Pediatric Gastrointestinal Foreign Bodies

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Background

Foreign body ingestion is a common problem encountered in the pediatric population, with outcomes ranging from inconsequential to life-threatening. It is a major cause of inpatient admission and death in this group.[1, 2] Children younger than 5 years are most commonly affected because of their mobility, hand-to-mouth behaviors, and natural propensity for experimentation. Although children younger than 6 months are rarely able to get a foreign object into the oropharynx on their own, infants can ingest foreign bodies with the assistance of a sibling. Any child can swallow a foreign body, and most instances result in a minor annoyance; however, some situations can become a challenging problem with potentially life-threatening complications.

Relevant Anatomy

The vast majority of foreign bodies that pass the level of the lower esophageal sphincter (LES) proceed through the remainder of the gut without complication. Nevertheless, sharp objects may lead to perforation at any level of the gastrointestinal (GI) tract. The corrosive nature of an alkaline battery can also lead to GI erosion or perforation.

Objects that are retained in the esophagus are typically upheld at one of the following three normal anatomic esophageal narrowings: the level of the cricopharyngeus muscle (ie, thoracic inlet, area between the clavicles on chest radiography), the level of the aortic arch, or the LES. Other physiologic narrowings or angulations where foreign bodies may become impacted include the pylorus, duodenal sweep, ileocecal valve, and anus. Congenital or acquired narrowings at any point within the GI tract also serve as barriers to free passage of a foreign body.

Problem

Foreign bodies that enter the oropharynx can exit through the route they entered, they can be hidden in the mouth by the child, or they can travel down either the trachea or the esophagus. Although children commonly aspirate food items, small children rarely present with impacted food in the absence of underlying esophageal disease. Foreign bodies that lodge in the airway are discussed in Pediatric Airway Foreign Body and are less common than gastrointestinal (GI) foreign bodies. Children with a retained or impacted GI foreign body are commonly referred for urgent surgical consultation and should be appropriately treated.[3]

Pathophysiology

For the sake of simplicity, objects are characterized based on size, shape, and radiolucency.

Oral ingestion

Perhaps the most common regularly shaped smooth foreign body encountered in the gastrointestinal (GI) tract is a coin. See the images below.



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Pediatric Gastrointestinal Foreign Bodies. An impacted esophageal coin in the thoracic inlet in a 2-year-old child. Note the coronal alignment on this....



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Pediatric Gastrointestinal Foreign Bodies. Lateral radiograph of an impacted esophageal coin in the thoracic inlet of a 2-year-old child.

 

Other objects include buttons, pen or bottle caps, rubber or plastic materials, marbles, seeds, and button batteries, the last of which presents a distinct problem (discussed below).[4, 5] In general, regularly shaped smooth foreign bodies cause the least difficulty and commonly pass through the GI tract with little concern once past the lower esophageal sphincter (LES). Irregularly shaped objects, such as keys, toys, tools, and jewelry, may have smooth or sharp edges. See the following image.



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Pediatric Gastrointestinal Foreign Bodies. A 3-year-old child had a buffalo-shaped pendant lodged in the esophagus at the thoracic inlet.

 

Sharp or long objects, such as pins, needles, bones, screws, razor blades, or nails, are of special concern because of their propensity for causing perforation. See the image below.



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Pediatric Gastrointestinal Foreign Bodies. A broken razor blade (yellow arrow) is lodged at the thoracic inlet of the esophagus. in a 7-month-old chil....

 

Button batteries

Button batteries are small coin-shaped batteries that have become ubiquitous. They are used in watches, calculators, hearing aids, greeting cards, toys, and other similar products. Button batteries can cause serious problems if they become lodged in the GI tract, with the greatest threat to the esophagus. When a button battery is lodged in the esophagus, esophageal damage can occur in as little as 2 hours.[6]

Sequelae of button battery ingestion include esophageal perforation, esophageal stricture, tracheoesophageal fistula, vocal cord paresis from recurrent laryngeal nerve injury, and aortoenteric fistula. The greatest risk of complications associated with button battery ingestion are in lithium batteries of at least 20 mm diameter due to the increased risk of impaction and increased voltage delivery.[3] Button battery ingestion is responsible for 12.8% of ingestion-related deaths in patients younger than age of 5 years.[7]



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Pediatric Gastrointestinal Foreign Bodies. Rigid esophagoscopic image showing mucosal damage following button battery removal.

 

Magnets and polymer beads

Another particularly dangerous type of foreign body is magnets. In isolation, they pass through the GI tract without incident, but often multiple magnets are ingested at once (eg, Bucky balls). If the magnets are in two different parts of the GI tract, the magnetic forces can attract them together. Eventually, this leads to necrosis of the intervening wall and either perforation or fistulization.

Ingestion of water-absorbing polymer beads (eg, Orbeez, MarvelBeads) can cause bowel obstruction requiring endoscopic or surgical retrieval. This is an emerging threat with increased marketing toward children.[8]

Rectal foreign bodies

Rectal foreign bodies are rare in children. Although they are most commonly inserted, they can also be impacted in the rectum after swallowing. Improperly inserted rectal thermometers or enema tips are the most commonly seen rectal foreign bodies in children. Other impacted rectal foreign bodies should alert the examiner to consider the possibility of autoeroticism in older children or sexual abuse in any aged child.

Body packers

Body packers (ie, individuals who ingest or insert wrapped packets of drugs such as heroin or cocaine into the GI tract) are often adults and teenagers who, either voluntarily or through coercion, have been involved in drug smuggling. These patients require vigilant management and admission to the hospital because rupture of the packets can lead to devastating consequences.[9]

Etiology

Most parents would attest that toddlers put whatever they get their hands on into their mouths. Gastrointestinal (GI) obstruction from bezoars are more common in teens with emotional disturbances or intellectual disability. Any child with a congenital or anastomotic narrowing of the GI tract is more susceptible to foreign body impaction. See the image below.



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Pediatric Gastrointestinal Foreign Bodies. A 4-year-old child presented with an impacted coin in the mid jejunum. A mini laparotomy revealed evidence ....

Epidemiology

Foreign body ingestion is relatively common among children. In 2021, the American Association of Poison Control documented 57,493 incidents of foreign body ingestion in patients younger than 5 years, representing 69.5% of reported foreign body ingestion among all children and adults.[7] Many children who swallow foreign bodies are unlikely to be diagnosed because the ingestion of foreign bodies in children is unwitnessed and unreported in about 40% of cases, and most experience no untoward consequences. However, gastrointestinal foreign bodies that come to the attention of the physician should not be dismissed.[10]

Presentation

History

Some foreign body ingestions are witnessed or reported by the patient and the swallowed object is known. However, many cases are not witnessed and only come to attention based on the development of symptoms. Any event that is witnessed by a parent, guardian, or sibling offers the best hope of early intervention because many pediatric patients with esophageal foreign bodies are, and will remain, asymptomatic. Many times, the object will pass through uneventfully.

Note the characteristics of the object and the time of ingestion. If the event is unwitnessed, establish the nature, onset, and progression of symptoms. Symptoms of esophageal foreign bodies include difficulty swallowing, choking, gagging, drooling, chest/neck pain, coughing, dysphonia, wheezing, or difficulty breathing. Children with chronic esophageal foreign bodies may also present with poor feeding, irritability, fever, or stridor. Symptoms of gastric and intestinal foreign objects include abdominal pain, vomiting, distention, and hematemesis or hematochezia. Note a history of previous gastrointestinal (GI) surgery or functional or anatomic abnormalities of the GI tract.[11]

For older children and teenagers, specific questioning regarding abnormal eating habits and psychosocial behavior may help to diagnose a bezoar, most commonly a conglomeration of hair (trichobezoar) or vegetable matter (phytobezoar), or intentional ingestions. Always remain unbiased with regard to the number of foreign bodies ingested because some children have swallowed more than one item.

When a child has ingested a button battery, symptoms may include refusal to take fluids, drooling with black flecks in the saliva, dysphagia, vomiting, and hematemesis; nevertheless, many patients with a battery impacted in the esophagus are asymptomatic. Rashes following disk battery ingestion have been reported and may be a manifestation of nickel hypersensitivity.[12]

Patients with a rectal foreign body may present with abdominal or rectal pain, pruritus, or bleeding. In the case of suspected or known sexual assault, immediately notify the appropriate legal authority or child protective services.[13]

Physical examination

Attention to the airway and breathing always takes precedence. Signs of airway obstruction (stridor, wheezing, tachypnea) require urgent investigation. Foreign bodies in the neck or upper chest can cause perforation, manifested by neck swelling or crepitus. Abdominal complications may be suggested by distention, tenderness, peritonitis. In almost all cases, the work-up should begin with radiographs of the neck, chest, and abdomen.

History of the Procedure

Endoscopes are a valuable tool in the armamentarium for the removal of foreign bodies from the upper aerodigestive tract. The development of endoscopic techniques dates back to the 10th century when Albukasim, an Arabian physician, used reflected light to inspect the cervix. In 1805, Bozzini developed the first endoscope by constructing the Lichtleiter, which used concave mirrors to reflect candlelight through an open tube into the esophagus, bladder, or rectum. Maximilian Carl-Friedrich Nitze, a German urologist, produced the first usable cystoscope in 1877 by using series of lenses to increase magnification. He was also the first to place light inside the organ of interest to aid visualization. In 1880, Mikulicz made the first gastroscope using a system similar to Nitze’s cystoscope.[14]

Modern endoscopy was born in the late 1950s with the introduction of the fiberoptic endoscope. Diagnostic and therapeutic endoscopy flourished in the 1960s, with endoscopic intervention first described in the 1970s. Technical refinements of endoscopy in the 1980s, including the introduction of a gastrointestinal endoscope with a small video camera and a charge-coupled device (CCD), facilitated storage of data and documentation.[15] Advanced endoscopic techniques in the 1990s and further improvements in the 2000s have introduced endoscopic procedures that are less-invasive alternatives to traditional operative procedures.[16, 17]

Indications

In general, foreign bodies in the esophagus should be removed or manipulated into the stomach, as described in Surgical Care. Accepted indications for endoscopic or surgical exploration and removal of ingested foreign bodies include the following[18] :

Contraindications

Contraindications to endoscopic removal include objects distal to the duodenum and proximal to the ileocecal valve. Concern for perforation is also a relative contraindication to endoscopic evaluation.

Relative contraindications to Foley catheter or bougienage removal include children who have swallowed more than a single coin and children who do not have a clear history of symptoms lasting shorter than 24 hours. Absolute contraindications to these techniques include children who have a known esophageal abnormality or who have undergone previous esophageal surgery, and children who have evidence of respiratory distress. Bougienage and Foley catheter removal are not indicated in an unstable patient.

Prognosis

The vast majority of ingested foreign bodies can be retrieved endoscopically. Endoscopy is well tolerated and generally safe in the setting of careful and competent anesthesia, and many patients can be discharged from the recovery room. Patients who undergo operative removal usually require postoperative observation in the hospital.

Patient Education

Counsel parents and/or guardians to keep small objects away from toddlers. If a parent or guardian witnessed their child swallow an object, they should inform their healthcare provider. Depending on the object and/or symptoms, the child may need to be evaluated. If the child develops choking, coughing, or trouble breathing, parents or guardians should seek emergent medical attention for them. Other concerning symptoms include vomiting, drooling, difficulty swallowing, and pain in the chest or abdomen.

Prevention strategies for button battery injuries include raising public awareness, cooperation with industry to develop safer batteries and more secure battery compartments in products, and negotiations with authorities on legislative issues to minimize the risk of button battery ingestion. Similarly, increased public awareness is needed toward the danger of ingesting water-absorbing beads and toys containing small magnets that are frequently marketed toward young children.

Imaging Studies

In general, diagnostic workup involves the use of imaging modalities as laboratory studies are usually not useful for diagnostic or treatment purposes.

Plain radiography

Radiography is mandated for children with suspected gastrointestinal (GI) foreign body ingestion.[19] Radiographs are helpful in locating radiopaque foreign bodies in the hypopharynx and esophagus. In small children, a mouth-to-anus film ("babygram") can be obtained. In older children, anteroposterior (AP) and lateral neck, chest, and abdomen radiographs will locate radiopaque foreign bodies in the hypopharynx, esophagus, stomach, intestines, and colon.

Coins in the esophagus are usually observed in a coronal alignment on AP films. If the foreign body is in the trachea, it typically lies in a sagittal orientation. Button batteries often appear with a double rim or halo sign on AP views and a step-off sign on lateral views. See the images below.



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Pediatric Gastrointestinal Foreign Bodies. An impacted esophageal coin in the thoracic inlet in a 2-year-old child. Note the coronal alignment on this....



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Pediatric Gastrointestinal Foreign Bodies. Anteroposterior (AP) (A) and lateral (B) x-ray of an impacted button battery in the thoracic inlet. Note th....

Contrast studies may be helpful if the foreign body in question is radiolucent. Gastrografin is the preferred contrast agent. Note that barium is contraindicated in cases of suspected perforation. Computed tomography (CT) scanning of the neck, chest, abdomen, and pelvis is highly reliable in localizing radiolucent or radiopaque foreign bodies, and it may be considered in certain situations.[20]

Approach Considerations

General agreement supports the immediate extraction of foreign bodies lodged in the esophagus. The management of objects that have reached the stomach is less consistent as many foreign bodies pass through the gastrointestinal tract uncomplicated on their own.[2, 21] The approach utilized depends on the patient's clinical status, the nature and number of objects ingested, as well as the location and transit time (most foreign bodies should be expelled within 4-6 d).

Medical Care

Foreign bodies in the esophagus that cause symptoms should be removed as is described in Surgical Care.

Parents and/or guardians of children who have swallowed a coin that has passed the gastroesophageal junction should be assured that the foreign body will probably pass through the gastrointestinal (GI) tract unimpeded and without consequence. Other objects that are likely to pass through without incident include small toys, buttons, and marbles.

Based on its results, one study concluded that the initial location of ingested foreign bodies is the main determining factor for spontaneous passage: When located below the esophagus, most ingested foreign bodies can be spontaneously passed without complication.[22] These patients can be sent home with instructions to return if abdominal pain, vomiting, or bloody stools occur. One exception to this general statement is in the case of magnet ingestion.[23, 24] Bowel perforation as a result of the attraction of two or more ingested magnets across loops of intestine may require more aggressive intervention via either endoscopy or surgical exploration.[25]

The transit time for an asymptomatic radiopaque foreign body varies and can normally take hours to weeks. Serial radiographs are generally not indicated to monitor the transitory progress of the foreign body. Screening of the stool for foreign bodies is largely impractical and unnecessary in most cases.

Button batteries mandate more vigilant management. Esophageal battery impaction has the highest risk of complications, especially in children younger than 5 years  and in batteries of 20 mm or larger in diameter. Batteries lodged in the esophagus should be immediately removed because of the propensity for erosion and perforation. Prior to emergent removal of an esophageal button battery, sucralfate or honey can be administered every 10 minutes to reduce the pH and lessen the alkaline burn to adjacent tissue; avoid honey in patients under 12 months of age. Every attempt should be made to get an esophageal button battery removed within 2 hours by an otolaryngologist, gastroenterologist, or surgeon—whoever is able to remove it most expeditiously.

Batteries of 20 mm or larger diameter in patients that are younger than age 5 years and past the lower esophageal sphincter (LES) should be removed within 24-48 hours with endoscopic evaluation for concurrent esophageal injury. Batteries that are beyond the LES, less than 20 mm in size, and/or in patients aged 5 years or older may be considered for outpatient observation if no clinical symptoms are present. Repeat radiography can be considered at 10-14 days if the foreign body fails to pass in the stool. Both the National Capital Poison Center and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) have recommended management algorithms for button battery ingestion.[3, 26]

Objects with sharp edges or points present a special problem because of the possibility for erosion or perforation. These include pins, needles, tacks, razor blades, glass fragments, or open safety pins. Vigilantly observe children who have swallowed such objects. Esophageal impaction demands surgical removal; however, many of these objects also pass through the GI tract without incident once they are past the gastroesophageal junction. For sharp or long radiopaque objects, obtain a daily radiograph and monitor closely for signs of peritonitis or GI bleeding, the development of which mandates surgical exploration and removal of the object.

Although smooth muscle relaxation agents (ie, glucagon, benzodiazepines) have been used in select circumstances in adults, these measures are generally unsuccessful in children and therefore not recommended. The use of meat tenderizer (papain) to digest meat impacted in the esophagus is also not recommended because these products can result in severe esophageal injury. Do not administer syrup of ipecac to patients with foreign bodies in the stomach; cases have been reported of the foreign body becoming lodged in the esophagus after ipecac administration.

Body packers are at risk of death if the packets of the illicit substance rupture. Hospitalize such patients and consider whole bowel irrigation (eg, Go-Lytely). Consultation with a specialist from a poison control center is recommended.

Surgical Care

Various methods have been described for removal of foreign bodies from the esophagus.[27] Historically, the initial method of management of esophageal foreign bodies was extraction through a rigid esophagoscope. Some surgeons still strongly advocate for the use of the rigid endoscope, but few have experience with this technique.

Removal of esophageal foreign bodies with a flexible endoscope is the most common technique used in most pediatric centers.[28] Flexible endoscopes can retrieve objects from the esophagus, stomach, and proximal small bowel. Colonoscopes can reach from the anus to the ileocecal valve. Both rigid and flexible endoscopy are safe and effective. Although the success and morbidity rates are similar, the flexible endoscope is more attractive, particularly to those physicians trained in its use but with limited training or experience with rigid esophagoscopy.[29]

Esophageal bougienage

Only experienced personnel should perform esophageal bougienage. Dislodging a coin that is stuck in the esophagus into the stomach with a bougie is a well-established technique; however, this approach is not universally accepted. Nevertheless, bougienage is equally safe and is more efficient and cost-effective than endoscopy in appropriately selected patients. Pediatric candidates for this technique must have swallowed a single coin, have a clear history of symptoms of less than 24 hours duration, have no previous esophageal abnormalities or previous esophageal surgery, and have no evidence of respiratory distress.

Foley catheter removal

Only experienced personnel should perform removal of a foreign body with a Foley catheter. For coins impacted in the esophagus above the lower esophageal sphincter (LES), and in patients without evidence of airway compromise or known preexisting anatomic abnormality, this technique has been shown to be safe and effective.[30] Over time, the use of Foley catheter extraction has waned. Flexible endoscopy and rigid endoscopy remain the two universally applicable methods.

Laparotomy and gastrotomy

Some gastrointestinal (GI) foreign bodies may require thoracotomy or laparotomy for definitive removal. Indications include objects that cannot be removed endoscopically, objects that are imbedded in the wall of the GI tract, objects beyond the reach of the endoscope, and/or complications of perforation or bleeding. For objects beyond the reach of endoscopes (jejunum to ileocecal valve), laparotomy is the only means of access. Bezoars often require surgical removal because endoscopic removal is either impossible or exceedingly difficult due to the size of the bezoars.[31] See the image below.



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Pediatric Gastrointestinal Foreign Bodies. A trichobezoar within the stomach of a 14-year-old with trichotillomania. This intraoperative photograph de....

For rectal foreign bodies, objects that get stuck, perforate, bleed, or are proximal to the rectosigmoid junction (because of difficulty visualizing with proctosigmoidoscopy) usually necessitate surgical removal via laparotomy. Low-lying rectal foreign bodies are usually palpable with digital examination and are candidates for removal under conscious sedation, although mucosal edema and muscular spasms can hinder such an attempt if the foreign body has been in place for a long time.

Preoperative Details

Keep the patient on nothing by mouth (NPO) status and well-hydrated via intravenous dextrose-containing solution prior to proceeding to the operating room. In the case of an esophageal foreign body, a radiograph should be obtained immediately prior to endoscopic removal to confirm that the object has not migrated into the stomach. Do not wait for sufficient NPO interval for button batteries.

Intraoperative Details

Endoscopy

A retained gastric foreign body that fails to pass through the gastric outlet (pylorus) after a prolonged period of observation can be removed with a flexible or rigid endoscopic technique. Experienced personnel, such as a pediatric surgeon or gastroenterologist, should perform the endoscopy.

For rigid esophagoscopy, the patient is placed under general endotracheal anesthesia and properly positioned to allow for safe esophageal intubation. Use a rigid telescopic endoscope that is connected to a fiberoptic light source and rod-lens telescope appropriately sized for the patient's age and weight. This device accepts a grasping forceps within the lumen to allow for foreign body removal. A flexible endoscope can also be used. Again, the operator should have ample experience with these techniques prior to unsupervised performance.

The operator manipulates the scope over the base of the tongue where the entrance to the cervical esophagus lies posterior to the vocal cords. Lifting the larynx gently forward often obviates this opening and allows for easier introduction of the scope into the esophagus. The scope is advanced under direct vision, and, once encountered, the foreign body is grasped with forceps and withdrawn under direct vision.

In cases in which the foreign body is lodged in a direction that precludes retrograde removal through the esophagus (eg, an open safety pin that is oriented with the sharp end superiorly), the object may be carefully advanced into the stomach then turned around and removed or managed expectantly. Another helpful technique for removal of sharp objects is to pass an overtube that provides a protective sheath with which to remove the object through.

When an object is difficult to grasp with forceps (eg, marble, round toy), a Fogarty catheter can be advanced through the scope past the object and inflated. Then, the Fogarty catheter can be pulled taut between the object and the endoscope, and the endoscope withdrawn to retrieve the foreign body. Another option is the use of an endoscopic basket.

Always be ready to perform rigid bronchoscopy if erosion into the airway is suspected or if the location of the foreign body was mistakenly misidentified by preoperative radiographic evaluation.

Foley catheter removal

With a McGill forceps, pediatric laryngoscope, and resuscitation equipment at the bedside, the child is immobilized by swaddling in multiple bed sheets or a papoose. The patient is positioned supine, and a Foley catheter is introduced via the intranasal or intraoral route. Under fluoroscopic guidance, the uninflated catheter tip is advanced distal to the object. The child is then positioned in the oblique prone position, and the table is placed into a steep Trendelenburg position. The catheter balloon is then inflated with dilute contrast material and gently withdrawn. If the object is a coin, when it reaches the oropharynx, the child can spit out the coin or the coin can be removed with a finger sweep of the oropharynx. A second look with fluoroscopy is taken to ensure that an additional foreign body is not present.

Esophageal coin bougienage

In select patients, coin bougienage can be safely performed, reducing cost, hospitalization, and operative time. Patients must be older than 6, without symptoms or radiographic findings that are concerning for perforation, and have no history of esophageal surgery or prior foreign bodies.

Only esophageal coins should be managed by bougienage (no other foreign bodies). The coin should be single and present for less than 24 hours. Additionally, the patient should be without respiratory distress, chest pain, and history of previous esophageal foreign bodies or esophageal surgery. Chest radiography should be performed immediately before bougienage to confirm not only the current location of the coin but also the absence of mediastinal air or pleural effusion that may suggest perforation. A coin appropriate for bougienage is located between the head of the clavicle and diaphragm on radiograph, as coins above the clavicular head have not yet passed the upper esophageal sphincter and the most common site of esophageal perforation.

A blunt-tipped Hurst esophageal dilator is selected, approximately the size of the patient's index finger or smaller. Generally, patients aged between 1-2 years require a size 28Fr; those aged 2-3 years, 32Fr; children aged 3-4 years, 36Fr; those aged 4-5 years, 38Fr; and children older than 5 years, 40Fr.[32] The patient is swaddled and held in an assistant's lap. The selected bougie is lubricated and the approximate distance to patient's stomach is noted. The bougie is passed orally to the desired length in smooth and rapid strokes, then immediately withdrawn; the entire passage should take less than 5 seconds. Oral suction should be readily available as bougie-associated emesis is common.

A post-bougienage chest radiograph should be obtained to confirm the gastric position of the coin and the absence of mediastinal air and pleural effusion. If the procedure was unsuccessful, do not make additional attempts at bougienage; patients should undergo endoscopic coin removal. If the coin is confirmed to be in the stomach with no additional concerns, the patient may be discharged home from the emergency department (ED). Parents and/or guardians should be instructed to feed the child normally and present back to the ED if and of the following symptoms develop: fever, inability to swallow, persistent chest pain, crepitus in the neck or chest, difficulty breathing, or emesis containing large amounts of blood or clot.[33]

Laparotomy

Under general anesthesia, most gastrointestinal (GI) foreign bodies can be removed through a small enterotomy once the location of the object is identified. The most common areas for foreign body impaction in the GI tract include the pylorus, the second portion of the duodenum, the ligament of Treitz, the ileocecal valve, or a congenital narrowing. Depending on the location and nature/size of the foreign body, a fairly limited or a generous laparotomy may be required. Most GI foreign bodies can be removed via small enterotomy followed by primary closure. Those presenting with perforation or bleeding may require a segmental bowel resection and primary anastomosis. Intraoperative radiography may be helpful in locating radiopaque objects.

Laparoscopy

Under general anesthesia, laparoscopy can be used in select circumstances to remove GI foreign bodies. Again, once the foreign body is located, an enterotomy is created in an appropriate location and the foreign body removed. This allows for a smaller abdominal wound, but it may require lengthier operating room time, depending on the laparoscopic skill of the surgeon and the location of the object.

Proctosigmoidoscopy

Rectal foreign bodies that become lodged, perforate, or bleed proximal to the rectosigmoid junction usually necessitate surgical removal via laparotomy. Low-lying rectal foreign bodies are usually palpable with digital examination and are candidates for removal manually or with a proctosigmoidoscope. Mucosal edema and muscular spasms can hinder such an attempt if the foreign body has been in place for a long time.

Rectal foreign bodies can be removed under conscious sedation or, preferably, general anesthesia. Under direct visualization with an anoscope or proctoscope, the object is grasped with forceps. After removal, a repeat examination is indicated to evaluate for rectal injuries. Some high-lying rectal foreign bodies can be manipulated into a low-lying position using a manual transabdominal massage. In rare cases, laparotomy is necessary to remove a high-lying rectal foreign body.

Postoperative Details

Following successful endoscopy, patients are observed, started on clear liquids as early as possible, and discharged when able to tolerate oral intake; in many cases discharge from the recovery unit is possible. For those who require laparotomy or laparoscopy for foreign body removal, oral intake is advanced with the return of bowel function, and the patient is discharged when able to tolerate oral intake without difficulty. Patients who have had a rectal foreign body removed via an uncomplicated proctosigmoidoscopy are discharged after recovery.

Complications

A foreign body lodged in the gastrointestinal (GI) tract may cause local inflammation that leads to pain, bleeding, fibrosis, and obstruction, or it may erode outside the GI tract. Migration from the esophagus can lead to mediastinitis, but it may evolve to aberrant communication to the upper respiratory tract (eg, acquired tracheoesophageal fistula) or great vessels (eg, aortoenteric fistulas). Migration from the lower GI tract may cause perforation. The most common complications of rectal foreign bodies are rectal laceration and perforation.

Finally, complications of the procedures required to remove a foreign body may lead to morbidity or mortality from the procedure itself or the necessary sedation or anesthesia. The success rate with the use of flexible esophagoscopy approaches 95% with reported complication rate of less than 5%.[29] Mortality is exceedingly rare; reported deaths have occurred after ingestion of button batteries, magnets, sharp objects, or water-absorbing beads.[3]

Long-Term Monitoring

After an esophageal foreign body is removed, children with uncomplicated courses do not need to undergo further evaluation. A healthy child with foreign body impaction repetitively or at an unusual site should be evaluated for an underlying esophageal or gastrointestinal motility disorder or anatomic abnormality. The usual outcome of foreign body ingestions is uneventful passage. Most children who require foreign body removal via an intervention experience no untoward consequences.

Routine follow-up 2-4 weeks following discharge is recommended for patients who undergo laparoscopy or laparotomy.

Patients with button battery ingestions should be closely followed; for those with necrosis noted on endoscopy, follow-up with contrast esophagrams can identify late strictures.

Author

Frederick Merrill Karrer, MD, FACS, Professor of Surgery and Pediatrics, Head, Division of Pediatric Surgery, University of Colorado School of Medicine; The Dr David R and Kiku Akers Chair in Pediatric Surgery, Surgical Director, Pediatric Transplantation, The Children’s Hospital of Colorado

Disclosure: Nothing to disclose.

Coauthor(s)

Amanda B Witte, MD, Resident Physician, Department of Surgery, Medical College of Wisconsin

Disclosure: Nothing to disclose.

Casey M Calkins, MD, Professor of Surgery, Division of Pediatric Surgery, Medical College of Wisconsin; Consulting Staff, Department of Pediatric Surgery, Children's Hospital of Wisconsin

Disclosure: Nothing to disclose.

Specialty Editors

Mary L Windle, PharmD, Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

B UK Li, MD, Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin; Attending Gastroenterologist, Director, Cyclic Vomiting Program, Children’s Hospital of Wisconsin

Disclosure: Nothing to disclose.

Chief Editor

Carmen Cuffari, MD, Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Disclosure: Received honoraria from Prometheus Laboratories for speaking and teaching; Received honoraria from Abbott Nutritionals for speaking and teaching. for: Abbott Nutritional, Abbvie, speakers' bureau.

Additional Contributors

Jayant Deodhar, MD, Associate Professor in Pediatrics, BJ Medical College, India; Honorary Consultant, Departments of Pediatrics and Neonatology, King Edward Memorial Hospital, India

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Casey M Calkins, MD and Denis Bensard, MD, to the original writing and development of this article.

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Pediatric Gastrointestinal Foreign Bodies. An impacted esophageal coin in the thoracic inlet in a 2-year-old child. Note the coronal alignment on this posteroanterior (PA) radiograph that is suggestive of an esophageal rather than tracheal location.

Pediatric Gastrointestinal Foreign Bodies. Lateral radiograph of an impacted esophageal coin in the thoracic inlet of a 2-year-old child.

Pediatric Gastrointestinal Foreign Bodies. A 3-year-old child had a buffalo-shaped pendant lodged in the esophagus at the thoracic inlet.

Pediatric Gastrointestinal Foreign Bodies. A broken razor blade (yellow arrow) is lodged at the thoracic inlet of the esophagus. in a 7-month-old child.

Pediatric Gastrointestinal Foreign Bodies. Rigid esophagoscopic image showing mucosal damage following button battery removal.

Pediatric Gastrointestinal Foreign Bodies. A 4-year-old child presented with an impacted coin in the mid jejunum. A mini laparotomy revealed evidence of a dilated jejunum with decompressed distal bowel. An eroded coin (penny) was found just proximal to an incomplete intestinal web.

Pediatric Gastrointestinal Foreign Bodies. An impacted esophageal coin in the thoracic inlet in a 2-year-old child. Note the coronal alignment on this posteroanterior (PA) radiograph that is suggestive of an esophageal rather than tracheal location.

Pediatric Gastrointestinal Foreign Bodies. Anteroposterior (AP) (A) and lateral (B) x-ray of an impacted button battery in the thoracic inlet. Note the halo (ie, double ring) sign on the AP view (A) and the step-off on the lateral view (B), raising suspicion for button battery ingestion.

Pediatric Gastrointestinal Foreign Bodies. A trichobezoar within the stomach of a 14-year-old with trichotillomania. This intraoperative photograph demonstrates the bezoar being delivered through a longitudinal gastrotomy made along the body of the stomach.

Pediatric Gastrointestinal Foreign Bodies. An impacted esophageal coin in the thoracic inlet in a 2-year-old child. Note the coronal alignment on this posteroanterior (PA) radiograph that is suggestive of an esophageal rather than tracheal location.

Pediatric Gastrointestinal Foreign Bodies. Lateral radiograph of an impacted esophageal coin in the thoracic inlet of a 2-year-old child.

Pediatric Gastrointestinal Foreign Bodies. A 3-year-old child had a buffalo-shaped pendant lodged in the esophagus at the thoracic inlet.

Pediatric Gastrointestinal Foreign Bodies. A broken razor blade (yellow arrow) is lodged at the thoracic inlet of the esophagus. in a 7-month-old child.

Pediatric Gastrointestinal Foreign Bodies. A trichobezoar within the stomach of a 14-year-old with trichotillomania. This intraoperative photograph demonstrates the bezoar being delivered through a longitudinal gastrotomy made along the body of the stomach.

Pediatric Gastrointestinal Foreign Bodies. A 4-year-old child presented with an impacted coin in the mid jejunum. A mini laparotomy revealed evidence of a dilated jejunum with decompressed distal bowel. An eroded coin (penny) was found just proximal to an incomplete intestinal web.

Pediatric Gastrointestinal Foreign Bodies. Anteroposterior (AP) (A) and lateral (B) x-ray of an impacted button battery in the thoracic inlet. Note the halo (ie, double ring) sign on the AP view (A) and the step-off on the lateral view (B), raising suspicion for button battery ingestion.

Pediatric Gastrointestinal Foreign Bodies. Rigid esophagoscopic image showing mucosal damage following button battery removal.