, prolonged impact, and any degree of hematemesis. In these specific cases, an interprofessional approach potentially including pediatric gastroenterology, pediatric surgery, cardiothoracic surgery, anesthesia, and radiology with management in the operating room or cardiac catheterization lab may be indicated.

Asymptomatic children with a coin impacted in the esophagus can be managed urgently with the observation of up to 24 hours without risk of further complications. Coin location is important, with 10% of proximal esophageal coins, 26% middle esophagus coins, and 43% of distal esophagus coins passing spontaneously within 16 hours of ingestion.

Differential Diagnosis

Esophageal abrasions can cause a foreign body sensation that remains after the passage of a foreign object. If the patient is stable and tolerating oral intake, they can be reassessed within 12 to 24 hours, and if symptoms continue, then a CT scan or endoscopy may be needed.

Other conditions that might cause a foreign body sensation without a foreign body present include:

• Infection such as Candida, Herpes simplex virus (HSV), or Cytomegalovirus (CMV)
• Esophagitis (acid reflux, pill esophagitis, eosinophilic esophagitis)
• Esophageal spasm
• Globus pharyngeus (also called globus hystericus) is a sensation of a lump or foreign body in the throat of uncertain etiology.

Again, if the patient is stable and tolerating oral intake then begin appropriate treatment for the underlying condition and/or arrange follow-up.

Prognosis

Eighty percent to 90% of ingested foreign bodies will pass spontaneously within 3 to 7 days.[1]

Children with esophageal injury from disc battery need short and long-term follow-up to look for complications related to erosion or perforation and esophageal stricture.

Adults with food impactions have abnormalities 85 to 90% of the time and will need evaluation and treatment of the underlining abnormalities.[8][9]

Enhancing Healthcare Team Outcomes

The management of foreign bodies in the esophagus requires an interprofessional team with an interprofessional approach. Most patients will present to the emergency department, and the triage nurse has to be aware of the symptoms and signs of an esophageal foreign body. These patients need immediate admission. Emergency department nurses need to assist the clinical team by monitoring the patient for respiratory distress while the workup is going on and keeping the parents apprised of the child's status.

Once the diagnosis is made, consultation with the appropriate specialist is highly recommended. Most foreign bodies in the esophagus pass spontaneously, but about 3 to 10% may require some type of intervention. Some may require removal of the foreign item with endoscopy, and others may require surgery.

Prior to discharge, all clinicians and nurses as part of an interprofessional team have the onus to educate the patient and caregivers to keep small objects away from the reach of children. The parent should also be educated on the signs of an esophageal foreign body and when to seek medical care. Only through an interprofessional approach can the morbidity of this condition be lowered.

The outcomes for most patients with foreign bodies in the esophagus are excellent.[17][18] [Level 5]