(Curr Gastroenerol Rep 2005 7:212; Pediatr Rev 2009;30:295)
Aspiration
• Classic Hx: Acute choking episode followed by coughing/wheezing/stridor
• Unless seen, history unreliable; should be on differential w/ Hx of chronic cough
• Exam: Cough (most common sx), localized wheeze, & localized ↓ breath sounds
• Location: Can be either side as children have approx symmetric bronchial angles
• Evaluation: Start w/ AP/lateral inspiratory/expiratory films
• If unable to cooperate, consider left and right lateral decubitus inspiratory films
• ↓ inflation on affected side. CXR can be nml. Freq w/ localized air trapping or atelectasis
• Clinical symptoms and radiologic findings before bronchoscopy have low diagnostic value. Usually foreign bodies are nuts/vegetables ∼80%, both radiolucent
• Management: If concern for aspiration or partial obstruction, rigid bronchoscopy under general anesthesia
• Postbronchoscopy will require observation, pulmonary toilet, and possible antibiotics
• Complete airway obstruction requires back slaps and chest thrusts in head down position for infants or abdominal thrusts for older children
• Asymptomatic patients who have normal exam and normal radiography can be observed at home
Ingestion
• Common foreign bodies ingested are coins (most common), toys, sharp objects, batteries, magnets, bones, & food
• 80–90% of foreign bodies that come to medical attention pass uneventfully, 10–20% require endoscopic removal & <1% require surgery
• Location: 5–10% in oropharynx, 20% in esophagus, 60% in stomach, and 10% distal to the stomach, usually in intestine (Eur J Emerg Med 1995;2:83)
• Symptoms: Drooling, choking, poor feeding, odynophagia, dysphagia, and chest pain. Fever suggests deep ulceration or perforation
• Evaluation: H&P, x-ray of neck, chest, and abdomen. Include lateral view of esophagus
• Metal detectors sensitive and specific for localizing coins
• For battery ingestions, call National Battery Ingestion Hotline at 202–625–3333
• Management of foreign body dependent on object, location, and patient’s age/size
• Esophagus: Early intervention 2/2 risk resp distress, esophageal erosions or fistulas
• No evidence for the use of motility agents such as glucagon
• Disc batteries are of great concern and need immediate removal
• If object is close to LES, could wait and repeat x-ray if passes into stomach
• Multiple magnets in esophagus or stomach should be removed endoscopically to prevent fistulization or perforation
• Stomach: Objects continue to pass uneventfully in GI tract. Prokinetics not helpful
• Endoscopy deferred unless pt is still symptomatic until 4–6 wk after ingestion
• Some FBs will not pass pylorus. FB >10 cm cannot pass in adults. Unclear in children
• Have greater concern for sharp objects, such as pins/needles
• Disc batteries often pass w/o issue; some cause ulcers & may need endoscopy
• Intestine: Safety pins in duodenum need removal because they can become lodged
• Coins/disc batteries eventually pass
• Rarely obstruct unless w/ anatomical abn (Meckel diverticulum or in appendix)
• Magnets – if multiple and beyond reach of endoscope, need careful follow-up or surgical intervention
• Outpatient management: Not necessary to sieve feces to find object
• Follow-up x-ray in 1–2 wk for passage
• If witnessed ingest of radiolucent FB, may need f/u endoscopy or contrast x-ray eval