Foreign Bodies

Question 1

What is the incidence of foreign body ingestion in small children?

Answer 1

The true incidence is unknown because ingestion is often unwitnessed, and most foreign bodies pass through the gastrointestinal tract without causing harm

Question 2

What types of foreign bodies can cause extensive clinical consequences if not managed properly?

Answer 2

Foreign bodies that can cause extensive clinical consequences include:
• Objects lodged in the oesophagus
• Magnet or battery ingestion
• Objects that remain in the stomach for more than 48 hours
• Systemically ill patients

Question 3

When should a patient be transferred to a center with specialized facilities for foreign body management?

Answer 3

Transfer is necessary when:
• The object is lodged in the oesophagus
• The patient has ingested a magnet or battery
• The object remains in the stomach for over 48 hours
• The patient is systemically ill

Question 4

What are the possible anatomical sites of obstruction for ingested foreign bodies?

Answer 4

The possible sites of obstruction are:
1. Cricopharyngeus muscle (6th cervical vertebra and clavicles) - the narrowest part of the child’s GIT and the most common site for coin obstruction
2. Upper mediastinum - where the oesophagus passes the left main bronchus
3. Lower oesophageal sphincter - just above the gastro-oesophageal junction
4. Ileo-caecal valve

Question 5

What is the most common site of coin obstruction in children?

Answer 5

The most common site of coin obstruction is the cricopharyngeus muscle, located at the level of the 6th cervical vertebra and clavicles.

Question 6

How may children present with a history of foreign body ingestion?

Answer 6

Children may present with a history of witnessed ingestion of a foreign body.

Question 7

What are the symptoms relating to the presence of oesophageal obstruction?

Answer 7

Symptoms of oesophageal obstruction include:
• Drooling
• Odynophagia (painful swallowing)
• Vomiting

Question 8

What are the symptoms of complications of retained oesophageal foreign bodies?

Answer 8

Symptoms of complications include:
• Oesophageal stricture: drooling, odynophagia, weight loss, failure to thrive
• Haematemesis: secondary to erosion into a nearby vascular structure
• Recurrent lower respiratory tract infections: due to aspiration or soiling via an acquired fistula

Question 9

What are the symptoms of distal complications following foreign body ingestion?

Answer 9

Symptoms of distal complications include:
• Entero-enteric fistulae after ingestion of multiple magnets: symptoms of bowel obstruction, peritonism, and sepsis
• Symptoms of perforation: very rare, except in the case of magnet ingestion

Question 10

How is foreign body ingestion usually diagnosed?

Answer 10

X-Ray is typically diagnostic for foreign body ingestion.

Question 11

What type of X-Ray films are sufficient to diagnose a foreign body lodged in the oesophagus or airway?

Answer 11

Plain anterior-posterior and lateral chest films, including the neck, are sufficient to diagnose a foreign body lodged in the oesophagus or airway if it is radio-opaque.

Question 12

What is the limitation of using X-Ray for foreign body ingestion diagnosis?

Answer 12

Certain objects, such as plastic toys, may be radiolucent and not visible on X-ray. If patients with these objects present with symptoms of oesophageal obstruction, they should be referred for further evaluation.

Question 13

When is an abdominal X-ray indicated?

Answer 13

An abdominal X-ray is indicated in the following cases:
• Ingestion of multiple magnets
• Ingestion of objects longer than 4cm, such as pins, needles, screws, or nails
• Any case with a history of ingestion and symptoms of peritonism or other concerning abdominal symptoms

Question 14

What type of X-Ray can be used where available for diagnosing foreign body ingestion?

Answer 14

Lodox X-rays can be used where available.

Question 17

What does a Chest X-ray with a button battery in the oesophagus show?

Answer 17

The X-ray will show:
• A dilated proximal oesophagus containing an air-fluid level
• A ‘halo’ sign, which indicates that the object is likely a battery, not a coin

Question 18

What does an X-ray show in the case of ingested magnetic beads?

Answer 18

The X-ray will show a string of ingested magnetic beads, with some located in the oesophagus and others in the stomach.

Question 19

How are most children with uncomplicated foreign body ingestion managed?

Answer 19

Most children with uncomplicated foreign body ingestion are well and generally require no immediate intervention beyond observation.

Question 20

What are the steps in managing children with complications from foreign body ingestion?

Answer 20

Children with complications require immediate resuscitation:
• Airway management in cases of respiratory complications and distress due to aspiration or infection
• Fluid and blood product administration if the patient is dehydrated or haemodynamically unstable due to blood loss
• Antibiotic therapy if there is established sepsis

Question 21

What is the management for objects that pass through the oesophagus but are lodged in the stomach?

Answer 21

For objects lodged in the stomach, a repeat plain abdominal radiograph should be done 48–72 hours later to confirm the object has moved.

Question 22

What should be done if a foreign object is beyond the stomach and duodenum?

Answer 22

If the object is beyond the stomach and duodenum, reassure the caregiver, as it will pass in almost all cases. There is no need for repeat films unless the patient develops concerning abdominal symptoms.

Question 23

When should children with foreign body ingestion be referred to an appropriate centre?

Answer 23

Referral is necessary in the following cases:
• All foreign bodies lodged in the oesophagus (confirmed radiologically or with high clinical suspicion in cases of radiolucent objects)
• Large or long foreign bodies lodged in the stomach or duodenum (greater than 4 cm long or wide)
• Foreign bodies lodged in the stomach or duodenum that have not passed within 48 hours of ingestion
• Ingestion of two or more magnets
• Any case of foreign body ingestion associated with abdominal pain, peritonism, sepsis, or symptoms of gastrointestinal obstruction

Question 24

How often are coins ingested, and where do they typically lodge?

Answer 24

Coins are frequently ingested and often lodge at the level of the cricopharyngeus muscle.

Question 25

What symptoms do children typically experience when a coin is lodged in the oesophagus?

Answer 25

Children are usually systemically well but may experience:
• Drooling
• Odynophagia (painful swallowing)

Question 26

What are the potential complications of a coin lodged in the oesophagus for an extended period?

Answer 26

Coins lodged for an extended period may cause: • Oesophageal strictures • Erosions

Question 27

How does a coin in the oesophagus appear on an X-ray compared to a coin in the trachea?

Answer 27

• A coin in the oesophagus will lie face-on (on an AP X-ray) due to the oesophagus being compressed between the vertebral bodies and trachea. • A coin in the trachea will lie end-on (on an AP X-ray) due to the trachea being wider in the sagittal plane because of the C-shape of the tracheal rings. • A lateral X-ray will confirm the location of the coin.

Question 28

How are coins typically removed from the oesophagus?

Answer 28

Coins are removed endoscopically using either a rigid or flexible endoscope.

Question 29

How can a Foley’s catheter be used to remove a coin lodged at the cricopharyngeus?

Answer 29

In some units, a Foley’s catheter is used for objects at the cricopharyngeus within 24 hours of ingestion. The procedure involves: • Passing the catheter beyond the point of obstruction • Inflating the balloon with 5ml of water • Leaning the child forward and retracting the catheter to dislodge the coin and lift it into the mouth

Question 30

What are the contraindications for using a Foley’s catheter for coin removal?

Answer 30

Contraindications include: • Signs of aspiration pneumonia or wheezing • More than 24 hours since ingestion • More than 2 failed attempts • An ill or uncooperative child • A foreign body other than a coin

Question 31

What are button batteries, and what are their typical dimensions?

Answer 31

Button batteries are small, disc-shaped batteries, typically 5 to 25mm in diameter and 1 to 6mm high. They are single-cell units with one half-cell being the positive electrode and the other the negative electrode.

Question 32

What happens when a button battery is lodged in the oesophagus?

Answer 32

Once a button battery is in the oesophagus and contacts the endothelium, it creates a circuit that rapidly heats up, causing: • Thermal cell damage • Erosion of the casing, leaking metals and hydroxide anions • Increased pH, resulting in liquefactive necrosis and cytotoxic damage These changes can occur within two hours of ingestion.

Question 33

What are the serious complications of button battery ingestion?

Answer 33

Serious complications include: • Oesophageal perforation • Aorto-oesophageal fistula, which can present as a herald bleed followed by a fatal upper GI bleed • Bilateral vocal cord paralysis • Trachea-oesophageal fistula, commonly presenting as aspiration pneumonia • Oesophageal necrosis and oesophageal stenosis

Question 34

What does a chest radiograph show when a button battery is lodged in the oesophagus?

Answer 34

A chest radiograph will reveal a smooth, round object, most commonly lodged in: • The cricopharyngeal area • The middle third of the oesophagus (where the left main bronchus crosses the oesophagus) • The lower oesophageal sphincter

Question 35

What are the clues to distinguish a button battery from a coin on X-ray?

Answer 35

Clues that suggest a button battery: • On lateral X-ray, one side of the battery is perfectly flat, and the other side is convex. • The ‘step-off’ sign, referring to the ‘step’ between the battery and its casing. • A halo sign, where a rim of lucency appears on the inside edge of the battery.

Question 36

How should button batteries lodged in the oesophagus be managed?

Answer 36

Button batteries lodged in the oesophagus are a surgical emergency. These patients should be transferred immediately to an appropriate service for endoscopic removal. Removal should never be attempted in the emergency unit.

Question 37

What problems do multiple magnets cause when ingested?

Answer 37

When multiple magnets are ingested, they attract each other through the intestinal walls, generating forces up to 1300 G, which can lead to: • Pressure necrosis • Perforation • Fistula formation anywhere along the gastrointestinal tract

Question 38

How do multiple magnets appear on a plain X-ray?

Answer 38

On a plain X-ray, multiple magnets may appear as a harmless string of beads with no intervening bowel, often leading to the assumption that they will pass spontaneously.

Question 39

What complications can arise from the delayed diagnosis of multiple magnet ingestion?

Answer 39

Due to the delay in diagnosis, children may present late with: • Peritonitis • Entero-enteric fistulation

Question 40

How should children who have ingested multiple magnets be managed?

Answer 40

Children who have ingested multiple magnets should always be referred to an appropriate surgical service. Management often requires laparoscopy or laparotomy.

Question 41

What happens when long, pointed objects (pins, needles, screws, nails) are ingested?

Answer 41

Most long, pointed objects pass without causing problems, but they may become stuck, often lodging in the duodenum where they can’t navigate the tight bends of the gastrointestinal tract.

Question 42

How are foreign bodies in the oesophagus typically removed?

Answer 42

Foreign bodies lodged in the oesophagus are usually removed under endoscopic vision while the patient is under general anaesthetic.

Question 43

How are button batteries managed when ingested?

Answer 43

Button batteries are removed urgently due to the potential for rapid tissue damage.

Question 44

How are coins typically managed when ingested?

Answer 44

Coins are removed on an emergency basis as soon as the patient is fasted.

Question 45

What additional procedures might be necessary for missed foreign body ingestion leading to complications?

Answer 45

For missed ingestion with complications, additional surgical procedures such as: • Thoracotomy • Neck exploration • Oesophagostomy may be indicated.

Question 46

How are foreign bodies lodged in the stomach for more than 48 hours managed?

Answer 46

Foreign bodies lodged in the stomach for more than 48 hours may be removed endoscopically on an elective basis.

Question 47

What is the management for patients who ingest more than one magnet?

Answer 47

Patients who ingest more than one magnet will most likely require laparoscopy or laparotomy.

Question 48

What should be done if there is a history of choking, cyanosis, or possible foreign body ingestion where the object is not visible on an X-ray?

Answer 48

Urgent bronchoscopy ± oesophagogastroduodenoscopy is mandated to exclude an aspirated foreign body, as sudden occlusion of a major airway can lead to asphyxiation, and smaller objects may cause infection.

Question 49

What are bezoars, and what can cause them?

Answer 49

Bezoars are masses of ingested material, such as hair or vegetable matter, that can form a bolus and cause obstruction.

Question 50

Who is most at risk for developing bezoars?

Answer 50

Bezoars are typically seen in psychologically disturbed or neurologically challenged patients.

Question 51

How are bezoars managed?

Answer 51

Endoscopic or laparotomy retrieval is required to remove the bezoar and relieve the obstruction.