EM@3AM: Esophageal Foreign Bodies
- Apr 7th, 2018
- Brit Long
Author: Brit Long, MD (@long_brit, EM Attending Physician, San Antonio, TX) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)
Welcome to EM@3AM, an emDOCs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.
A 52-year-old male presents with inability to swallow. He was eating steak one hour ago and swallowed a large piece without chewing. He thinks it is stuck around his upper sternal area and has noted difficulty swallowing secretions afterwards. This has never happened before, and he denies shortness of breath. His only medical problem is hypertension.
Triage vital signs (VS): BP 153/81, HR 102, T 98.9 Oral, RR 22, SpO2 97% on RA.
Physical exam reveals a patient who appears uncomfortable, sitting upright, constantly spitting into a bag. His lungs and heart are normal, and you do not see anything in his mouth.
What is the next step in your evaluation and treatment?
Answer: Esophageal Foreign Body
- Background: A foreign body (FB) in the esophagus may result in impaction (typically food), obstruction, perforation, or stricture.
- Perforation is usually due to mechanical (sharp object) or chemical injury (ingestion or button battery).
- Common pediatric FBs: coins, food, toys.
- Common adult FBs: food bolus or objects (psychiatric patient).
- Obstruction location:
- Cricopharyngeus muscle is most common (75%); C6.
- Aortic crossing over the esophagus.
- Lower esophageal sphincter.
- Irritation of the esophagus may feel like a foreign body.
- If the FB passes the gastric pylorus, it frequently will pass without complication, except for the following: >2-2.5 cm wide, > 6 cm long, objects with sharp and/or irregular edges.
- History and Exam:
- Adults may describe retrosternal pain, choking/aspiration, vomiting, dysphagia. If unable to pass the FB and object is obstructing passage, patients may be repeatedly spitting (unable to tolerate secretions). Ask about choking or any activity to dislodge the object (Heimlich maneuver). If able to swallow and pass secretions, patients do not have a completely obstructing FB. Ask about prior episodes (many patients have had prior episodes and known pathology).
- Pediatric patients may present with recurrent vomiting, refusal/inability to eat, gagging/choking, neck/throat pain, drooling, or stridor. Ask parents, sibiling, and/or other caregivers about missing toys, recent snacks/meals, and child’s tendency to place objects in his/her mouth.
- Evaluate airway status. If in extremis, prepare airway equipment and cricothyrotomy equipment.
- If not in extremis, closely evaluate oral cavity, neck, lungs. Always consider other FB’s (nasal FB in pediatric patient).
- Laboratory studies typically are not required. If perforation is suspected, WBC and lactate may be elevated.
- Imaging is the most often ordered assessment, including a chest X-ray (PA and lateral).
- Chest X-ray: Most commonly ordered test.
- This may not be required if the FB is a food bolus.
- Other patients with non-food objects (tools, toys, coins) should undergo imaging.
- Esophageal coins typically present en face on AP view, while if located within the trachea, they present en face in lateral view.
- Bones are visualized less than 50% of the time if ingested.
- Button batteries may demonstrate a double-ring sign.
- Chest CT:
- High-yield for radiopaque and non-radiopaque objects, with sensitivity approaching 99%. Specificity ranges from 70%-92%.
- Gold standard test and therapeutic (see management below).
- Barium Swallow Study:
- Typically not recommended due to greater risk of aspiration, mediastinitis, and difficulty with endoscopy.
- GI consult required for emergent endoscopy with the following:
- Airway obstruction, complete obstruction (inability to tolerate secretions), ingestion of button battery still in the esophagus, sharp or elongated FB (> 2cm wide, > 6 cm long), presence of multiple FB’s, multiple magnets present (can cause perforation), coin at the cricopharyngeus level, concern for perforation.
- Food Impaction
- Impacted food bolus: attempt medical therapy with glucagon or carbonated beverage; consult GI. If ineffective, GI consultation for endoscopy is needed.
- Uncomplicated food bolus with no bones and ability to tolerate secretions (incomplete obstruction) may be managed expectantly, but these should not be left within the esophagus for > 12 hours due to greater risk of esophageal damage.
- Glucagon 1-2 mg IV or IM may relax the lower esophageal sphincter. Data are controversial regarding efficacy. Major side effect is nausea and vomiting, which increases risk of tissue damage. For a deep dive, see this REBEL EM post.
- Provide antiemetic before glucagon is given (such as ondansetron).
- Carbonated beverages may result in dilation of the esophagus, though data are controversial.
- Other medications (nifedipine, benzodiazepines, nitroglycerin, papain) have low success rate and risk of side effects. They are not recommended for use.
- Button Battery
- National Button Battery Ingestion Hotline: 202-625-3333.
- If located within the esophagus, this is a true emergency, as perforation may occur within 6 hours of ingestion due to electrical conduction and direct pressure.
- Mercury toxicity is a risk.
- Emergent removal via endoscopy.
- If past the lower esophageal sphincter, can be managed expectantly.
- Coin Ingestion
- Sharp Objects
- Require immediate removal if located within the esophagus, stomach, or duodenum (Result in perforation in up to 35% of patients).
- If distal to duodenum and the patient has symptoms concerning for intestinal damage, consult surgery immediately. If no symptoms, may document passage through GI tract with daily radiographs.
- Provide antiemetics and analgesia for symptom control.
- GI consult required for emergent endoscopy with the following:
- Complications: Airway compromise, pneumonia, perforation/necrosis, mediastinis/infection, stricture, aortic perforation, vocal cord damage/paralysis.
- Patients require GI follow up for evaluation of structural abnormality, typically via endoscopy.
- If passes FB or FB is removed, patient may be discharged with follow up.
- Patients with concern for continued obstruction or perforation should be admitted.
A 49-year-old man with an extensive psychiatric history presents thirty minutes after swallowing 30 wooden toothpicks at his group home. He is asymptomatic. Which of the following is the most appropriate management?
A. Endoscopy with removal of the toothpicks
B. Supportive care as the toothpicks will likely pass on their own
C. Surgical removal in the operating room
D. Whole bowel irrigation with polyethylene glycol
The first step in evaluating a patient with a foreign body is to identify the location. Respiratory symptoms like cough and stridor usually suggest location in the airway, though the distinction can be difficult in young children who cannot verbalize their symptoms. In addition, large proximal esophageal foreign bodies can result in extrinsic airway compression with resultant respiratory distress, stridor, and cyanosis. Foreign bodies lodged in the esophagus usually cause dysphagia and neck or chest pain, while a foreign body that has reached the stomach usually causes no symptoms. The majority of foreign bodies that have entered the stomach can be managed conservatively. However, sharp objects (such as the toothpicks in this clinical scenario) require endoscopic removal because the risk of intestinal perforation is high. In addition, objects longer than 5 cm or wider than 2.5 cm in diameter also require endoscopic retrieval because they rarely pass through the pylorus. Smooth, smaller objects that have passed into the stomach can be followed with serial radiographs and inspection of the stool to confirm passage.
Supportive care (B) is not appropriate in this case because the toothpicks are sharp and carry a high risk of intestinal perforation if they are not removed. Surgical removal in the operating room (C) is a last-resort option for foreign bodies that fail to pass spontaneously. Whole bowel irrigation with polyethylene glycol solution (D) is used in in the management of cocaine body packing to speed gastrointestinal passage of drug packets, which could be lethal if ruptured, but is not indicated for more benign swallowed foreign bodies.
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