AUTHOR AND EDITOR INFORMATION

Section 1 of 9  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Intervention
• Multimedia
• References

INTRODUCTION

Section 2 of 9  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Intervention
• Multimedia
• References

Background

Prompt treatment of an infant or child with a suspected esophageal foreign body is crucial because of the potential for severe complications. Radiographic evaluation of the esophageal foreign body is warranted in both symptomatic and asymptomatic patients. Ingestions that are witnessed are generally managed without problems. Conversely, diagnosis of nonwitnessed ingestions can often be difficult and delayed. This delay in diagnosis can result in severe morbidity and mortality.^{1, 2, 3, 4, 5, 6, 7, 8}

For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education article Battery Ingestion.

(Also see the eMedicine Radiology article Esophagus, Tear and the Medscape article Ingested Coins in the Esophagus May Pass Spontaneously Without Complications.)

Pathophysiology

The inherent curiosity of children may lead them to ingest many types of objects other than appropriately sized foodstuffs. Most esophageal foreign bodies are radiopaque; the most common ones are coins. Other frequently ingested items include small metal and plastic toys, buttons, bones, batteries, safety pins, thumbtacks, and wood or glass objects. Fortunately, the vast majority of ingested objects pass through the gastrointestinal tract without problems.⁹ Some of these foreign bodies, however, become lodged in the esophagus because of normal physiologic narrowings, and others may become lodged at the site of underlying pathology. A foreign body that is retained for a long period can serve as a nidus for a local tissue reaction and result in chronic inflammatory change.

Frequency

United States

In the United States, thousands of children per year have a foreign body in the esophagus. Evaluation of the esophageal foreign body remains relevant given the prevalence of the condition.

Mortality/Morbidity

High morbidity rates are associated with the chronic retention of esophageal foreign bodies. Complications of retained esophageal foreign bodies are primarily related to perforation of the esophagus, but they may also result in intrinsic esophageal stenosis.

Esophageal diverticula are less common complications of prolonged retention of esophageal foreign bodies such as plastic disks (eg, tiddlywinks, bingo chips) and coins. Both true and false diverticula can result. True diverticula result from esophageal dilatation proximal to a long-term obstruction, whereas false diverticula result from a contained esophageal perforation with a persistent communication to the contained encapsulated area involved with a paraesophageal inflammatory process.

Foreign bodies that migrate outside the esophagus into the mediastinum or soft tissues usually cause respiratory symptoms. Complete foreign body migration outside the esophagus is occult on esophagoscopic images, but it may be depicted on chest radiographs. Also, esophageal foreign body granulomas that cause tracheal stenosis, lobar atelectasis, and bronchoesophageal fistulas are reported as complications. Foreign bodies can become lodged above esophageal strictures, and chronically embedded esophageal foreign bodies can induce stricture formation, although these are less common. Although esophageal-vascular fistulas are rare, one fatality has been reported; this involved an infant who exsanguinated through an aorto-esophageal fistula caused by an open safety pin.

Sex

Boys account for a slight majority of patients who ingest foreign bodies.

Age

Most patients with an esophageal foreign body are younger than 5 years. However, cases involving teenagers have been reported. Most patients with a chronically retained foreign body are nonverbal.

Anatomy

The most common locations of foreign body lodgment are the 3 areas of normal physiologic esophageal narrowing. The first and most common location is the proximal esophagus at the level of the thoracic inlet. The thoracic inlet is the junction between the neck and the thorax. This is delineated by the Sibson fascia, which extends bilaterally from the transverse process of C7 to the medial border of the first rib. Because the posterior attachment is more cranial, the plane of the thoracic inlet is oblique and higher posteriorly than anteriorly. The second location is the mid esophagus at the level of the carina and aortic arch. The third location is the distal esophagus, slightly proximal to the gastroesophageal junction.

Prior conditions such as the ingestion of a caustic substance, tracheoesophageal fistula repair, a vascular ring, or other esophageal pathology also may cause esophageal strictures above which a foreign body may lodge.

Clinical Details

Most patients with an esophageal foreign body present several hours after ingestion, usually to a medical facility in the early-to-late evening. A variety of signs and symptoms are observed on initial presentation. Infants and children with a retained foreign body may be asymptomatic. In some instances, the ingested foreign body is incidentally discovered in an asymptomatic patient who undergoes radiographic examination for reasons other than the evaluation of the foreign body. Alternatively, depending on the time the foreign body has been lodged, advanced vague signs and symptoms, including weight loss or an altered level of consciousness, may be present.

Common signs and symptoms in patients with a foreign body that has been retained for less than 24 hours tend to be gastrointestinal and include dysphagia, drooling, vomiting, gagging, and/or anorexia. Significant respiratory symptoms, such as coughing, stridor, fever, chest pain, wheezing, chronic upper respiratory tract infections (eg, persistent croup), pneumonia, and hemoptysis, are more common weeks or months after ingestion. Patients may also have acute respiratory distress with choking and cyanosis.

Obtaining a history from the child or caretaker is important in determining the amount of time that the foreign body has been present. A foreign body lodged longer than 24 hours poses a greater risk of esophageal perforation, mediastinal abscess formation, and airway compromise. The removal procedure depends on the features of this history as much as on the findings at initial radiographic examination.

Preferred Examination

The radiographic evaluation begins with the acquisition of anteroposterior and lateral chest, lateral neck, and supine abdominal radiographs to complete the examination from the nasopharynx to the rectum.

If a child is referred from an outside institution, a repeat chest radiograph can be obtained to reconfirm the presence of the foreign body in the esophagus or confirm its passage beyond the esophagus, obviating a retrieval procedure.

If the presence of a nonradiopaque object is suspected after the initial series of radiographs is obtained, contrast-enhanced esophagography is indicated to rule out a radiolucent foreign body. Further evaluation with cross-sectional imaging may be required to determine the presence and extent of mediastinitis versus mediastinal abscess formation.^{4, 10}

Limitations of Techniques

The major limitation of the initial plain radiographic evaluation is the potential failure to visualize the nonradiopaque foreign body. Small esophageal foreign bodies may also be difficult to visualize on plain radiographs alone. Additional evaluation is required when the suspected foreign body is not radiopaque or when the presence of a retained object is highly suspected. The initial radiographic evaluation also can cause underestimation of the extent or degree of involvement, such as the amount of edema with foreign bodies that are retained for long periods.

DIFFERENTIALS

Section 3 of 9  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Intervention
• Multimedia
• References

RADIOGRAPH

Section 4 of 9  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Intervention
• Multimedia
• References

Findings

The initial plain radiographic series is crucial in the diagnosis of an esophageal foreign body because the location and characteristics of the esophageal foreign body direct treatment. The most common site of foreign body lodgment is the upper esophagus at the level of the thoracic inlet. On the frontal chest radiograph, an opaque foreign body is depicted at the midclavicular level. A coin in the esophagus is depicted in the coronal plane of a frontal image because of the inherent configuration of the esophagus. If the coin is in the sagittal plane of the frontal image, the foreign body most likely is in the trachea. The orientation is generally caused by the incomplete circumferential cartilaginous rings along the posterior aspect of the trachea that allow the coin to protrude posteriorly.

The second most common site for esophageal foreign body retention is the level of the carina and aortic arch because of normal physiologic narrowing in the mid esophagus at this level. The third location is the distal esophagus slightly above the gastroesophageal junction. On the frontal chest radiograph, this location is approximately 3 vertebral body levels above the gastric air bubble. If a radiopaque foreign body is seen at another level, an underlying stricture should be suspected, and further investigation with contrast-enhanced esophagography is indicated.

The characteristics of the object (eg, radiopaque or radiolucent and sharp or blunt) and the number of retained items affect the choice of retrieval method. Additional plain radiographic findings may include soft-tissue masses; these may represent inflammatory changes and possibly indicate a more chronic process. Tracheal displacement or compression suggests mediastinal inflammation and airway compromise. An air-fluid level suggests mediastinal abscess formation, whereas a pneumomediastinum may indicate an esophageal perforation.

If the presence of a nonradiopaque foreign body is suspected, contrast-enhanced esophagography is indicated. Positive findings on the esophagram include irregularity of the contrast medium column or esophageal mucosa, as well as deviation in the expected course of the esophagus. Underlying stricture formation, with or without proximal esophageal dilatation or diverticula formation caused by chronic esophageal perforation, also may be present.

CT SCAN

Section 5 of 9  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Intervention
• Multimedia
• References

Findings

Contrast-enhanced CT is indicated for the assessment of a suspected esophageal foreign body when the plain radiographic findings are negative, the contrast-enhanced esophagographic findings are positive, or the presence of an esophageal foreign body is highly suspected. CT can aid in characterizing the nature of the foreign body, as well as the presence and extent of surrounding disease such as mediastinitis or abscess formation. Also, small foreign bodies that cannot be visualized with a standard radiologic examination can be evaluated with CT. Chicken and fish bones lodged in the hypopharynx and cervical esophagus are difficult to evaluate on plain radiographs. CT is also valuable in the assessment of complications of foreign body removal.

MRI

Section 6 of 9  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Intervention
• Multimedia
• References

Findings

Although MRI is the preferred cross-sectional imaging tool for evaluating the full extent of cervicothoracic masses and the relationships between neurovascular structures, it is not the initial imaging method of choice for the workup for a retained foreign body or traumatic lesion. However, MRIs can readily demonstrate the extent of a mediastinal inflammatory abscess or granuloma formation.

INTERVENTION

Section 7 of 9  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Intervention
• Multimedia
• References

A variety of methods can be used to remove an esophageal foreign body. Careful patient selection aids in determining the method of choice. The chosen strategy depends on the type and location of foreign body, the length of time it has been in the esophagus, and the relative degree of experience with the different techniques at a given facility. The success rate for the removal of foreign bodies from the esophagus is 95-100% regardless of the technique used. The cost of the procedures varies depending on the patient setting. All of the methods for esophageal foreign body removal are successful when chosen appropriately. Whichever technique is used, trained professionals with experience in pediatric resuscitation procedures must be available.^{2, 6, 8, 11, 12, 13, 14, 15, 16}

Current strategies for the removal of retained foreign bodies include endoscopy or surgery; temporization, which allows the foreign body to pass into the stomach on its own; rigid or flexible esophagoscopy; balloon catheter extraction with radiographic guidance; and bougienage or a balloon catheter technique to push the foreign body into the stomach. The last technique is appropriate only when the object is lodged in the distal portion of the esophagus.

Absolute contraindications to fluoroscopic balloon catheter removal, esophageal bougienage, and temporization include chest radiographic findings of esophageal edema with airway compromise, esophageal perforation, and pneumomediastinum.

Endoscopy or surgery

In witnessed ingestions in asymptomatic patients, diagnosis and treatment are usually straightforward because foreign bodies in the mid or upper esophagus have little prospect of passing spontaneously, and instruments should be used immediately. Sharp objects and irregular or unknown foreign bodies always should be removed promptly with endoscopy or surgery. A battery lodged in the esophagus should be removed immediately, whereas a battery in the stomach can be observed initially. Repeat radiography should be performed 24 hours after presentation, and the battery should be removed if it remains in the stomach. Serial follow-up images should be obtained every 3 days until passage is verified.

Temporization

Temporization is an option if a child is examined within 24 hours after ingestion and if a single smooth object is depicted in the distal aspect of the esophagus on the chest radiograph. Temporization may be performed in an inpatient setting or outpatient setting if the child is tolerating the foreign body. Repeat radiography, performed 24 hours after ingestion, is recommended. The caretaker should look for the object in the patient's stool and must be instructed to notify a physician if the child has abdominal pain. If the object is still retained in the distal esophagus, it can be removed with an alternative method.

Rigid or flexible esophagoscopy

Most often, esophageal foreign bodies are retrieved with rigid esophagoscopy. Some advantages include a high success rate, direct visualization of the foreign body in the esophagus, the variety of objects that can be extracted, and direct visualization of the esophagus after removal of the object. The airway is protected because the procedure is performed with general anesthesia. Some disadvantages are the risks of general anesthesia and the higher cost compared with that of other methods. Complications are generally related to anesthesia, injury to the esophageal mucosa, bleeding, and perforation. Flexible esophagoscopy is performed with a child under sedation and without intubation. It is primarily limited to retrieval of objects from the mid esophagus to the duodenum.

Fluoroscopic balloon catheter extraction

Fluoroscopic balloon catheter extraction is another common technique. Advantages include its avoidance of the risk with general anesthesia, low cost, and time efficiency. Disadvantages include lack of direct visualization of the esophagus and lack of direct protection of the airway. Known abnormalities of the esophagus, such as repaired esophageal atresia, peptic stricture, a vascular ring, or esophagitis, are relative contraindications to balloon catheter removal. Under these conditions, only an experienced operator should perform the procedure.^{13, 14, 17}

Fluoroscopic balloon catheter extraction is performed in the radiology suite. An infant may be strapped to a board, whereas an older child rarely requires immobilization. Under fluoroscopic guidance, a 12F or 14F Foley catheter is inserted orally or nasally just beyond the radiopaque foreign body and inflated to the width of the esophagus with a water-soluble contrast material. The patient is placed in the prone-oblique steep Trendelenburg position. The catheter is withdrawn with gentle and steady traction as the balloon is used to pull the opaque foreign body ahead of it. The object is expectorated or removed from the mouth with the aid of forceps. Contrast-enhanced esophagography is indicated if examination is difficult or if blood is present on the catheter. In some cases, the balloon catheter technique is used to push the foreign body into the stomach, where it can be followed through the gastrointestinal tract.

Complications of the balloon catheter technique include epistaxis, vomiting, and mucosal injury or perforation. The most serious complication of balloon catheter removal is transient airway compromise caused by displacement of the foreign body from the esophagus into the airway. The reported complication rates with this technique vary; however, a potential risk does exist and must be avoided when this treatment method is used.

Bougienage

Esophageal bougienage with a Foley catheter balloon or bougienage dilator is a less frequently used method, but it may be a feasible option in patients whose ingestion was witnessed and the object has been lodged for less than 24 hours, in those with no history of previous esophageal disease or surgery, and in those without respiratory compromise at presentation.^{2, 6}

Medical/Legal Pitfalls

• Forethought is important in determining the type of extraction method.
• Although the Foley catheter technique can be a simple, safe, and effective method of extraction, controversy exists regarding the safety of the procedure.
• The choice of the procedure depends on the skill and preference of the physician.

MULTIMEDIA

Section 8 of 9  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Intervention
• Multimedia
• References

Media file 1:  Chest radiograph depicts deviation of the trachea to the right in an 18-month-old female infant with upper respiratory congestion lasting 3 months.
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Media file 2:  Anteroposterior radiograph of the neck (obtained in the same patient as in Image 1) demonstrates tracheal deviation to the right.
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Media file 3:  Barium esophagram (obtained in the same patient as in Images 1 and 2) demonstrates irregularity along the anterior aspects of the barium column.
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Media file 4:  Anteroposterior esophagram (obtained in the same patient as Images 1-3) demonstrates irregularity of the contrast material column along the right lateral aspect of the esophagus. These findings suggest the presence of a nonradiopaque foreign body, and the patient was referred for further evaluation with CT.
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Media file 5:  Nonenhanced axial CT scan demonstrates a retained esophageal foreign body. Its attenuation is similar to that of adjacent bone. Note the adjacent soft-tissue swelling and tracheal narrowing. At esophagoscopy, a metal-coated plastic disk was retrieved.
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Media type:  CT

Media file 6:  Anteroposterior chest radiograph depicts a penny at the thoracic inlet of a 13-month-old infant who refused to eat.
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Media file 7:  Lateral chest radiograph (obtained in the same patient as in Image 6) depicts soft-tissue thickening at the tracheoesophageal interface. A penny was removed at esophagoscopy.
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Media type:  X-RAY

Media file 8:  Radiograph in a 13-year-old girl who was playing with jacks recently.
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Media file 9:  Oblique barium esophagram depicts pseudodiverticulum formation that required thoracotomy for repair in the same patient as in Image 8 who had persistent discomfort while eating.
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Media type:  X-RAY

REFERENCES

Section 9 of 9

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Intervention
• Multimedia
• References

1. Dokler ML, Bradshaw J, Mollitt DL. Selective management of pediatric esophageal foreign bodies. Am Surg. Feb 1995;61(2):132-4. [Medline].
2. Emslander HC, Bonadio W, Klatzo M. Efficacy of esophageal bougienage by emergency physicians in pediatric coin ingestion. Ann Emerg Med. Jun 1996;27(6):726-9. [Medline].
3. Gilchrist BF, Valerie EP, Nguyen M. Pearls and perils in the management of prolonged, peculiar, penetrating esophageal foreign bodies in children. J Pediatr Surg. Oct 1997;32(10):1429-31. [Medline].
4. Jaramillo D, Cleveland RN, Blickman JG. Radiologic management of esophageal foreign bodies. Semin Intervent Radiol. 8:198-203.
5. Soprano JV, Mandl KD. Four strategies for the management of esophageal coins in children. Pediatrics. Jan 2000;105(1):e5. [Medline]. [Full Text].
6. Arms JL, Mackenberg-Mohn MD, Bowen MV, Chamberlain MC, Skrypek TM, Madhok M. Safety and Efficacy of a Protocol Using Bougienage or Endoscopy for the Management of Coins Acutely Lodged in the Esophagus: A Large Case Series. Ann Emerg Med. Oct 13 2007;[Medline].
7. Lin HH, Lee SC, Chu HC, Chang WK, Chao YC, Hsieh TY. Emergency endoscopic management of dietary foreign bodies in the esophagus. Am J Emerg Med. Jul 2007;25(6):662-5. [Medline].
8. Smith MT, Wong RK. Esophageal foreign bodies: types and techniques for removal. Curr Treat Options Gastroenterol. Feb 2006;9(1):75-84. [Medline].
9. Soprano JV, Fleisher GR, Mandl KD. The spontaneous passage of esophageal coins in children. Arch Pediatr Adolesc Med. Oct 1999;153(10):1073-6. [Medline].
10. Castellote A, Vazquez E, Vera J. Cervicothoracic lesions in infants and children. Radiographics. May-Jun 1999;19(3):583-600. [Medline].
11. Harned RK II, Strain JD, Hay TC. Esophageal foreign bodies: safety and efficacy of Foley catheter extraction of coins. AJR Am J Roentgenol. Feb 1997;168(2):443-6. [Medline].
12. Kaye RD, Towbin RB. Interventional procedures in the gastrointestinal tract in children. Radiol Clin North Am. Jul 1996;34(4):903-17. [Medline].
13. Morrow SE, Bickler SW, Kennedy AP. Balloon extraction of esophageal foreign bodies in children. J Pediatr Surg. Feb 1998;33(2):266-70. [Medline].
14. Schunk JE, Harrison AM, Corneli HM. Fluoroscopic foley catheter removal of esophageal foreign bodies in children: experience with 415 episodes. Pediatrics. Nov 1994;94(5):709-14. [Medline].
15. Lin CH, Chen AC, Tsai JD, Wei SH, Hsueh KC, Lin WC. Endoscopic removal of foreign bodies in children. Kaohsiung J Med Sci. Sep 2007;23(9):447-52. [Medline].
16. Kalayci A, Tander B, Kocak S, Rizalar R, Bernay F. Removal of open safety pins in infants by flexible endoscopy is effective and safe. J Laparoendosc Adv Surg Tech A. Apr 2007;17(2):242-5. [Medline].
17. Kirks DR. Fluoroscopic catheter removal of blunt esophageal foreign bodies. A pediatric radiologist''s perspective. Pediatr Radiol. 1992;22(1):64-5. [Medline].
18. Carlson DH. Removal of coins in the esophagus using a foley catheter. Pediatrics. Sep 1972;50(3):475-6. [Medline].
19. Conners GP, Chamberlain JM, Ochsenschlager DW. Symptoms and spontaneous passage of esophageal coins. Arch Pediatr Adolesc Med. Jan 1995;149(1):36-9. [Medline].
20. Kelley JE, Leech MH, Carr MG. A safe and cost-effective protocol for the management of esophageal coins in children. J Pediatr Surg. Jul 1993;28(7):898-900. [Medline].
21. Litovitz T, Schmitz BF. Ingestion of cylindrical and button batteries: an analysis of 2382 cases. Pediatrics. Apr 1992;89(4 Pt 2):747-57. [Medline].
22. Macpherson RI, Hill JG, Othersen HB. Esophageal foreign bodies in children: diagnosis, treatment, and complications. AJR Am J Roentgenol. Apr 1996;166(4):919-24. [Medline].
23. McGahren ED. Esophageal foreign bodies. Pediatr Rev. Apr 1999;20(4):129-33. [Medline].
24. Nandi P, Ong GB. Foreign body in the oesophagus: review of 2394 cases. Br J Surg. Jan 1978;65(1):5-9. [Medline].
25. Towbin R, Lederman HM, Dunbar JS. Esophageal edema as a predictor of unsuccessful balloon extraction of esophageal foreign body. Pediatr Radiol. 1989;19(6-7):359-60. [Medline].
26. Towbin RB, Dunbar JS, Rice S. Magnetic catheter for removal of magnetic foreign bodies. AJR Am J Roentgenol. Jan 1990;154(1):149-50. [Medline].
27. Waltzman ML. Management of esophageal coins. Curr Opin Pediatr. Oct 2006;18(5):571-4. [Medline].
28. Webb WA. Management of foreign bodies of the upper gastrointestinal tract: update. Gastrointest Endosc. Jan 1995;41(1):39-51. [Medline].
29. Yalçin S, Karnak I, Ciftci AO, Senocak ME, Tanyel FC, Büyükpamukçu N. Foreign body ingestion in children: an analysis of pediatric surgical practice. Pediatr Surg Int. Aug 2007;23(8):755-61. [Medline].

Article Last Updated: Nov 1, 2007