What is the emergency department (ED) management for esophageal foreign body ingestion?

Updated: Oct 04, 2018
  • Author: Gregory P Conners, MD, MPH, MBA, FAAP, FACEP; Chief Editor: Dale W Steele, MD, MS  more...
  • Print
Answer

Esophageal foreign bodies

  • Objects found within the esophagus should generally be considered impacted. Because impacted esophageal foreign bodies may lead to significant morbidity (and even mortality), removal of impacted esophageal foreign bodies is mandatory. An important exception is blunt esophageal foreign bodies (except button [disk] batteries) that are well tolerated and are known to have been in place for less than 24 hours (see Spontaneous passage below).

  • Endoscopy (esophagoscopy) is by far the most commonly used means of removal and is usually the procedure of choice. Most children with esophageal foreign bodies are stable. Endoscopy usually can be delayed until the child's stomach is emptied and a surgical team is assembled. However, pointed objects, such as an embedded esophageal thumbtack, should be removed as rapidly as possible to avoid further injury to the esophageal mucosa and mediastinitis. Impacted button (disk) batteries are notorious for rapidly causing local necrosis and should be emergently removed. Children with esophageal food impaction, an unusual finding in childhood, may benefit from endoscopic evaluation, perhaps with biopsies, of the esophageal mucosa. [2]

  • Because endoscopy is relatively invasive and expensive, other methods of esophageal foreign body removal have been investigated [24] and are probably more cost-effective when used appropriately. Both have been performed most commonly on children with esophageal coins. Because any esophageal foreign body may pass spontaneously, chest radiography should be performed immediately prior to any removal procedure.

    • Foley catheter method: Blunt foreign bodies may be removed by use of a Foley catheter. Typically, the patient is restrained in a head-down position on a fluoroscopy table, and an uninflated catheter is passed until distal to the object. The catheter is then inflated and gently withdrawn, drawing the foreign body with it. One some occasions, the object is dislodged and passed into the stomach. Progress is typically monitored fluoroscopically. This procedure is performed without radiographic monitoring at some centers with extensive experience.  Only experienced personnel should perform this procedure, and it should be reserved for previously healthy children whose ingestion of a blunt object was witnessed less than 24 hours prior to the procedure.

    • Bougienage method: Blunt esophageal foreign bodies may be advanced into the stomach with a bougie. While the child is sitting upright, the lubricated instrument is gently passed down the esophagus, dislodging the object. The object is then expected to pass through the rest of the GI tract; thus, this procedure should not be performed on children with known lower GI tract abnormalities. A brief observation period and a repeat radiograph should follow any removal procedure to rule out retained foreign bodies and other complications (eg, pneumomediastinum). Because any esophageal foreign body may pass spontaneously, chest radiography should be performed immediately prior to any removal procedure. Again, only experienced personnel should perform this procedure, and it should be reserved for healthy children whose ingestion of a blunt object was witnessed less than 24 hours prior to the procedure.

    • The Foley catheter and bougienage methods have been shown to be more cost-effective than endoscopy, for properly selected patients. [25, 26, 27, 28, 29]
    • Emergency department rapid sequence intubation, followed by removal of esophageal coins with Magill forceps and/or a Foley catheter, has been shown to be safe and effective in children. [30]
  • Spontaneous passage: Blunt foreign bodies located at the LES often spontaneously pass within several hours of ingestion. This has been best studied in coin ingestions. Previously healthy children may be given food and drink and have repeat radiographs 24 hours following ingestion. Often, the coin passes through the LES, and a removal procedure can be avoided. [1, 31] This may be most successful in asymptomatic children.


Did this answer your question?
Additional feedback? (Optional)
Thank you for your feedback!