Foreign Body Ingestion

About 80% of the more than 100,000 foreign body ingestions reported each year in the United States occur in children. The highest incidence is in children ages 6 months to 3 years, and most of these ingestions are accidental. About 10% to 20% of foreign body ingestions require endoscopic removal, and fewer than 1% require surgery for removal. Mortality rates associated with foreign body ingestions are extremely low, although fatal ingestions can occur.

Management of foreign body ingestions depends on many factors, including the object ingested, the size of the patient, and the timing of the ingestion. Common examples of foreign objects ingested are listed in the following table:

Presentation

Most children with foreign body ingestion are asymptomatic and present to the hospital because of a witnessed ingestion. A broad array of symptoms can be associated with foreign body ingestion, including the following presentations:

• drooling

• choking

• respiratory symptoms (e.g., wheezing, stridor, or respiratory distress)

• chest pain

• abdominal pain

• vomiting

• nonspecific symptoms (e.g., food refusal or generalized fussiness), particularly in young children

Evaluation

Initial evaluation should focus on assessment of the patient’s airway, breathing, and symptoms. History is helpful in determining the timing of the ingestion and the objects ingested.

All patients should receive plain radiographs in two views (anteroposterior and lateral) of the neck, chest, and abdomen. Metallic objects are visible on radiographs, but other objects (e.g., glass, fish bones, food, or wood) may be radiolucent.

Special care should be taken to distinguish between coins and button batteries, which may look similar in radiographs. Features that suggest a button battery include the double halo sign and a “step-off” between positive and negative poles.

Management

Management of pediatric foreign body ingestion is complex, and many aspects remain controversial.

Management can be categorized as follows:

• emergency endoscopy (<2 hours from presentation)

• urgent endoscopy (<24 hours from presentation)

• elective (>24 hours from presentation)

• nonendoscopic expectant management

As a general rule, objects in the esophagus require endoscopic removal. Patients with signs or symptoms of esophageal obstruction (pain, unable to swallow secretions, respiratory symptoms) should undergo endoscopic removal as soon as possible.

• Button battery ingestion: Button battery ingestion is one of the few gastrointestinal procedural emergencies. Retention of a button battery in the esophagus is the most emergent because it can either erode into surrounding blood vessels or cause significant inflammation leading to stricture formation. The goal is often removal within 2 hours of presentation. Management algorithms for ingestion of button batteries can be found in the NASPGHAN guidelines and from the National Capital Poison Control Center (shown below).

  

  (Source: National Capital Poison Center Button Battery Ingestion Triage and Treatment Guideline. National Capital Poison Center 2018.)

• Coin ingestion: NASPGHAN provides a proposed algorithm for management of coin ingestions.

• Magnet ingestion: See NASPGHAN consensus guidelines for the evaluation and management of magnet ingestion. Distinguishing between single and multiple magnet ingestion and removal of multiple magnets when possible are critical to avoid surgical complications.

  

  (Source: Ingested Magnets. N Engl J Med 2009.)

• Ingestion of sharp objects:

  • Long and sharp objects should be removed endoscopically because of the high likelihood of retention or injury in the GI tract.

  • Radiopaque materials: If a sharp object is in the esophagus, it requires immediate removal. However, if the sharp object is short with a heavy blunt end and in the stomach, it can be managed conservatively. Often objects with a heavy blunt end will be excreted with low risk of perforation. Surgical intervention is required in patients with significant symptoms and an object found in the duodenum.

  • Radiolucent materials: Need for endoscopy is based on presenting symptoms. Symptomatic patients should undergo urgent endoscopic removal (although radiolucency may preclude accurate localization on radiography).

• Ingestion of long objects (>25 mm): Long objects are unlikely to pass through the pylorus and should be removed.

• Ingestion of superabsorbent objects: The need for urgent removal remains controversial. The need for endoscopy is dependent on symptoms and endoscopists discretion.

• Ingestion of blunt, small objects (< 25 mm): Small blunt objects in the stomach may be managed without endoscopic intervention, with the expectation that the objects will be excreted in the stool.