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Kosko B, Thielhelm TP, Ahluwalia R, Levy M, Kosko J. Bilateral vocal cord paralysis caused by accidental button battery ingestion in children: A case report and literature review. EAR, NOSE & THROAT JOURNAL 2024; 103:163-167. [PMID: 34541933 DOI: 10.1177/01455613211043678] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Button battery ingestion in pediatric populations is a common occurrence with severe sequelae. Multiple case reports have established the occurrence of death, fistula formation, mucosal erosion, esophageal perforation, and bleeding post-ingestion of button batteries. However, there is a gap in the literature on the occurrence of bilateral vocal cord paralysis post-lithium battery ingestion. We present a case in which a 12-month-old male developed bilateral vocal cord paralysis following ingestion of a button battery. We compare our case to eleven other reports that exist in the literature based on age, sex, time until removal, clinical presentation, day upon which vocal cord paralysis developed, anatomic location, and post-operative course. We conclude that bilateral vocal cord paralysis is a time-sensitive complication which requires prompt diagnosis. Any child with stridor following button battery ingestion should undergo consultation with pediatric otolaryngology immediately. In addition, long-term follow-up is necessary to evaluate return of normal vocal cord function.
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Affiliation(s)
- Brendan Kosko
- Florida State University College of Medicine, Tallahassee, FL, USA
| | - Torin P Thielhelm
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ranbir Ahluwalia
- Florida State University College of Medicine, Tallahassee, FL, USA
| | - Marc Levy
- Children's Surgical Associates, Orlando, FL, USA
| | - James Kosko
- Children's Ears, Nose, Throat, and Allergy, Orlando, FL, USA
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Ko TS, Catennacio E, Shin SS, Stern J, Massey SL, Kilbaugh TJ, Hwang M. Advanced Neuromonitoring Modalities on the Horizon: Detection and Management of Acute Brain Injury in Children. Neurocrit Care 2023; 38:791-811. [PMID: 36949362 PMCID: PMC10241718 DOI: 10.1007/s12028-023-01690-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 01/31/2023] [Indexed: 03/24/2023]
Abstract
Timely detection and monitoring of acute brain injury in children is essential to mitigate causes of injury and prevent secondary insults. Increasing survival in critically ill children has emphasized the importance of neuroprotective management strategies for long-term quality of life. In emergent and critical care settings, traditional neuroimaging modalities, such as computed tomography and magnetic resonance imaging (MRI), remain frontline diagnostic techniques to detect acute brain injury. Although detection of structural and anatomical abnormalities remains crucial, advanced MRI sequences assessing functional alterations in cerebral physiology provide unique diagnostic utility. Head ultrasound has emerged as a portable neuroimaging modality for point-of-care diagnosis via assessments of anatomical and perfusion abnormalities. Application of electroencephalography and near-infrared spectroscopy provides the opportunity for real-time detection and goal-directed management of neurological abnormalities at the bedside. In this review, we describe recent technological advancements in these neurodiagnostic modalities and elaborate on their current and potential utility in the detection and management of acute brain injury.
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Affiliation(s)
- Tiffany S Ko
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, USA.
| | - Eva Catennacio
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Samuel S Shin
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Joseph Stern
- Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, USA
| | - Shavonne L Massey
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Misun Hwang
- Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, USA
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Sinclair EM, Agarwal M, Santore MT, Sauer CG, Riedesel EL. Single-Center Retrospective Review of the Presentation and Initial Care of Esophageal Button Battery Impactions 2007-2020. Pediatr Emerg Care 2023; 39:259-264. [PMID: 35353766 PMCID: PMC9519803 DOI: 10.1097/pec.0000000000002690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aims of this study were to characterize the patient population and initial presentation and care of esophageal button battery ingestion and provide descriptive data including factors affecting accurate diagnosis, duration of battery exposure, and battery removal. METHODS This was a retrospective cohort study from 2007 to 2020 at a single-center, large-volume, urban academic pediatric hospital system. Included participants were children 6 months to 18 years old who underwent removal of an esophageal button battery impaction at our institution. RESULTS Our cohort comprised 63 patients; ages ranged from 7 to 87 months with a median of 27 months. Median button battery size was 2.12 cm with 59% lodged in the proximal esophagus. A prolonged impaction, greater than 12 hours, occurred in 46% of patients. Risk ratio analysis demonstrated that lack of caregiver suspicion of ingestion was associated with prolonged impaction (risk ratio, 3.39; confidence interval, 2.15-5.34). Misdiagnosis of button battery ingestion occurred in 10% of cases. The majority of patients, 87%, required transfer from a referring facility with a median total distance of 37 miles (range, 1.4-160 miles) from home to facility where battery was removed. CONCLUSION AND RELEVANCE This study describes the initial presentation and care of a large cohort of pediatric esophageal button battery ingestion. It emphasizes the continued need for primary prevention, prompt identification, and removal of these batteries. There are many challenges in caring for these patients involving multiple pediatric disciplines, and guidelines encompassing a multidisciplinary approach would be beneficial.
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Affiliation(s)
| | - Maneesha Agarwal
- Pediatric Emergency Medicine, Children's Healthcare of Atlanta, Department of Pediatrics
| | - Matthew T Santore
- Pediatric Surgery, Children's Healthcare of Atlanta, Department of Surgery and Pediatrics
| | | | - Erica L Riedesel
- Pediatric Radiology, Children's Healthcare of Atlanta, Department of Radiology and Pediatrics, Emory University School of Medicine, Atlanta, GA
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Scalise PN, Durgin JM, Staffa SJ, Wynne N, Meisner J, Ngo P, Zendejas B, Kim HB, Demehri FR. Pediatric button battery ingestion: A single center experience and risk score to predict severe outcomes. J Pediatr Surg 2023; 58:613-618. [PMID: 36646540 DOI: 10.1016/j.jpedsurg.2022.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE The purpose of this study was to analyze the management and outcomes of primary button battery ingestions and their sequelae at a single high-volume center, and to propose a risk score to predict the likelihood of a severe outcome. METHODS The medical record was queried for all patients under 21 years old evaluated at our institution for button battery ingestion from 2008 to 2021. A severe outcome was defined as having at least one of the following: deep/circumferential mucosal erosion, perforation, mediastinitis, vascular or airway injury/fistula, or development of esophageal stricture. From a selection of clinically relevant factors, logistic regression determined predictors of a severe outcome, which were incorporated into a risk model. RESULTS 143 patients evaluated for button battery ingestion were analyzed. 24 (17%) had a severe outcome. The independent predictors of a severe outcome in multivariate analysis were location of battery in the esophagus on imaging (96%), battery size >/ = 2 cm (95%), and presence of any symptoms on presentation (96%), with P < 0.001 in all cases. Predicted probability of a severe outcome ranged from 88% when all three risk factors were observed, to 0.3% when none were present. CONCLUSION We report the presentation, management, and complication profiles of a large cohort of BB ingestions treated at a single institution. A risk score to predict severe outcomes may be used by providers initially evaluating patients with button battery ingestion in order to allocate resources and expedite transfer to a center with pediatric endoscopic and surgical capabilities. LEVEL OF EVIDENCE Level IV. TYPE OF STUDY Clinical Research Paper.
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Affiliation(s)
- P Nina Scalise
- Department of Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA, 02115, United States
| | - Jonathan M Durgin
- Department of Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA, 02115, United States
| | - Steven J Staffa
- Boston Children's Hospital, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, MA, United States
| | - Nicole Wynne
- Department of Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA, 02115, United States
| | - Jay Meisner
- Department of Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA, 02115, United States
| | - Peter Ngo
- Boston Children's Hospital, Division of Gastroenterology, Hepatology and Nutrition, Boston, MA, United States
| | - Benjamin Zendejas
- Department of Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA, 02115, United States
| | - Heung Bae Kim
- Department of Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA, 02115, United States
| | - Farokh R Demehri
- Department of Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA, 02115, United States.
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Wang HC, Hu SW, Lin KJ, Chen AC. A novel approach to button battery removal in a two-and-half year-old patient's esophagus after ingestion: a case report. BMC Pediatr 2022; 22:96. [PMID: 35177027 PMCID: PMC8851756 DOI: 10.1186/s12887-022-03142-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 01/29/2022] [Indexed: 11/29/2022] Open
Abstract
Background Accidental swallowing of a foreign body occurs more frequently in children than in adults. Among these cases, button battery impaction in the esophagus may cause severe complications. While prevention is always ideal, if button battery impaction is suspected, immediate diagnosis and retrieval are important. Case presentation We introduce a novel method for retrieval of a button battery after ingestion by a 2.5-year-old child. When the patient arrived at our center, the battery was incarcerated in the upper esophagus. The battery could not be removed, despite the use of several methods such as alligator forceps under endoscopy and net retrieval. We decided to use a novel method that combined endoscopic balloon extraction and forceps retrieval. This resulted in a push-and-pull effect, creating synergy and easy removal of the battery. There were no long term complications based on the follow-up endoscopy examination. Conclusions This new procedure was very effective for removing the esophageal foreign body. When button battery in esophagus was too tight to be removed by the traditional retrieval methods, this procedure was suggested to use. It could be performed at medical institutions. If it fails or esophageal perforation (iatrogenic or spontaneous) occurs, pediatric surgeons could take over immediately.
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Affiliation(s)
- Hung-Chun Wang
- Department of Pediatrics, Chang Bing Show Chwan Memorial Hospital, Lukang, Changhua, Taiwan
| | - Shu-Wei Hu
- Department of Pediatrics, Tungs' Taichung MetroHarbor Hospital, Taichung, Taiwan
| | - Ke Jian Lin
- Department of Pediatric Gastroenterology of Children's Hospital, China Medical University, Taichung, Taiwan
| | - An-Chyi Chen
- Department of Pediatric Gastroenterology of Children's Hospital, China Medical University, Taichung, Taiwan.
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Fraser JA, Briggs KB, Svetanoff WJ, Attard TM, Oyetunji TA, St Peter SD. Evaluation of a Symptom-Based Algorithm for Managing Battery Ingestions in Children. Eur J Pediatr Surg 2022; 32:2-8. [PMID: 34918312 DOI: 10.1055/s-0041-1740537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES While complications from battery ingestion can be severe, especially with the emergence of stronger battery elements, not all ingestions require prompt removal. We aim to evaluate a symptom-focused algorithm for battery ingestion that emphasizes observation over intervention to investigate its safety. MATERIALS AND METHODS Patients were identified through a query of foreign-body ingestion radiographs obtained between 2017 and 2020. A retrospective chart review was then performed of all patients who presented with button battery ingestions to identify compliance with our algorithm, overall outcomes, and complications. RESULTS In total, 2% of all radiographs (44/2,237) demonstrated button battery ingestions. The median age of patients was 3.8 years (interquartile range, 2.6-5.3). Most batteries were found in the stomach (64%, n = 28), but were also identified in the esophagus (14%, n = 6), small bowel (14%, n = 6), and colon (9%, n = 4). All esophageal batteries were managed with immediate endoscopic retrieval. Ten gastric batteries were not managed per protocol, with seven admitted for observation despite being asymptomatic and repeat abdominal X-rays demonstrating persistent gastric location of the battery. Four patients underwent esophagogastroduodenoscopy; however, in two patients the battery had migrated past the stomach prior to intervention. All small bowel batteries and three of four asymptomatic colon batteries were managed per protocol; one patient had additional imaging that demonstrated battery passage. CONCLUSION Adherence to a symptom-focused protocol for conservative management of button battery ingestions beyond the gastroesophageal junction is safe and frequently does not require admission, serial imaging, or intervention.
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Affiliation(s)
- James A Fraser
- Department of Pediatric Surgery, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, United States
| | - Kayla B Briggs
- Department of Pediatric Surgery, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, United States
| | - Wendy Jo Svetanoff
- Department of Pediatric Surgery, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, United States
| | - Thomas M Attard
- Department of Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, United States.,Department of Gastroenterology, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, United States
| | - Tolulope A Oyetunji
- Department of Pediatric Surgery, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, United States
| | - Shawn D St Peter
- Department of Pediatric Surgery, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, United States
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Sinclair EM, Santore MT, Agarwal M, Kitzman J, Sauer CG, Riedesel EL. Evolving Clinical Care in Esophageal Button Batteries: Impact of Expert-Opinion Guideline Adoption and Continued Gaps in Care. J Pediatr Gastroenterol Nutr 2022; 74:236-243. [PMID: 34724451 PMCID: PMC8799493 DOI: 10.1097/mpg.0000000000003346] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND/OBJECTIVES Esophageal button battery impactions (BBI) in children pose a significant danger to children. Although there are expert-opinion guidelines to help manage this population, few studies detail the impact of guidelines on the clinical care of these patients. With this study, we aimed to describe the care of these patients before and following adoption of guidelines at a single center. METHODS Retrospective cohort study of patients with esophageal BBI at a single center, large volume, urban academic pediatric hospital system before adoption of expert-opinion guidelines (2007-2017) and following adoption (2018-2020). RESULTS Cohort was comprised of 31 patients before adoption and 32 patients following adoption of guidelines. Patient characteristics did not differ between groups. After 2018, significantly more patients received acetic acid irrigation, initial cross-sectional imaging, and serial cross-sectional imaging. There was also an increase in intensive care unit (ICU) stays, number of intubations, nil per os time, and hospital length of stay. There was no difference in patient outcomes. CONCLUSION This study describes a large cohort of pediatric esophageal BBI before and following adoption of guidelines. Findings detail increased adherence to guidelines resulting in more cross-sectional imaging which led to ICU stays, longer length of stays, and more nil per os time. This study emphasizes the need for multi-disciplinary guidelines as well as further multi-institutional study.
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Affiliation(s)
| | | | | | - Jamie Kitzman
- Pediatric Anesthesiology, Department of Anesthesiology and Pediatrics
| | - Cary G Sauer
- Pediatric Gastroenterology, Department of Pediatrics
| | - Erica L Riedesel
- Pediatric Radiology, Department of Radiology and Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
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Lorenzo C, Azevedo S, Lopes J, Fernandes A, Loreto H, Mourato P, Lopes AI. Battery Ingestion in Children, an Ongoing Challenge: Recent Experience of a Tertiary Center. Front Pediatr 2022; 10:848092. [PMID: 35573958 PMCID: PMC9091558 DOI: 10.3389/fped.2022.848092] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/21/2022] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Morbidity related to childhood battery ingestions (BI) has increased recently due to the expanding use of larger lithium cells. A prompt endoscopic removal is vital to prevent severe complications in cases of esophageal batteries (EB). MATERIALS AND METHODS A retrospective, descriptive study of admissions for BI requiring endoscopic removal in a tertiary hospital's pediatric emergency department (Jan. 2011/Dec. 2020). RESULTS We had 35 cases, with an increasing incidence in the last 6 years; median age, 26 m (8 m-10 years), witnessed ingestion in 86%. On the X-ray: 14 (40%) had an EB, 21 (60%), a gastric battery (GB). Symptoms were present in 57% (100% EB/24% GB), and vomiting was the most frequent (50%). Endoscopy revealed: EB, 13 (37%); GB, 17 (49%); duodenal battery, 1 (3%); no battery, 4 (11%). Median time to removal: EB, 7 h (2 h-21days); GB, 12 h (2 h-3 days). All the patients with EB on the X-ray (14) had severe mucosal injury (Zargar classification): Grade IIIa, 7 (50%); IIIb, 5 (36%); IV, 2 (14%). CT-scan showed perforation in 2 patients (total, 4; 29% of EB). In patients with GB (21), 14 (67%) had mucosal damage; 13 (93%), mild (< Grade III, two esophageal erosions); 1 (7%) IIIa (esophageal ulceration). A statistically significant association between exposure time, younger age or battery size and severity of endoscopic lesions was found in EB location. There were no mortality cases. Acute complications occurred in 57% of EB: infection, 50%; perforation, 29%; pneumomediastinum/stridor, 14%; pneumothorax/subglottic stenosis/hemodynamic instability, 7 vs. 0% GB. Stenosis subsequently developed in 6 (43%) of EB: mild, 4 cases (29%); severe, 2 cases (14%, one resolved after endoscopic dilation; one needed a gastrostomy and esophagocoloplasty). CONCLUSION We verified recent increase in admissions due to battery ingestions and associated complications, despite the availability of an emergency pediatric endoscopy team. The patients with EB had more severe mucosal injury and poorer short/long-term outcomes. Children with GB had milder lesions, although the presence of a GB did not exclude esophageal injury. The availability of actual data from national referral centers will support advocacy efforts among stakeholders, including industry representatives and policy makers, in preventing worldwide button battery injury.
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Affiliation(s)
- Cristina Lorenzo
- Paediatric Gastroenterology Unit, Department of Paediatrics, University Hospital Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, EPE, Lisbon, Portugal
| | - Sara Azevedo
- Paediatric Gastroenterology Unit, Department of Paediatrics, University Hospital Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, EPE, Lisbon, Portugal
| | - João Lopes
- Gastrenterology Service, University Hospital Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, EPE, Lisbon, Portugal
| | - Ana Fernandes
- Paediatric Gastroenterology Unit, Department of Paediatrics, University Hospital Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, EPE, Lisbon, Portugal
| | - Helena Loreto
- Paediatric Gastroenterology Unit, Department of Paediatrics, University Hospital Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, EPE, Lisbon, Portugal
| | - Paula Mourato
- Paediatric Gastroenterology Unit, Department of Paediatrics, University Hospital Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, EPE, Lisbon, Portugal
| | - Ana Isabel Lopes
- Paediatric Gastroenterology Unit, Department of Paediatrics, University Hospital Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, EPE, Lisbon, Portugal.,Medical School, University of Lisbon, Lisbon, Portugal
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Langham J, Sulton C, Holmes S. A 3-Year-Old Male Presenting With Sore Throat and Torticollis. Glob Pediatr Health 2020; 7:2333794X20953304. [PMID: 33062807 PMCID: PMC7536469 DOI: 10.1177/2333794x20953304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/31/2020] [Accepted: 08/04/2020] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Carmen Sulton
- Emory University School of Medicine, Atlanta, GA, USA
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Fung BM, Sweetser S, Wong Kee Song LM, Tabibian JH. Foreign object ingestion and esophageal food impaction: An update and review on endoscopic management. World J Gastrointest Endosc 2019; 11:174-192. [PMID: 30918584 PMCID: PMC6425280 DOI: 10.4253/wjge.v11.i3.174] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 03/08/2019] [Accepted: 03/11/2019] [Indexed: 02/06/2023] Open
Abstract
Foreign body ingestion encompasses both foreign object ingestion (FOI) and esophageal food impaction (EFI) and represents a common and clinically significant scenario among patients of all ages. The immediate risk to the patient ranges from negligible to life-threatening, depending on the ingested substance, its location, patient fitness, and time to appropriate therapy. This article reviews the FOI and EFI literature and highlights important considerations and implications for pediatric and adult patients as well as their providers. Where published literature is insufficient to provide evidence-based guidance, expert opinion is included to supplement the content of this comprehensive review.
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Affiliation(s)
- Brian M Fung
- UCLA-Olive View Internal Medicine Residency Program, Sylmar, CA 91342, United States
| | - Seth Sweetser
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States
| | - Louis M Wong Kee Song
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States
| | - James H Tabibian
- Division of Gastroenterology, Olive View-UCLA Medical Center, Sylmar, CA 91342, United States
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