An Unvaccinated Girl With Wheezing After Foreign Body Removal

Jesse Borke, MD

Disclosures

February 10, 2020

As many as 10%-20% of ingested foreign bodies do not successfully pass spontaneously through the gastrointestinal tract without incident.[3] Complications of objects that do not pass can include obstruction and perforation. Perforation can lead to fistula formation, severe infection, or life-threatening bleeding (eg, aortoenteric fistula), depending on the location of the perforation.[4]

Children with preexisting gastrointestinal abnormalities (eg, esophageal stenosis, previous surgery, diverticular disease, preexisting fistulae) are at increased risk for complications.[1] Perforation from a foreign body is significantly more likely to occur from those lodged in the esophagus then elsewhere in the gastrointestinal tract.[5] The most common site of esophageal foreign body impaction is the level of the thoracic inlet, which is approximately around the level of the clavicles on chest radiography; the second most common is the gastroesophageal junction, and the third is the level of the aortic arch (in the middle esophagus).[6] Likewise, most complications of pediatric foreign body ingestion are due to esophageal impaction, usually at one of the three levels noted above.[7]

The traditional workup for suspected esophageal foreign body ingestion is anteroposterior and lateral radiography of the chest. Occasionally, contrast studies or CT scans are needed to evaluate for complications or for a radiolucent foreign body.[5] Once a disk or button battery is found in the esophagus, removal is imperative and should be emergently performed (< 2 hours after presentation), regardless of NPO status.[8] Disk battery ingestions are particularly concerning because they cause corrosive injury that leads to perforation. All disk batteries in the esophagus should be removed endoscopically on an emergent basis, if at all possible.

Esophageal foreign bodies, including disk batteries, may result in the formation of a tracheoesophageal fistula. This is most commonly seen in children, such as this patient. Common symptoms of tracheoesophageal fistula include cough, feeding intolerance, dysphasia, cyanosis, choking, vomiting, inability to swallow secretions, sore throat, and nonspecific respiratory or gastrointestinal symptoms. A high index of suspicion must be maintained for patients who present with new respiratory symptoms after endoscopic removal of an esophageal foreign body. Unfortunately, pediatric patients commonly present many hours or even days after the ingestion of a foreign body, such as a disk battery. This delay, and the often nonspecific symptoms of an unwitnessed ingestion, lead to further delays in diagnosis of an impacted battery. The incidence of perforation due to an impacted battery becomes fairly high only a few hours after ingestion.

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