Acute esophageal coin ingestions: is immediate removal necessary?

History and radiographic findings as predictors for esophageal coins versus button batteries

OBJECTIVE

To determine if clinical history and radiographic findings are reliable predictors for coin versus button battery in children presenting with esophageal foreign bodies to accurately guide decision making regarding the urgency of removal.

METHODS

A retrospective chart review was conducted in a single pediatric tertiary care center of all children who presented with suspected coin or button battery esophageal foreign body ingestion from 2017 to 2019. Patients with documented surgical removal, completed consultation notes, and available radiographic studies were included. Descriptive statistical analysis was performed and predictive characteristics of the diagnostic tests were calculated.

RESULTS

139 patients met inclusion criteria for the study. Of 5 patients who had esophageal button batteries removed, clinical history was concerning for button battery in 2; accuracy of 12.35%. However, radiology reports suggested a battery in all 5. The negative predictive value for radiology alone for diagnosis of button battery was 97% with 81% accuracy. The clinical history for coin foreign body was accurate in 85.28% while radiography was 87% accurate. Wait time on average for all coin foreign body cases was 6.3 h. Day cases waited on average 5.5 h while after-hours cases waited a statistically significantly longer 7.5 h (p = 0.006).

CONCLUSION

Button batteries, while clinically important emergencies, are rare esophageal ingestions. Radiography has a strong negative predictive value for button battery. Children whose radiographic studies do not demonstrate concern for button battery could be considered for delayed elective removal. This could allow children to complete a period of observation at home, thereby reducing prolonged in-house wait times prior to operative removal.

Injuries due to foreign body aspirations in Georgia: A prevention perspective

BACKGROUND

Suffocation due to foreign bodies (FB) is a leading cause of death in children aged 0-3. No data from the former U.S.S.R. are available in the international scientific literature.

METHODS

Consecutive patients admitted at the Iashvili Central Children Hospital in Tbilisi, Georgia from 1989 to 2011 were analyzed. Injuries in the upper airways due to foreign bodies' inhalation were collected and compared with the Susy Safe Registry and the pooled estimates of the meta-analysis.

RESULTS

2896 cases were collected. Distribution of injuries in children younger than 3 years was significantly higher than in the Susy Safe Registry and in the "High-Income" countries in the meta-analysis. Percentage of injuries due to organic objects (86%) was significantly higher than in published data.

CONCLUSIONS

Since Georgia is not showing any substantial difference, both in epidemiology and treatment of foreign bodies injuries, as compared to the other case series, translation of public health initiatives from other most advanced prevention experiences is possible and it is likely to be effective.

LEVEL OF EVIDENCE

Level V, Epidemiological case series.

The removal of coins from the upper esophageal tract of children by emergency physicians: a pilot study

Objective:

There are few reports in the medical literature describing removal of a coin from the upper esophageal tract of a child by an emergency physician. However, given the nature of their training and practice, emergency physicians are well suited to perform this common procedure. We describe our experience with this procedure.

Methods:

This was a retrospective review of a continuous quality improvement data set from a university-based tertiary care pediatric emergency department between Nov. 1, 2003, and Mar. 31, 2004.

Results:

Thirteen children, with a median age of 20 months, underwent rapid sequence intubation and had coins successfully removed from their upper esophageal tract by emergency physicians. In 10 cases, the coin was visible at laryngoscopy and removed with Magill forceps. In 3 cases this approach failed and a Foley catheter was used to remove the coin. One child suffered a tonsillar abrasion and two sustained minor lip trauma, but all were extubated and discharged home from the emergency department with no significant complications. Eleven of the 13 patients were successfully followed up, and the parents reported no problems.

Conclusions:

This pilot study suggests that the removal of a coin from the upper esophageal tract by an emergency physician can be both safe and effective. A larger study is needed before this procedure can be generally recommended.

Esophageal coin removal by emergency physicians: a continuous quality improvement project incorporating rapid sequence intubation

Objective:

The objective of this study was to describe our experience removing esophageal coins from children in a tertiary care pediatric emergency department over a 4-year period.

Methods:

We retrospectively reviewed a continuous quality improvement data set spanning October 1, 2004, through September 30, 2008.

Results:

In 96 of 101 cases (95%), emergency physicians successfully retrieved the coin. The median age of the children was 19 months (interquartile range [IQR] 13–43 months; range 4 months–12.8 years). The median time to removal of coin from initiation of intubation was 8 minutes (IQR 4–14 minutes; range 1–60 minutes). Coins were extracted using forceps only in 56 cases, whereas forceps and a Foley catheter were used in the remainder. Succinylcholine and etomidate were used in almost all cases for rapid sequence intubation prior to coin removal. Complications were identified in 46 cases: minor bleeding (13), lip laceration (7), multiple attempts (5), hypoxia (3), accidental extubation (3), dental injuries (3), bradycardia (2), coin advanced (1), right main-stem bronchus intubation (1), and other (8).

Conclusions:

Emergency physicians successfully removed esophageal coins following rapid sequence intubation in most cases. Our approach may be considered for the management of pediatric esophageal coins, particularly in an academic pediatric emergency department.

Ingested foreign bodies: a case series demonstrating a novel application of point-of-care ultrasonography in children

In an era of recognizing the risks of radiation exposure, it is important to develop alternatives to radiographs. Bedside ultrasound has become an important adjunct to clinical diagnoses and procedural guidance in the emergency department. We present a case series of two patients who presented to a pediatric emergency department after witnessed coin ingestions. Point-of-care ultrasonography was able to accurately identify the location of each of the coins, at the thoracic inlet and in the stomach, as confirmed by chest radiography. To our knowledge, point-of-care ultrasonography has not been previously utilized to detect and localize esophageal foreign bodies in the emergency department.

Esophageal foreign bodies in pediatric patients: a thirteen-year retrospective study

We discuss clinical symptoms and radiological findings of variable esophageal foreign bodies as well as therapeutic procedures in Caucasian pediatric patients. A retrospective study of 192 cases of suspected esophageal foreign bodies between 1998 and 2010 was conducted. Data were statistically analyzed by chi-square test. A foreign body was removed from a digestive tract of 163 children aged 6 months to 15 years (mean age 4.9). Most objects were located within cricopharyngeal sphincter. Dysphagia occurred in 43%, followed by vomiting (29%) and drooling (28%). The most common objects were coins. Plain chest X-rays demonstrated aberrations in 132 cases, and in doubtful situations an esophagram test was ordered. In the group of thirty-seven patients whose radiograms were normal, esophagoscopy revealed fifteen more objects, which were eventually successfully removed. No major complications occurred. Esophagram should be a second X-ray examination if an object is not detected in plain chest X-ray. We recommend a rigid esophagoscopy under general anesthesia in doubtful cases as a safe treatment for pediatric patients.

Diagnosis and endoscopic management of upper gastrointestinal foreign bodies

INTRODUCTION

The objective is to evaluate the diagnosis of foreign body (FB) ingestion and report on the endoscopic management in Taiwan.

METHODS

This retrospective study enrolled 159 adult patients with confirmed diagnosis of upper gastrointestinal FBs who received endoscopic management in the emergency department.

RESULTS

The patients' mean age was 57.0 ± 19.2 years, and 66 (37.7%) of the patients were 65 years or older. Majority had a clear history and symptoms of FB ingestion. However, 9 (5.7%) initially ignored the accidental swallowing of FBs and were diagnosed late. The mean time spent for diagnosis was 1.8 days in those with uncertain history. Only 47.1% of those with radiographic studies had positive findings. Fish bones, press-through package and dentures were the most common culprits in this population of Asian elderly. Majority of FBs were located in the esophagus, especially in the upper third. Endoscopic FB extraction was successful in 96.9% of cases, while surgery was required in only 5 patients. The complication rate was 6.9%, including mucosal laceration (n = 10) and suspected perforation (n = 1), all of which were successfully managed conservatively. There was no death due to FB ingestion or endoscopy.

CONCLUSIONS

In FB ingestion, history usually points toward the diagnosis. Patients with an uncertain history are usually diagnosed late, and plain radiography cannot reliably predict the presence of FB. Endoscopic management is safe and effective for FBs.

Esophageal foreign bodies: 177 cases

The aim of this study is to assess patients treated for esophageal foreign bodies. The charts of patients (n=177), between January 1994 and April 2009, were investigated retrospectively. Patients' age and gender, locations and types of foreign bodies (FBs) and interventions were taken into consideration. Fifty-seven percent of the patients were male. The youngest patient was 6 months, whereas the oldest was 83 years old. The median age was 9 years. Half of the patients were in their first decade. Treatment took place 11 h (ranging from 1 to 120 h) after impaction of the FB. One hundred fifty-two FBs were removed in 177 patients. Our negative esophagoscopy (n=25) rate was 14%. The FBs were radiopaque in 75% (n=114) and were commonly (71%; n=109) located in the cervical esophagus. Metallic coins (n=81-53%) were the most commonly observed inorganic FB while bones and/or meat impaction (n=54-35%) were the most frequent organic FB. A total of 182 endoscopic interventions were performed on these patients. One hundred eleven of them were esophagoscopy and the remaining 71 were direct laryngoscopy. The FB was pushed into the stomach in 11 patients. Our morbidity rate was 1.6% (n=3). Iatrogenic perforation occurred in two patients. There was no mortality. Esophageal FBs may vary in type: sharp or round objects, metallic, plastic or organic material. FBs are commonly found at pharyngoesophageal junction and usually removed by McGill forceps. Rigid esophagoscopy is used for children and adults because of its large working channel. Rigid instruments are considered reliable and safe for extracting foreign bodies.

The cost of foreign body injuries in the upper aero-digestive tract: need for a change from a clinical to a public health perspective?

OBJECTIVE

This paper addressed the impact in terms of direct costs of the injuries in children due to foreign bodies in the upper aero-digestive tract.

METHODS

Two thousand one hundred and three consecutive cases were collected from 2000 to 2002 in 16 European hospitals, 1 hospital for each participating country, and referred to children aged until 14 who had FB injuries. Costs were based on the extraction of the FB procedures and on hospitalization length, based on DRGs. Determinants of costs and of length of stay (LOS) were analyzed using a multilevel model.

RESULTS

The major cost of the treatment of FB injuries is covered by the ENT Departments, which are usually the first choice of referral, directly from the patients. Children had a mean LOS of 2.13 days (95% C.I. 1.99-2.29). Treatment of the FB was associated with a mean cost of euro 1017.37 (95% C.I. 963.27-1073.51). In the multivariable analysis higher costs are related to the modality of arrival to the hospital by walk, to the site of the injury (ICD-933, ICD-934, ICD-935 in particular) and to the use of surgery in removing the FB.

DISCUSSION

Foreign bodies injuries are posing a great threat not only with regards to the clinical aspects but also from the public health perspective, their treatment being associated with high costs, in particular when surgery is needed.

Accidental ingestion of coins by children: management at the ENT Department of the João XXIII Hospital

The ingestion of foreign bodies by children is frequently seen in emergency departments. ENTs can manage those lodged in the esophagus but experience is important for a successful intervention.

Aim

Describe seven cases of children that ingested coins, managed at the ENT Department of João XXIII Hospital.

Study design

Clinical/prospective.

Materials and Methods

We describe seven cases (gender, age, family status, coin size and treatment/evolution).

Results

Age ranged from one to nine years. Two patients were only children and five were the youngest in their families. Coins sizes ranged from 1.9 to 2.5 cm. After eight hours of observation, three cases were treated in the surgery room because the foreign body was lodged in the cricopharynx. Four cases resolved spontaneously.

Conclusion

The ENT department has good results removing coins lodged in the upper esophagus using forceps and laryngoscopy; and also using rigid esophagoscopy for the lower esophagus. In this study it was not possible to establish the importance of coin size and patient age in attempting to predict spontaneous resolution, nor if the child being an only child or the youngest in the family may have some predisposition in this kind of accident.

Foreign body in the esophagus: a review

Foreign body in the esophagus is a common emergency presentation. The approach towards a patient with a foreign body in the esophagus comprises a thorough history and systematic examination followed by relevant investigations. However, there is considerable debate over the most appropriate treatment option for such patients. This review aims to develop a comprehensive approach towards patients presenting with foreign body ingestion by developing clinical practice guidelines. These guidelines address not only the initial evaluation of the patient but also the various management alternatives and their advantages, limitations and applicability in various scenarios, based upon a review of the literature.

Pediatric foreign bodies and their management

Ingestion of foreign bodies is a common pediatric problem, with more than 100,000 cases occurring each year. The vast majority of pediatric ingestions are accidental; increasing incidence of intentional ingestions starts in the adolescent age group. In the United States, the most common pediatric foreign bodies ingested are coins, followed by a variety of other objects, including toys, toy parts, sharp objects, batteries, bones, and food. In adolescents and adults, meat or food impactions are the most common accidental foreign body ingestion. Esophageal pathology underlies most cases of food impaction. Management of foreign body ingestions varies based on the object ingested, its location, and the patient's age and size. Esophageal foreign bodies as a group require early intervention because of their potential to cause respiratory symptoms and complications, esophageal erosions, or even an aortoesophageal fistula. Ingested batteries that lodge in the esophagus require urgent endoscopic removal even in the asymptomatic patient due to the high risk of complications. Sharp foreign bodies increase the foreign body complication rate from less than 1% to 15% to 35%, except for straight pins, which usually follow a relatively benign course unless multiple pins are ingested. Magnets are increasingly ingested, due to their ubiquitous nature and the perception that they do not pose a risk. Ingestion of multiple magnets creates a significant risk of obstruction, perforation, and fistula development. Methods to deal with foreign bodies include the suture technique, the double snare technique, and the combined forceps/snare technique for long, large, and sharp foreign bodies, along with newer equipment, such as retrieval nets and a variety of specialized forceps.

Imaging of the Esophagus in Children

The main role of the esophagus is to facilitate passage of food from the mouth to the stomach. A number of conditions can alter esophageal structure or function including congenital anomalies, trauma, infection, and neoplasm. This article reviews the anatomy, imaging evaluation, and common problems seen in the pediatric thoracic esophagus.

Case of the missing penny: thoracoscopic removal of a mediastinal coin

Complications of coin ingestion in children, although rare, include esophageal perforation, tracheoesophageal fistula, esophago-aortic fistula, and death. The authors describe thoracoscopic removal of a mediastinal coin that migrated extraluminally from the esophagus in a 23-month-old girl. Right-sided thoracoscopic exploration using a 3-trocar technique in a modified prone position was used. Coin location was assisted by manipulation of a transorally placed Foley catheter and intraoperative fluoroscopy. The coin was retrieved successfully with no intraoperative or postoperative complications and minimal postoperative pain. This is the first report of successful thoracoscopic removal of a mediastinal coin. Thoracoscopy may be a valuable approach for mediastinal foreign body removal in children.