Chapters Transcript Management of Ingested Foreign Bodies Kimberly Sutton, MD, discusses the management of ingested foreign bodies. So yeah, like you said, I'm Kim Sutton, I'm with PHG I um at children's, I'm gonna be talking about ingested foreign bodies. Um So I have no disclosures. Um So our objectives for today are to kind of review the diagnosis um in cases of ingested foreign bodies, discuss the management and then then understand the potential complications. So why are we talking about this? Um It's super common. So in the year 2000, which is, is just a single representative year. Um there was greater than 100 and 16,000 ingestions reported to poison control. Um in the US, 75% of those um were in kids, five or younger. Some of the majority of these ingestions fall in our patient population. Um 98% of ingestions in kids are accidental. Um and they're common household objects. So the things that we all have sitting around on our counters on, you know, have fallen on the floor, et cetera. Um So what are the symptoms? So it really depends on kind of where the foreign body is lodged. Um We think about both the respiratory and the G I tract so they can have respiratory symptoms like strider wheezing respiratory distress. Um and then there's some that overlap like chest pain and then you have more your esophageal symptoms like um with your drooling and feeding refusal and sometimes things are farther down and you can get things like belly pain and fever, um depending on kind of complications, but all those things can kind of make you suspect a foreign body. Um depending on kind of the history that the parent gives you. I would say these are just incredibly common. I don't think I've ever made it through a week on service without at least a couple calls um about an ingested foreign body. Um So I'll start with a case that I saw just a couple of months ago. Um So this was a previously healthy three year old who presented um to an outside hospital with a what the parents said was a quarter ingestion the night prior um in, in the evening, she had been tolerating her secretions in liquids. So they just, um you know, went about their evening is normal, went to bed the next day. She wasn't able to tolerate solid food, it was vomiting. So they took her to their local er um where she had an X ray that showed a round metallic foreign body that appeared to be in the mid esophagus. Um So here is the film they got from just a quick look, you could say, oh yeah, it does look like that would be consistent with the quarter. Um But when you got a little closer on that picture, you actually see, um, that halo sign. So that second ring around the outside. Um, that is very concerning for a button battery. Um, and very classic. I have been fooled one time by a kid who had a combination of a quarter and a nickel in his esophagus that were laying on top of each other and looked just like that. But all other times that I've seen that it has in fact been a button battery. So um very appropriately, this kid was taken um for emergent endoscopy actually at the outside hospital um where they found significant mucosal injury, necrosis. These are pictures from her upper endoscopy, so, really significant injury. Um and so she was after the um button battery was removed, she was stable and she was um transferred to our center for further care. Um On arrival, we got further imaging with an Mr A um where we saw that there was um circumferential injury to the esophagus um with thickening and there was a focal outpouching um along the right lateral aspect um concerning for um erosion but a possible contained perforation. Um thankfully, there was no evidence of aortic arch perforation, a T fistula or an aortic esophageal fistula. So, with these findings, um she was kept NPO um placed on TPN. Um sometimes we're able to place an NG tube during the initial procedure and are able to um feed NR but since she did not have a tube placed during the initial scope, and there was a concern for um potentially a contained perforation, we did not feel it was safe to go back um and instantly to place an NG tube and it definitely wasn't safe to place one without direct visualization. Um So unfortunately, we didn't have a, an enteral feeding option for her. Um Initially, so um did get a pick line in TPN. Um She was put on IV antibiotics and PP I. Um And then just observed, she thankfully um clinically was doing great. Um We repeated the MRA a week later, um which showed an unchanged injury. Um And then another week after that got a um a contrast study with an esophagram that didn't show any leak at that area of concern for perforation. So her diet was then advanced to mechanical soft. Um She did well and on the soft diet was discharged home, um she got a repeat esophagram a month later um to look for any changes to the injury and development of structure, um which also looked good. And so she was then liberalized to a regular diet. The acid suppression was continued for a couple of months, but so far has been doing great. So, button batteries, um they've actually been around for quite a while. Um So been in use for about 30 years. But these uh but significant injuries are actually a more common or a more recent problem. Um, there's been a couple changes that have led to that, um, increase in battery diameter and then the transition to the lithium cells, um, which make them better at being batteries but more dangerous. Um, and you may have noticed they're in just about everything these days, um, from, you know, lots of different toys and obviously the old things like watches and things like that. Um But also even all those little tracking devices like those apple air tags all have, um, button batteries inside. Um So how do these cause injury? Um So it's actually primarily the generation of the hydroxide radicals. So it increases the ph um and causes a caustic injury to the tissue that way. Um, rather than primarily an electrical thermal injury. Um, injury starts fast but can also change with time and have delayed injury as well. So you can get necrosis within Lamin app propria within as little as 15 minutes of contact time. Um, and it can extend to the outer muscular layer in as little as 30 minutes. So this is a true emergency. Um, and every minute that you get this out sooner counts. Um Which is why in our, the case, I just talked about it was absolutely appropriate for the local hospital who had someone that felt comfortable, um, removing it endoscopically doing that as fast as possible rather than waiting um, to get her to us. Um, injury can involve evolve over time after removal. Um So we can see catastrophic delay injuries as far as three weeks out um from the initial removal. Um So what kind of, what kind of injuries do we see? Um It is primarily associated with esophageal infection is really when we're seeing the complications and then um kind of what structures are close to that. Um If you um burn through the esophagus itself, so you can see te fistula's um obviously perforation, which is the complication. We were watching in our patient, they can develop strictures over time as they heal from these severe injuries in the esophagus. And that's why we do the delayed esophagram and are monitoring for symptoms. Um Then those again can be a very delayed finding. Um They can get vocal cord paralysis from recurrent laryngeal nerve injury, meis. Um There are cases of um cardiac arrest and death from these complications. Um pneumo, the and the one that we're all kind of most terrified of with the button batteries is the um aorta enteric fistula. And what you know, the risk for that is just here's a little picture that's really just to kind of remind everyone of the anatomy in the chest. Um But where your aortic arch crosses your esophagus, um It narrows it just ever so slightly. So it's a common area for foreign bodies, whether it's a button battery a coin. Um Anything to get stuck on the way down. The problem with that is if, um, you burn through the esophagus, at that point, you're then right up against the aorta can cause a fistula and a catastrophic bleed. Um, risk factors for complications. Um, really make sense. So, it's. Created by Presenters Kimberly Sutton, MD Pediatric Gastroenterology View full profile
