Esophageal Foreign Body

Continuing Education Activity

Most patients who present for evaluation of a foreign soundbox in the esophagus do so after accidental consumption of a know aim, and the patient has mild symptoms and is in stable condition. The challenges come from patients who are unable or unwilling to provide a history of the object ingested or when it occurred. Examples are infants, children, mentally impaired, psychiatric, and prisoners. besides, the wide range of possible symptoms and clinical presentations, plus the across-the-board range of electric potential complications, can make this a unmanageable condition to evaluate and manage. This natural process reviews the etiology, presentation, evaluation, and management of esophageal foreign body consumption and reviews the function of the interprofessional team in evaluating, diagnosing, and managing the condition. Objectives:

• Describe the distinctive etiology of an esophageal foreign body .
• Discuss the pathophysiology of an esophageal alien soundbox.

  Reading: Esophageal Foreign Body

• Review the management options available for a patient who presents with an esophageal alien body .
• Explain the importance of improving coordination among the interprofessional team to enhance concern for patients affected by foreign bodies lodged in the esophagus .

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Introduction

Most patients who present for evaluation of a alien body in the esophagus do so after accidental consumption of a know object, and the patient has mild symptoms and is in stable condition. The challenges come from patients who are unable or unwilling, for model, infants, children, mentally afflicted, psychiatric, prisoners, to provide a history of the aim ingested or when it occurred. besides, the wide image of possible symptoms and clinical presentations, plus the wide range of likely complications, can make this a difficult condition to evaluate and manage. [ 1 ] [ 2 ] [ 3 ] [ 4 ]

Etiology

In adults, the esophagus is approximately 20 to 25 centimeter in length, extending from the hypopharynx to the abdomen. The esophagus has an inner mucous membrane layer and a brawn layer made up of inner circular muscles and out longitudinal muscles. The upper third base is voluntary striate muscles that allow trigger of swallow, while muscles of the lower third base are involuntary smooth muscles. The esophagus is the most park site for an acute foreign body or food impaction in the gastrointestinal tract, and 80 to 90 % of swallow objects that reach the stomach will finally pass without intervention. While a wide variety of objects could be ingested, common accidental esophageal foreign body ingestions include food bolus ( largely kernel ), pisces or chicken bones, dentures, and coins. The type of objects ingested varies between different regions and cultures. For example, in southerly China, fish bones were the most common esophageal foreign body impaction. [ 4 ] [ 5 ] [ 6 ]

Epidemiology

Children make up roughly 80 % of patients presenting to emergency departments with an esophageal foreign body. [ 1 ] [ 7 ] These are typically accidental ingestions of humble objects such as coins, sharp-pointed objects ( pins, needles ), batteries, toy dog parts, crayons, fish and chicken bones, large food bolus, jewelry, among others. Coins are the most common foreign body ingested by children. Most children have normal human body. however, there is an increase hazard of impactions with abnormalities such as eosinophilic esophagitis, prior esophageal atresia repair, and prior Nissen fundoplication. [ 8 ] similarly, in adults, similar accidental extraneous body ingestions occur ; however, the most coarse cause of impingement in adults is a food ( by and large meat ) bolus. The estimate annual incidence of food impaction is 13.0 per 100,000. Eighty percentage to 90 % happen in the distal esophagus associated with anatomic or motor abnormalities. These abnormalities include diverticulum, web, rings, strictures, tumors, eosinophilic esophagitis, achalasia, scleroderma, or esophageal spasms. For this reason, it is recommended that adults with a history of food impaction, even if it resolves spontaneously, need follow-up evaluation of the esophagus .

Pathophysiology

The normal esophagus has 3 primary areas of physiologic narrowing : the upper esophageal sphincter ( UES ) which includes the cricopharyngeus muscle, the middle esophagus where the esophagus crosses over the aortal arch, and the lower esophageal sphincter ( LES ). In children, approximately 74 % of extraneous bodies are entrapped at the UES grade. In adults, approximately 68 % of obstructions occur at the distal esophagus associated with pathological abnormalities. [ 9 ] possible complications include local injury to the mucous membrane, such as abrasion, lacerations, necrosis, and stenosis formation. other serious complications include injury beyond the esophagus, such as air passage obstruction, esophageal perforation, tracheoesophageal fistulous withers, vascular injury ( for example, aortoesophageal fistula ), retropharyngeal abscess, mediastinitis, pericarditis, or outspoken cord injury. [ 10 ] Three limited types of extraneous body ingestions with a higher risk of complications are button batteries ( besides called “ magnetic disk ” or “ coin ” batteries ), multiple magnets, and sharp-pointed objects. If a button battery become impacted in the esophagus, an electrical current is created between the incontrovertible and veto poles. This current can cause thermal injury plus produce hydroxide ions with a rapid rise in the local ph resulting in a acerb alkaline injury. injury begins within 15 minutes and can lead to a perforation in hours. Complications can include localized esophageal mucosal necrosis and chronic stenosis formation. More serious complications involve esophageal perforation and erosion into adjacent structures such as the mediastinum, trachea, or vascular structures. Leinwand et alabama. reported 13 cases of good complications, including 30.8 % perforation, 23.1 % stenosis constitution, and 23.1 % deathrate from aortoesophageal fistula formation and exsanguination. More than 90 % of dangerous complications occurred in children 5 years old or younger, with batteries 20-mm diameter and greater and impactions for elongated periods. [ 2 ] [ 10 ] While a individual, minor, smooth magnet will normally pass without complications, multiple magnets create complications. tissue may become trapped between the magnets leading to pressure ischemia, perforation, fistula formation, obstruction, or volvulus. [ 11 ] sharp-pointed objects stuck in the esophagus besides have a higher risk of perforation and need pressing removal .

History and Physical

key factors to consider in assessing patients with consume alien bodies include type and number of objects, localization, prison term since consumption, and presenting signs and symptoms. These factors will help determine if the object needs to be retrieved emergently, urgently or if the affected role can be safely managed with observation and follow-up. Most adults and older children can give a history of foreign body consumption and time of onset. The most coarse symptoms are foreign body sense or difficulty swallow ( dysphagia ). Symptoms typically develop in minutes to hours. Foreign bodies in the upper esophagus are more accurately localized by the patient. however, impactions in the mid or lower esophagus may be described as a undefined discomfort, ache, or chest pain. other symptoms include hypersalivation, retrosternal fullness, regurgitation, gag, choking, hiccups, and retching. If patients report afflictive swallow ( odynophagia ), this may indicate more good problems such as esophageal laceration or perforation. On examination, the patient may appear anxious and uncomfortable with swallowing. If the patient is ineffective to swallow saliva, this indicates a complete obstruction is needing more pressing treatment. Infants, younger children, the mentally impaired, or prisoners may be unable or unwilling to provide history. In these situations, a high index of intuition is needed. For infants and young children, symptoms may include gag, poor feed, drooling, or temper. An esophageal foreign torso might besides press on the trachea, causing respiratory symptoms such as wheeze, cough, dyspnea, or stridor. however, airline extraneous bodies would besides need to be considered. The physical examination should initially focus on air lane obviousness, vital signs, patient ’ second ability to handle secretions, and looking for signs of complications such as hematemesis, abnormal breath sounds, tenderness in the neck, thorax, or abdomen, or hypodermic air .

Evaluation

routine x-rays are normally the first gear footstep if a radioopaque object is suspected. This will help determine the object, the location, and possible complications. Chest x-ray ( posterior-anterior ( PA ) and lateral pass views ) is normally adequate, but the neck and abdominal x-rays may be needed depending on clinical presentation. flat objects like coins, bottle caps, or magnetic disk batteries are normally oriented in the wreath airplane if they are lodged in the esophagus and appear round on the frontal ( PA ) view. however, if they are lodged in the trachea, they orient in the sagittal plane and appear round on the lateral view. If a round “ coin-like ” object is seen on the x ray, the object needs careful inspection looking for a “ ring ” or “ double-ring ” appearance, which identifies it as a push button battery and the indigence for emergent removal. A thorax x-ray can differentiate coins from button batteries with sensitivity, specificity, and accuracy of approximately 80 %. Food, credit card, wood, and aluminum are not radioopaque, so they are not seen on routine x-rays. Bones and glaze may or may not be seen on x-rays. If nothing is seen on routine x-rays, but misgiving of a extraneous body remains high, then diagnostic endoscopy or CT scan may be indicated. CT scans have a high sensitivity for detecting foreign bodies plus are utilitarian for detecting complications such as perforation .

Treatment / Management

Assuming a stable air passage and no develop complications, the discussion and management are guided by the type of foreign body, the location, the degree of obstruction, and the duration. Endoscopic removal is the procedure of choice and is successful in more than 90 % of cases with less than a 5 % complication rate. Endoscopic management can be divided into emergency, pressing, and nonurgent. [ 12 ] [ 13 ] [ 14 ] [ 15 ] Emergency

• esophageal obstruction : inability to handle oral secretions
• phonograph record batteries in the esophagus
• sharp-pointed objects in the esophagus

Urgent (within 12 to 24 hours)

• esophageal objects that are not sharp-pointed
• Food impactions without complete obstacle
• sharp-pointed objects in the digest or duodenum
• Objects greater than 6 curium in duration above the duodenum
• multiple magnets ( or single magnet plus another ferromagnetic object within endoscopic scope )
• Coins in esophagus

Nonurgent

• Objects in the stomach greater than 2.5 cm diameter
• magnetic disk battery in abdomen up to 48 hours if asymptomatic
• Blunt objects that fail to pass stomach in 3 to 4 weeks

respective types of medical management have been studied. In theory, medications that relax the placid muscles of the LES might allow smooth, dull objects to pass spontaneously into the stomach. Glucagon is the most normally discourse agentive role ; dose 0.25 milligram to 2 mg intravenously ( IV ) over 1 to 2 minutes in a sit affected role. This is followed by oral body of water or carbonated beverage in 1 minute to promote esophagus dilatation along with LES relaxation. Glucagon can cause nausea and vomit. Vomiting may dislodge the aim but besides may increase the risk of esophagus tear. unfortunately, most studies looking at glucagon have a variety of weaknesses, including belittled sample distribution size, excommunication criteria making them non-generalizable, or are underpowered for evaluating side-effects, so most results show slight or no benefit over placebo. [ 8 ] [ 16 ] Papain ( an ingredient in kernel tenderizers ) is not recommended for kernel bolus impactions because of possible complications and a theoretical risk of damage to the esophagus. A magnetic disk battery impacted in the esophagus is a true hand brake and needs contiguous removal. The greatest concern is the potentially black complication of an aortoesophageal fistulous withers with the highest risk in children less than five years erstwhile, battery size 20 millimeter or greater, impaction at the aortal arch level, prolong impact, and any degree of hematemesis. In these specific cases, an interprofessional approach potentially including pediatric gastroenterology, pediatric surgery, cardiothoracic operation, anesthesia, and radioscopy with management in the operational room or cardiac catheterization lab may be indicated. asymptomatic children with a coin impacted in the esophagus can be managed urgently with the observation of up to 24 hours without risk of foster complications. Coin placement is significant, with 10 % of proximal esophageal coins, 26 % center esophagus coins, and 43 % of distal esophagus coins passing ad lib within 16 hours of consumption .

Differential Diagnosis

esophageal abrasions can cause a extraneous body sensation that remains after the passage of a alien object. If the affected role is stable and tolerating oral inhalation, they can be reassessed within 12 to 24 hours, and if symptoms continue, then a CT scan or endoscopy may be needed. early conditions that might cause a foreign body sensation without a foreign body present include :

• infection such as Candida, Herpes simplex virus ( HSV ), or Cytomegalovirus ( CMV )
• esophagitis ( acidic ebb, pill esophagitis, eosinophilic esophagitis )
• Esophageal spasm
• Globus pharyngeus ( besides called globus hystericus ) is a sensation of a swelling or alien soundbox in the throat of uncertain etiology .

again, if the affected role is stable and tolerating oral consumption then begin appropriate treatment for the implicit in stipulate and/or dress follow-up .

Prognosis

Eighty percentage to 90 % of consume foreign bodies will pass ad lib within 3 to 7 days. [ 1 ] Children with esophageal injury from disk battery indigence short and long-run follow-up to look for complications related to erosion or perforation and esophageal stenosis. Adults with food impactions have abnormalities 85 to 90 % of the prison term and will need evaluation and treatment of the underscore abnormalities. [ 8 ] [ 9 ]

Enhancing Healthcare Team Outcomes

The management of alien bodies in the esophagus requires an interprofessional team with an interprofessional overture. Most patients will present to the hand brake department, and the triage harbor has to be aware of the symptoms and signs of an esophageal alien body. These patients need immediate admission. Emergency department nurses need to assist the clinical team by monitoring the affected role for respiratory distress while the workup is going on and keeping the parents apprised of the child ‘s condition.

once the diagnosis is made, reference with the appropriate specialist is highly recommended. Most foreign bodies in the esophagus sink spontaneously, but about 3 to 10 % may require some type of intervention. Some may require removal of the alien item with endoscopy, and others may require operating room. prior to discharge, all clinicians and nurses as partially of an interprofessional team have the burden to educate the patient and caregivers to keep little objects away from the range of children. The parent should besides be educated on the signs of an esophageal foreign body and when to seek medical manage. alone through an interprofessional approach can the unwholesomeness of this condition be lowered. The outcomes for most patients with extraneous bodies in the esophagus are excellent. [ 17 ] [ 18 ] [ Level 5 ]

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