Pediatric Foreign Body Pediatric Foreign Body
IngestionsIngestions
Kara Wong, Harvard Medical School Year IVKara Wong, Harvard Medical School Year IV
Gillian Lieberman, MDGillian Lieberman, MD
Kara Wong, HMS IV
Gillian Lieberman, MD
October 20, 2008
Kara Wong, HMS IV
Gillian Lieberman, MD
2
AgendaAgenda
Presentation of our patientsPresentation of our patients
EpidemiologyEpidemiology
Symptoms and ComplicationsSymptoms and Complications
Approach to FB IngestionApproach to FB Ingestion
Radiological diagnosisRadiological diagnosis
Therapy: Observation Therapy: Observation vsvs
InterventionIntervention
Special situations (magnets, batteries)Special situations (magnets, batteries)
Management of our patientsManagement of our patients
Kara Wong, HMS IV
Gillian Lieberman, MD
3
Our first patientOur first patient’’s presentations presentation
7 year old boy 7 year old boy p/wp/w
accidental ingestion of accidental ingestion of
Monopoly battleship. Monopoly battleship.
Denies chest pain, Denies chest pain, abab
pain, or SOB. pain, or SOB.
Vitals AFFS, PE Vitals AFFS, PE
unremarkable.unremarkable.
KUB obtained revealing KUB obtained revealing
metallic object in metallic object in
stomach.stomach.
Supine KUB of FB in stomach
Courtesy of Dr. Mark Waltzman, Children’s Hospital Boston
Battle ship
Kara Wong, HMS IV
Gillian Lieberman, MD
4
Our second patientOur second patient’’s presentations presentation
11 month old girl 11 month old girl p/wp/w
accidental ingestion of hair clip. No accidental ingestion of hair clip. No
drooling, cough, vomiting, drooling, cough, vomiting, stridorstridor, or respiratory distress. , or respiratory distress.
Vitals AFFS. PE unremarkable. Vitals AFFS. PE unremarkable.
KUB and lateral neck films reveal foreign body in esophagus.KUB and lateral neck films reveal foreign body in esophagus.
Courtesy of Dr. Mark Waltzman, Children’s Hospital Boston
Lateral neck plain film of FB in esophagus PA CXR of FB in esophagus
Kara Wong, HMS IV
Gillian Lieberman, MD
5
Our third patientOur third patient’’s presentations presentation
3 year old girl 3 year old girl p/wp/w
with fever, abdominal pain, decreased oral with fever, abdominal pain, decreased oral
intake. Mother believes she may have swallowed a quarter. intake. Mother believes she may have swallowed a quarter.
PE unremarkable except for refusal to take oral intake. PE unremarkable except for refusal to take oral intake.
KUB reveals round metallic object in esophagusKUB reveals round metallic object in esophagus
Courtesy of Dr.
Marc Baskin,
Children’s
Hospital Boston
PA CXR with FB in esophagus Lateral CXR with FB in esophagus
Kara Wong, HMS IV
Gillian Lieberman, MD
6
Approach to evaluation of FB Approach to evaluation of FB
Ingestion: Ingestion:
Questions to ConsiderQuestions to Consider
How are FB ingestions diagnosed and identified ? How are FB ingestions diagnosed and identified ?
Which patients need intervention and which Which patients need intervention and which
patients can be observed? patients can be observed?
What are the possible outcomes ?What are the possible outcomes ?
Kara Wong, HMS IV
Gillian Lieberman, MD
7
EpidemiologyEpidemiology
Over 100,000 cases of foreign body ingestion reported per year Over 100,000 cases of foreign body ingestion reported per year
in US. Many go unin US. Many go un--reported or unreported or un--discovered. discovered.
80% of cases occur in children and infants, who are prone to 80% of cases occur in children and infants, who are prone to
sticking objects in their mouth and less able to control their sticking objects in their mouth and less able to control their
oropharnxyoropharnxy
and airways.and airways.
Fatalities have been reported for children under age 4.Fatalities have been reported for children under age 4.
From: Chen, X., S. Chen, X., S. MilkovichMilkovich, et al. (2006). "Pediatric coin ingestion and aspiration." , et al. (2006). "Pediatric coin ingestion and aspiration."
IntInt J J PediatrPediatr OtorhinolaryngolOtorhinolaryngol 70(2): 32570(2): 325--99
Diagram showing association of child’s age with incidence of FB ingestion and injury rate
Kara Wong, HMS IV
Gillian Lieberman, MD
8
Menu of FB IngestionsMenu of FB Ingestions
Frequently found objects Frequently found objects
include coins (most include coins (most
common), safety pins, common), safety pins,
batteries, toy parts, batteries, toy parts,
magnets, bones.magnets, bones.
Anything a child can Anything a child can
possibly grab and possibly grab and
swallow is fair game!swallow is fair game!
Supine KUB of child with
safety pin and key in
jejunum and rubber doll
head in descending colon From: Hunter, T. B. and M. S. From: Hunter, T. B. and M. S. TaljanovicTaljanovic (2003). (2003).
"Foreign bodies." "Foreign bodies." RadiographicsRadiographics 2323(3): 731(3): 731--57.57.
Kara Wong, HMS IV
Gillian Lieberman, MD
9
FB ingestions by the numbersFB ingestions by the numbers
At diagnosis, 60% located in stomach, 20% located in At diagnosis, 60% located in stomach, 20% located in
esophagus.esophagus.
Older children and male children more likely to Older children and male children more likely to
spontaneously pass FB.spontaneously pass FB.
6060--90% spontaneously pass when located in distal 90% spontaneously pass when located in distal
esophagus or below GE junction.esophagus or below GE junction.
Only 10Only 10--20% require endoscopic removal.20% require endoscopic removal.
66% of spontaneously passed 66% of spontaneously passed FBFB’’ss
are never found in are never found in
stool by parents.stool by parents.
Previous surgery or congenital malformations (Previous surgery or congenital malformations (TEFTEF’’ss) )
increase risk of obstruction and complications.increase risk of obstruction and complications.
Kara Wong, HMS IV
Gillian Lieberman, MD
10
Symptoms of FB ingestionSymptoms of FB ingestion
Most are asymptomatic! History is most important clue. Most are asymptomatic! History is most important clue.
Symptoms most often associated with location in upper Symptoms most often associated with location in upper
esophagus.esophagus.
Acute Esophageal: Acute Esophageal: retrosternalretrosternal
pain, cyanosis, pain, cyanosis,
dysphagiadysphagia, drooling, wheezing, , drooling, wheezing, stridorstridor, choking, , choking,
vomiting, vomiting, hemoptysishemoptysis, decreased PO intake, gagging., decreased PO intake, gagging.
Chronic Esophageal: weight loss, recurrent aspiration Chronic Esophageal: weight loss, recurrent aspiration
PNA.PNA.
Stomach or Bowel: Abdominal pain, bloody stool.Stomach or Bowel: Abdominal pain, bloody stool.
Kara Wong, HMS IV
Gillian Lieberman, MD
11
Complications of FB IngestionComplications of FB Ingestion
Aspiration and airway obstructionAspiration and airway obstruction
Stricture or fistula formationStricture or fistula formation
GI obstruction, perforation, or bleedingGI obstruction, perforation, or bleeding
Erosion into esophagus, aorta, or other Erosion into esophagus, aorta, or other
structuresstructures
DeathDeath
Kara Wong, HMS IV
Gillian Lieberman, MD
12
Approach to FB IngestionApproach to FB Ingestion
We have our history, now what do we do?We have our history, now what do we do?
Kara Wong, HMS IV
Gillian Lieberman, MD
13
Indications for imaging Indications for imaging
Previous recommendations: asymptomatic children Previous recommendations: asymptomatic children
tolerating PO intake do not need radiographs.tolerating PO intake do not need radiographs.
However, 20% of asymptomatic patients had an However, 20% of asymptomatic patients had an
esophageal FB.esophageal FB.
28% of esophageal coins pass spontaneously within 24 28% of esophageal coins pass spontaneously within 24
hours.hours.
Risk of complications increases with esophageal FB.Risk of complications increases with esophageal FB.
Current recommendations: ALL suspected foreign Current recommendations: ALL suspected foreign
body ingestion patients need radiographs.body ingestion patients need radiographs.
Frontal radiograph of chest, KUB, and lateral Frontal radiograph of chest, KUB, and lateral
radiograph of neck needed to image entire length of GI radiograph of neck needed to image entire length of GI
tract.tract.
Kara Wong, HMS IV
Gillian Lieberman, MD
14
Diagnosing Foreign BodiesDiagnosing Foreign Bodies
Opaque: glass, most metal except aluminum, Opaque: glass, most metal except aluminum,
animal bones, food, soil.animal bones, food, soil.
NonopaqueNonopaque: Fish bones, wood, plastics, : Fish bones, wood, plastics,
aluminum.aluminum.
Consider CT, US, or oral contrast for nonConsider CT, US, or oral contrast for non--
opaque objects.opaque objects.
Courtesy of Dr. Mark Waltzman, Children’s Hospital Boston
Kara Wong, HMS IV
Gillian Lieberman, MD
15
Patient with nonPatient with non--radioradio--opaque FB opaque FB
20 month old boy with plastic spear in parapharyngeal
space seen on axial CT with contrast.
Courtesy of Dr. Mark Waltzman, Children’s Hospital Boston
Kara Wong, HMS IV
Gillian Lieberman, MD
16
Indications for removal of FB Indications for removal of FB
Patient SymptomaticPatient Symptomatic
Sharp or long (>5cm)Sharp or long (>5cm)
MagnetMagnet
Disk battery in Disk battery in
esophagusesophagus
In esophagus >24 hoursIn esophagus >24 hours
In stomach >4In stomach >4--6 wks6 wks
Kara Wong, HMS IV
Gillian Lieberman, MD
17
Techniques for RemovalTechniques for Removal
Choice depends on patientChoice depends on patient’’s s
condition, surgeoncondition, surgeon’’s experience, s experience,
location and type of FB.location and type of FB.
Flexible or rigid endoscopyFlexible or rigid endoscopy
Most successful methodMost successful method
Allows visualization of object Allows visualization of object
(good for sharps)(good for sharps)
Risks: pharyngeal bleeding, Risks: pharyngeal bleeding,
bronchospasmbronchospasm, accidental , accidental
extubationextubation, , stridorstridor, hypoxia, , hypoxia,
esophageal perforation, esophageal perforation,
mediastinitismediastinitis
Magill forceps and laryngoscopeMagill forceps and laryngoscope
Allows visualization of object Allows visualization of object
(good for sharps)(good for sharps)
Endoscopy and removal of esophageal coin
From:
http://www.gastrointestinalatlas.com/ForeignbodyCoin3.jpg
10/18/08
Magill forceps and laryngoscopeMagill forceps and laryngoscope
From:
http://www.ispub.com/xml/journals/ijorl/vol4n2/body-fig4.jpg
10/18/08
Kara Wong, HMS IV
Gillian Lieberman, MD
18
Techniques for RemovalTechniques for Removal
BougienageBougienage
DilaterDilater
used to push object in used to push object in
esophagus into stomachesophagus into stomach
No reported complicationsNo reported complications
Foley catheterFoley catheter
Deflated catheter passed Deflated catheter passed
distally to FB, inflated, and distally to FB, inflated, and
withdrawn under fluoroscopywithdrawn under fluoroscopy
1.8% complication rate: 1.8% complication rate:
epistaxisepistaxis, emesis, transient , emesis, transient
respiratory distressrespiratory distress
Penny pincherPenny pincher
Grasping object with forceps Grasping object with forceps
through NGT under through NGT under
fluoroscopyfluoroscopy
Lateral neck fluoroscopy showing Foley catheter
extraction of coin
under fluoroscopy
From: Donnelly, L. F. (2001). Fundamentals of Pediatric Radiology.
Philadelphia, W.B. Saunders Company.
Kara Wong, HMS IV
Gillian Lieberman, MD
19
ObservationObservation
Acceptable if patient asymptomatic, FB not sharp or Acceptable if patient asymptomatic, FB not sharp or
long (>5cm), not magnet, not esophageal battery. long (>5cm), not magnet, not esophageal battery.
2020--30% of esophageal 30% of esophageal FBFB’’ss
pass spontaneously.pass spontaneously.
Most Most FBFB’’ss
pass spontaneously after passing the narrow pass spontaneously after passing the narrow
esophagus, pylorus and duodenal sweep.esophagus, pylorus and duodenal sweep.
Repeat radiograph in 8Repeat radiograph in 8--16 hours for esophageal FB. 16 hours for esophageal FB.
Serial radiographs weekly for distal FB until it passes.Serial radiographs weekly for distal FB until it passes.
Endoscopic removal of FB if retained in esophagus Endoscopic removal of FB if retained in esophagus
>16 hours or retained in stomach >4 weeks, or if >16 hours or retained in stomach >4 weeks, or if
patient becomes symptomatic.patient becomes symptomatic.
Kara Wong, HMS IV
Gillian Lieberman, MD
20
Special considerations for magnetsSpecial considerations for magnets
Multiple magnets attract across multiple loops of bowel Multiple magnets attract across multiple loops of bowel
and cause pressure necrosis, ischemia, perforation, and cause pressure necrosis, ischemia, perforation,
volvulusvolvulus..
From: KircherKircher, M. F., S. , M. F., S. MillaMilla, et al. (2007). "Ingestion of magnetic foreign bodies causing m, et al. (2007). "Ingestion of magnetic foreign bodies causing multiple bowel perforations." ultiple bowel perforations." PediatrPediatr
RadiolRadiol
3737(9): 933(9): 933--6.6.
Serial supine KUB’s
showing three magnets attracting each other across multiple bowel loops and causing a
total of 6 perforations of bowel wall.
Kara Wong, HMS IV
Gillian Lieberman, MD
21
Special considerations for magnetsSpecial considerations for magnets
Single magnet shouldnSingle magnet shouldn’’t t
cause problems. cause problems.
Difficult to tell whether a Difficult to tell whether a
single or multiple magnets single or multiple magnets
have been ingested.have been ingested.
Suspect magnet ingestion Suspect magnet ingestion
if metallic object fails to if metallic object fails to
progress.progress.
Current recommendation: Current recommendation:
ANY suspected magnet ANY suspected magnet
ingestion should be ingestion should be
removed.removed.
Various Magnets
From: http://www.global-b2b-
network.com/direct/dbimage/50242200/Alnico_Magnet.jpg
Kara Wong, HMS IV
Gillian Lieberman, MD
22
Special considerations for button Special considerations for button
batteriesbatteries
Higher risk of perforation, erosion, Higher risk of perforation, erosion,
fistula, fistula, stenosisstenosis
if lodged in the if lodged in the
esophagus.esophagus.
Electricity flow between both Electricity flow between both
battery poles through contact of battery poles through contact of
the tightly surrounding esophageal the tightly surrounding esophageal
walls may cause liquefaction walls may cause liquefaction
necrosis and perforation.necrosis and perforation.
Leakage of contents: acidic Leakage of contents: acidic
environment may erode seal of environment may erode seal of
battery and release heavy metals battery and release heavy metals
and cause necrosis of membranes.and cause necrosis of membranes.
Lithium cell ingestions associated Lithium cell ingestions associated
with most severe outcomes.with most severe outcomes.
Esophageal batteries should be Esophageal batteries should be
removed immediately.removed immediately.
Distal batteries can be managed Distal batteries can be managed
with observation and weekly with observation and weekly
radiographs to ensure passage.radiographs to ensure passage.
Lithium button battery
From:
http://img.alibaba.com/photo/10122824/Recharge_Lithium_Ion_Button_Battery.jpg
Kara Wong, HMS IV
Gillian Lieberman, MD
23
Button batteries: Beware the Button batteries: Beware the ““coin coin
fake outfake out””
•Look for “Halo Sign”
of button battery
PA CXR of Coin ingestion (left)
courtesy of Dr. Booya
BIDMC and Upright KUB
Battery ingestion (right)
courtesy of Dr. Waltzman
Children’s Hospital Boston
Kara Wong, HMS IV
Gillian Lieberman, MD
24
Button batteries: Beware the Button batteries: Beware the ““coin coin
fake outfake out””
On lateral, On lateral, battery shows battery shows ““step off appearance of edgesstep off appearance of edges””
while while coin has sharp coin has sharp
edgesedges
Lateral CXR of Battery ingestion
Courtesy of Dr. Marc Baskin, Children’s Hospital Boston
Lateral neck fluoroscopy of two coin ingestion,
Courtesy of Dr. Fargol
Booya, BIDMC
Kara Wong, HMS IV
Gillian Lieberman, MD
25
We have a systematic approach to We have a systematic approach to
pediatric FB ingestionspediatric FB ingestions
Now letNow let’’s go take care of our patientss go take care of our patients
Kara Wong, HMS IV
Gillian Lieberman, MD
26
Management of our first patientManagement of our first patient
7 year old 7 year old assymptomaticassymptomatic
boy with small, nonboy with small, non--
sharp, gastric metallic toy sharp, gastric metallic toy
on KUB.on KUB.
Patient discharged home Patient discharged home
with instructions to with instructions to
return if he became return if he became
symptomatic. symptomatic.
F/u KUB in 1 week.F/u KUB in 1 week.
Supine KUB of FB in stomach
Courtesy of Dr. Mark Waltzman, Children’s Hospital Boston
Battle ship
Kara Wong, HMS IV
Gillian Lieberman, MD
27
Management of our second patientManagement of our second patient
••
11 month old asymptomatic girl with esophageal hair clip on 11 month old asymptomatic girl with esophageal hair clip on
CXR.CXR.
••
Admitted to surgery for rigid endoscopic removal of sharp, Admitted to surgery for rigid endoscopic removal of sharp,
long object.long object.
Courtesy of Dr. Mark Waltzman, Children’s Hospital Boston
Lateral neck plain film of FB in esophagus PA CXR of FB in esophagus
Kara Wong, HMS IV
Gillian Lieberman, MD
28
Management of our third patientManagement of our third patient
3 year old symptomatic girl with esophageal FB on CXR.3 year old symptomatic girl with esophageal FB on CXR.
ORL consulted for endoscopic removal and discovered ORL consulted for endoscopic removal and discovered
lithium battery surrounded by friable mucosal tissue. lithium battery surrounded by friable mucosal tissue.
Barium swallow normal, no sign of stricture or fistula.Barium swallow normal, no sign of stricture or fistula.
Courtesy of Dr.
Marc Baskin,
Children’s
Hospital Boston
PA CXR with FB in esophagus Lateral CXR with FB in esophagus
Kara Wong, HMS IV
Gillian Lieberman, MD
29
Summary of Approach to Pediatric Summary of Approach to Pediatric
FB IngestionFB Ingestion
1.1.
Radiographs are indicated for ALL patients with Radiographs are indicated for ALL patients with
suspected FB ingestion. Consider CT or US for nonsuspected FB ingestion. Consider CT or US for non--
opaque opaque FBFB’’ss. .
2.2.
Immediate removal indicated for all symptomatic Immediate removal indicated for all symptomatic
patients or for sharp, long (>5cm), magnet, or patients or for sharp, long (>5cm), magnet, or
esophageal battery esophageal battery FBFB’’ss. .
3.3.
Patients who do not meet these criteria may be Patients who do not meet these criteria may be
observed with repeat CXR in 8observed with repeat CXR in 8--16 hrs for esophageal 16 hrs for esophageal
FBFB’’ss
and weekly KUB for distal and weekly KUB for distal FBFB’’ss.