upper GIT foreign body

see also:

• FB_lowerGIT

• a large food bolus such as inadequately chewed meat, or accidental FB ingestion tend to become trapped at the following sites in the oesophagus:
  • upper oesophageal sphincter (cricopharyngeus)
  • level of the aortic arch
  • the diaphragmatic hiatus
  • areas of pathology - oesophageal cancer, oesophageal strictures, diverticulum, post-gastrectomy,hiatus hernia, achalasia, eosinophilic oesophagitis
• in addition sharp ingested foreign bodies such as fish bones are commonly impacted in the upper oesophagus and pharynx such as the pyriform fossa, tonsil, posterior tongue.
• flat objects, such as coins, usually orient themselves in the coronal plane (this distinguishes them from being in the trachea) when lodged in the cervical oesophagus, and are best seen on anteroposterior projections.
• hoarse voice suggests laryngeal involvement rather than GIT.
• recurrent food bolus obstructions require endoscopy to rule out underlying pathology.

• fresh water fish bones tend to be radiolucent and may often spontaneously dissolve with time.
• saltwater fish bones tend to be radio-opaque and not dissolve.

• examine pharynx using direct or indirect laryngoscopy
  • consider spraying posterior pharynx with topical lignocaine anaesthesia
  • use laryngoscope mirrors or a laryngoscope with patient seated and relaxed to reduce risk of gagging and emesis
  • if fish bone visible, remove using Magill forceps or similar
  • nil orally for at least 1hr post-anaesthesia
  • tetanus prophylaxis if evidence of bleeding
  • no antibiotics indicated
• if unable to visualise the bone:
  • if pain but no dysphagia, perforation or infection then consider discharge home with review in 48hrs if still symptomatic
  • otherwise contact ENT for fiberoptic laryngoscopy +/- plain soft tissue neck XR

• fever, sweats suggests infection
• crepitus, mass, fever, regional LNs, or decreased neck movement suggest perforation
• gas in tissues or soft tissue mass on Xray suggests perforation
• examine pharynx, and perform laryngoscopy as above
• nil orally
• contact ENT +/- CT scan
• if neck abscess present, surgical drainage and removal of FB at time of drainage is indicated.
• hospital admission
• iv antibiotics
• tetanus prophylaxis

• consider gentle cricoid massage under light sedation to break down meat bolus if no bone seen on plain X-ray

• consider iv glucagon 1mg, iv buscopan 20mg plus sips of a fizzy drink such as Coke to attempt to relax the oesophagus and allow the bolus to pass
• if obstruction persists, endoscopy is generally required to prevent pulmonary aspiration
• DO NOT use meat tenderisers - they do not work and may increase oesophagitis in adults

• exclude inhaled foreign body which is suggested by a history of coughing at the time, or ongoing cough, stridor, or wheeze
• in the absence of the above suspicion, a plain A-P CXR including neck and stomach is generally sufficient to find the FB if it is radio-opaque HOWEVER as children often ingest multiple FBs, consideration should be given to plain Xray showing nasopharynx to anus, particularly if the suspected foreign body is worrisome such as button batteries.
• failure to find a FB on Xray or a known radio-lucent FB:
  • generally can be managed expectantly with no follow up unless they become symptomatic.
  • may require MRI if history is worrisome or patient is symptomatic, in which case initial referral to ENT or general surgeon for advice is generally appropriate.
• follow up Xrays or the checking of stool for passage has very limited utility

• flat objects such as coins lie in the coronal plane in the upper oesophagus which distinguishes them from being in the trachea.
• objects greater than 5 cm in length or 2cm in diameter are less likely to pass
• button batteries may cause damage to the esophagus as early as two hours after ingestion, with more severe damage after 8 to 12 hours. In animal models, full-thickness oesophageal injury has been demonstrated within four hours of ingestion.
• in general, it is usual practice to contact ENT or general surgeons for ALL cases of radio-opaque or symptomatic oesophageal FB's in children
  • see RCH guideline
• oesophageal FB's in children are referred for that day extraction (preferably within 2hrs if button battery) using endoscopy if either:
  • sharp - although most will pass uneventfully, even sewing needles, ~1/3rd will cause complications and are thus generally extracted. Those managed expectantly or unable to be removed, should have repeat Xrays and referral for surgical removal if no change in position in GIT for 3 days.
  • long (>5cm)
  • has multiple magnets
  • button battery
  • unable to swallow secretions
  • fever, abdominal pain or vomiting
  • retained in oesophagus > 12-24hrs

• the likelihood that the foreign body will pass spontaneously and be evacuated in the stool without causing damage while passing through the alimentary canal depends upon its size, shape, composition, the age of the patient, and whether the patient has anatomical abnormalities
• most foreign bodies once in the stomach will pass spontaneously and advice to return if become symptomatic
  • exceptions include:
    • long objects > 5cm such as spoons, toothbrushes - these will need extraction
    • button batteries in the stomach will need repeat Xrays to ensure exit from the stomach within 48hrs
      • patients should be considered for repeat Xrays if:
        • at 48 hrs
        • they become symptomatic
        • at 4 days after ingestion if under age 6 years and button battery diameter > 15mm
        • weekly if passage not visualised in stool
      • endoscopic removal of gastric button battery should be considered if:
        • battery remains in stomach at 48hrs
        • unlikely to pass stomach - ≥15 mm in diameter in a child under six years of age
        • patient becomes symptomatic
    • sharp objects
    • those with at least one magnet and another metal object (eg. a button battery or another magnet) may need extraction
    • ingestion of lead foreign bodies can cause systemic lead absorption if they are retained for more than a few hours, absorption is increased by gastric acid and thus there may be a role for proton pump inhibitors (PPIs) and urgent endoscopic removal within hours.
      • markedly elevated lead levels have been measured within 90 minutes of ingestion of a foreign body containing lead and fatalities have been reported.