Foreign Body in the Esophagus of Children
Introduction to Foreign Body in the Esophagus of Children
Foreign body ingestion is a common pediatric emergency, with the esophagus being a frequent site of impaction. Prompt recognition and appropriate management are crucial to prevent potentially serious complications.
Key points:
- Most common in children aged 6 months to 3 years
- Can cause significant morbidity if not managed promptly
- Majority of cases resolve spontaneously, but some require intervention
- Prevention through education is essential
Epidemiology of Esophageal Foreign Bodies in Children
Understanding the epidemiology helps in prevention and management strategies:
- Age distribution:
- Peak incidence: 6 months to 3 years
- 80% of cases occur in children under 3 years
- Gender: Slight male predominance
- Frequency:
- Accounts for 80% of foreign body ingestions in children
- Estimated 1 in 1,000 children per year in the US
- Risk factors:
- Developmental stage (oral exploration)
- Neurodevelopmental disorders
- Pre-existing esophageal abnormalities
Types of Foreign Bodies in the Esophagus of Children
The nature of the foreign body influences management and potential complications:
1. Coins
- Most common foreign body (70% of cases)
- Often lodge at physiological narrowings
2. Button Batteries
- Potentially life-threatening
- Can cause severe tissue damage within hours
3. Magnets
- Dangerous if multiple are ingested
- Can cause pressure necrosis and perforation
4. Food Bolus
- More common in older children
- May indicate underlying esophageal pathology
5. Sharp Objects
- Examples: pins, needles, fish bones
- Higher risk of perforation
6. Toys and Toy Parts
- Variable in size and shape
- Plastic objects often radiolucent
Clinical Presentation of Esophageal Foreign Bodies in Children
Symptoms can vary based on the location, size, and nature of the foreign body:
1. Acute Presentation
- Dysphagia (difficulty swallowing)
- Odynophagia (painful swallowing)
- Drooling
- Gagging or choking
- Vomiting
- Chest pain or throat pain
- Respiratory symptoms (cough, stridor, wheezing)
2. Delayed Presentation
- Refusal to eat
- Weight loss
- Recurrent respiratory infections
- Fever (indicating possible complication)
3. Asymptomatic Cases
- Up to 50% of children may be asymptomatic
- Often discovered incidentally on imaging
4. Location-Specific Symptoms
- Upper esophagus: More likely to cause respiratory symptoms
- Lower esophagus: May present with chest pain or vomiting
5. Red Flag Symptoms
- Excessive drooling
- Inability to swallow liquids
- Respiratory distress
- Signs of perforation (subcutaneous emphysema, severe pain)
Diagnosis of Esophageal Foreign Bodies in Children
A systematic approach to diagnosis is crucial for appropriate management:
1. History
- Witnessed ingestion or child's report
- Nature of the foreign body
- Timing of ingestion
- Associated symptoms
2. Physical Examination
- Assess for respiratory distress
- Evaluate for drooling, stridor
- Check for cervical subcutaneous emphysema
- Abdominal examination
3. Imaging Studies
- Plain Radiography:
- Anteroposterior and lateral views of neck, chest, and abdomen
- Can detect radiopaque objects
- Contrast Studies:
- Not routinely recommended
- Risk of aspiration
- Computed Tomography (CT):
- For suspected complications
- Can detect radiolucent objects
4. Endoscopy
- Gold standard for diagnosis and treatment
- Allows direct visualization and removal
- Can assess for mucosal injury
5. Metal Detector
- Can be useful for locating metallic objects
- Non-invasive and radiation-free
Management of Esophageal Foreign Bodies in Children
Management depends on the type of foreign body, location, and associated symptoms:
1. Initial Management
- Assess airway, breathing, and circulation
- NPO (nil per os) status
- IV access and fluid resuscitation if needed
2. Observation
- Appropriate for small, blunt objects in asymptomatic patients
- Serial X-rays to monitor progression
- Not suitable for button batteries or sharp objects
3. Endoscopic Removal
- Indications:
- Symptomatic patients
- Objects > 2.5 cm in diameter or > 6 cm in length
- Sharp objects
- Button batteries
- Magnets
- Techniques:
- Rigid esophagoscopy
- Flexible esophagogastroduodenoscopy
4. Foley Catheter Technique
- For removal of blunt objects in the upper esophagus
- Less invasive than endoscopy
- Requires fluoroscopic guidance
5. Glucagon Administration
- May help relax the lower esophageal sphincter
- Limited evidence for efficacy
6. Surgical Intervention
- Rarely needed
- Indications: perforation, failed endoscopic removal
7. Post-Removal Care
- Observation for complications
- Follow-up imaging if mucosal injury noted
- Gradual reintroduction of oral intake
Complications of Esophageal Foreign Bodies in Children
Prompt management is crucial to prevent potential complications:
1. Mucosal Injury
- Ranges from mild erosions to deep ulcerations
- Risk of stricture formation
2. Perforation
- More common with sharp objects or prolonged impaction
- Can lead to mediastinitis, pneumomediastinum
3. Esophageal Stricture
- Long-term complication of mucosal injury
- May require repeated dilations
4. Tracheoesophageal Fistula
- Rare but serious complication
- Often associated with button battery ingestion
5. Aortoesophageal Fistula
- Life-threatening complication
- Can result in massive hemorrhage
6. Aspiration
- Risk during removal attempts
- Can lead to pneumonia
7. Infection
- Retropharyngeal abscess
- Mediastinitis
Prevention of Esophageal Foreign Body Ingestion in Children
Prevention strategies are crucial to reduce the incidence of foreign body ingestions:
1. Parental Education
- Awareness of common household hazards
- Proper storage of small objects out of children's reach
- Supervision during mealtimes
2. Age-Appropriate Feeding Practices
- Avoid high-risk foods (e.g., whole grapes, nuts) in young children
- Teach proper chewing and swallowing techniques
3. Child-Proofing
- Use of safety locks on cabinets
- Regular inspection of play areas for small objects
4. Toy Safety
- Choose age-appropriate toys
- Regularly check toys for loose or broken parts
5. Button Battery Safety
- Secure battery compartments in devices
- Store spare batteries out of reach
- Dispose of used batteries properly
6. Public Awareness Campaigns
- Community education on foreign body hazards
- School-based programs on choking prevention
7. Healthcare Provider Role
- Anticipatory guidance during well-child visits
- Educate parents on signs of foreign body ingestion
Foreign Body in the Esophagus of Children
- What is the most common type of foreign body ingested by children?
Coins - At which age group is foreign body ingestion most common?
Children between 6 months and 3 years old - Which anatomical location in the esophagus is most likely to trap a foreign body?
The upper esophageal sphincter (cricopharyngeus muscle) - What is the most common symptom of an esophageal foreign body in children?
Dysphagia (difficulty swallowing) - Which diagnostic imaging technique is typically used first to identify an esophageal foreign body?
Plain chest X-ray - What is the "coin sign" on a chest X-ray?
A round, radiopaque object visible in the esophagus - Which view is preferred for identifying an esophageal foreign body on X-ray?
Anteroposterior (AP) and lateral views - What is the danger of button battery ingestion in the esophagus?
Rapid tissue necrosis and perforation - Within what timeframe should a button battery in the esophagus be removed?
Within 2 hours of ingestion - Which procedure is the gold standard for removing esophageal foreign bodies in children?
Flexible endoscopy - What is the Foley catheter technique used for in foreign body removal?
To remove blunt objects like coins from the upper esophagus - Which complication can occur if a sharp object is ingested?
Esophageal perforation - What is the "halo sign" on a chest X-ray?
A radiolucent rim around a disk battery, indicating its double-rim effect - Which type of foreign body is more likely to pass spontaneously through the digestive tract?
Small, blunt objects - What is the main concern with magnets as ingested foreign bodies?
They can attract each other across bowel walls, causing perforation or obstruction - Which symptom suggests potential esophageal perforation?
Chest pain or neck pain - What is the role of barium studies in diagnosing esophageal foreign bodies?
They are contraindicated due to risk of aspiration and interference with subsequent endoscopy - Which medication can be used to relax the lower esophageal sphincter and aid passage of a foreign body?
Glucagon - What is the "stair-step sign" on a lateral neck X-ray?
Multiple coins stacked on top of each other in the esophagus - Which type of foreign body is most likely to cause chemical burns in the esophagus?
Button batteries - What is the recommended first-aid measure for a child who has ingested a caustic substance?
Rinse the mouth with water and seek immediate medical attention (do not induce vomiting) - Which complication can occur from prolonged impaction of a foreign body in the esophagus?
Esophageal stricture - What is the role of CT scan in evaluating esophageal foreign bodies?
It can help identify complications such as perforation or mediastinitis - Which type of foreign body is more likely to cause obstruction in the lower esophagus?
Large, round objects like large coins or toy parts - What is the significance of drooling in a child with a suspected esophageal foreign body?
It suggests complete esophageal obstruction - Which approach is typically used for removing sharp objects from the esophagus?
Rigid endoscopy under general anesthesia - What is the "double rim" or "double density" sign on a chest X-ray?
It indicates the presence of a button battery - Which complication can occur from the use of a Foley catheter for foreign body removal?
Aspiration of the foreign body - What is the role of esophageal bougienage in managing esophageal foreign bodies?
It can be used to push blunt objects into the stomach in specific cases - Which symptom suggests potential tracheal compression by an esophageal foreign body?
Stridor or wheezing
Further Reading
- Foreign Body Ingestion in Children - Comprehensive review article from the World Journal of Gastrointestinal Endoscopy
- Ingested Foreign Bodies in Children: Types and Management - Clinical review from American Family Physician
- Management of Ingested Foreign Bodies in Children: A Clinical Report of the NASPGHAN Endoscopy Committee - Clinical practice guidelines
- European Society for Paediat
