Excerpt from Gastrointestinal Foreign Bodies

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In general, foreign bodies in the air and food passages are the sixth most common cause of accidental death in the United States. In the pediatric population, toddlers aged 2-3 years are most commonly affected because these children are ambulatory and more orally explorative. Although children younger than 6 months are rarely able to get a foreign object into the oropharynx, infants can ingest foreign bodies with the assistance of a sibling. Any child can swallow a foreign body; most incidents result in minor annoyance, but some can lead to major catastrophe.

Problem

Foreign bodies that enter the oropharynx can exit through the route they entered, they can be hidden in the mouth by the child, or they can travel down either the trachea or the esophagus. Foreign bodies that lodge in the airway are discussed in Airway Foreign Body and are less common than GI foreign bodies. Children with a retained or impacted GI foreign body are commonly referred for urgent surgical consultation and should be treated appropriately.

For the sake of simplicity, objects are characterized based on size, shape, and radiolucency. Perhaps the most common regularly shaped smooth foreign body in the GI tract is a coin (see Images 1-2). Others include buttons, pen or bottle caps, rubber or plastic materials, marbles, seeds, and batteries, which present a special problem. In general, regularly shaped smooth foreign bodies cause the least difficulty and commonly pass through the GI tract with little concern once they are past the lower esophageal sphincter (LES). Disk batteries are small coin-shaped batteries used in watches, calculators, hearing aids, and other similar products; disk batteries may not cause problems unless they become lodged in the GI tract. When a disk battery is lodged in the esophagus, esophageal damage can occur in a relatively short period, and perforation has occurred as few as 6 hours after ingestion.

Although children commonly aspirate food items, small children rarely present with impacted food. Irregularly shaped objects, such as keys, toys, tools, and jewelry (see Image 3), may have smooth or sharp edges. Sharp objects, such as pins, needles, bones, screws, razor blades (see Image 4), or nails, are of special concern because of their propensity for causing perforation. Additionally, objects are classified as either radiopaque (eg, metallic objects) or radiolucent (eg, plastic objects, bones).

Rectal foreign bodies are rare in children. They are most commonly inserted, but they can be impacted in the rectum after swallowing. Improperly inserted rectal thermometers or enema tips are the most commonly seen rectal foreign bodies in children. Other impacted rectal foreign bodies should alert the examiner to consider the possibility of sexual abuse or autoeroticism (in the teenage population).

Although body packers, ie, individuals who ingest or insert wrapped packets of drugs such as heroin or cocaine into the GI tract, are often adults, teenagers have been perpetrators of this crime. These patients require vigilant management and admission to the hospital because rupture of the packets can lead to devastating consequences.

Frequency

Although exact figures are unavailable, foreign body ingestion is very common among children. In the United States, approximately 1,500 deaths per year are attributed to the ingestion of foreign bodies. In 1999, the American Association of Poison Control documented 182,105 incidents of foreign body ingestion by patients younger than 20 years. Many children who swallow foreign bodies are likely to be undiagnosed (because the ingestion of foreign bodies in children is unwitnessed and unreported in about 40% of cases) and experience no untoward consequences. Alternatively, GI foreign bodies that come to the attention of the physician should not be dismissed.

Etiology

Most parents would attest that toddlers put whatever they get their hands on into their mouths. In addition, infants may swallow objects with the assistance of suggestive siblings. Bezoar formation and GI obstruction are more common in teens with emotional disturbances or mental retardation (see Image 5). Finally, any child with a congenital or anastomotic narrowing of the GI tract is more susceptible to foreign body impaction (see Image 6).

Pathophysiology

Of foreign bodies that pass the level of the LES, the vast majority proceed through the remainder of the gut without complication. Nevertheless, sharp objects may lead to perforation at any level of the GI tract. The corrosive nature of an alkaline battery can also lead to GI erosion or perforation. Objects that are retained in the esophagus are typically upheld at 1 of the following 3 normal anatomic esophageal narrowings: the level of the cricopharyngeus muscle (ie, thoracic inlet, area between the clavicles on chest radiography), the level of the aortic arch, and the LES. Congenital or acquired narrowings at any point within the GI tract also serve as barriers to free passage of a foreign body.

Clinical

An event that is witnessed by a parent, guardian, or sibling offers the best hope of early intervention because up to 35% of pediatric patients with esophageal foreign bodies are asymptomatic. Note the exact nature of the object, if known, and the time of ingestion. If the event is unwitnessed, establish the nature, onset, and progression of symptoms. These include choking, gagging, drooling, coughing, wheezing, dysphagia, dyspnea, dysphonia, fever, hematochezia, or neck, chest, or abdominal pain. Children with chronic esophageal foreign bodies may also present with poor feeding, irritability, fever, or stridor. Note a history of previous GI surgery or functional or anatomical abnormalities of the GI tract.

For older children and teenagers, specific questioning regarding bizarre eating habits and psychosocial behavior may help to diagnose a bezoar, a conglomeration of hair (trichobezoar), or a conglomeration of vegetable matter (phytobezoar). Additionally, always remain unbiased with regard to the number of foreign bodies ingested because some children have swallowed more than 1 item.

When a child has ingested a button battery, symptoms may include refusal to take fluids, drooling with black flecks in the saliva, dysphagia, vomiting, and hematemesis. Nevertheless, as many as 35% of patients with a battery impacted in the esophagus are asymptomatic. Rashes following disk battery ingestion have been reported and may be a manifestation of nickel hypersensitivity.

Patients with a rectal foreign body may present with abdominal or rectal pain, pruritus, or bleeding. In the case of suspected or known sexual assault, the appropriate legal authority or child protective services should be notified immediately.

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