Cecal retention of a swallowed penny mimicking appendicitis in a healthy 2 year old

Analysis of Radiopaque Gastrointestinal Foreign Bodies Expelled by Spontaneous Passage in Children: A 15-Year Single-Center Study

Background: Most ingested foreign bodies (FBs) pass spontaneously through the gastrointestinal (GI) tract, but only limited data on transit time are available. We evaluated the relationship of FB size and shape with transit time. Methods: We retrospectively reviewed medical records collected over 15 years (January 2001 to December 2015) on pediatric patients with radiopaque FBs in the GI tract. We categorized the FBs as regularly (round or spherical) or irregularly shaped (ovoid, long, flake-like, or projecting) and measured their sizes radiographically. The diameter of regularly shaped FBs and the length of irregularly shaped FBs were correlated with transit time. Results: In total, 484 patients with GI FBs were surveyed, and 267 (55.1%) FBs were radiopaque. Among the 267 radiopaque FBs, 88 (33.1%) required endoscopic removal and 7 (2.6%) underwent surgical intervention. Eighty-seven patients with single FBs in the GI tract for whom precise details of transit time were enrolled into the analysis of transit time; their mean age was 3.48 ± 2.21 years. Of the 87 FBs, 61 (70.1%) were regularly shaped, and 26 (29.9%) were irregularly shaped. The diameter of regularly shaped FBs was positively associated with transit time, as revealed by Mann-Whitney U test; diameters >1.5 and >2 cm were significantly correlated with longer transit times (both p = 0.003). A trend toward an increased transit time for long irregularly shaped FBs was also apparent; the p-values for lengths of 1.5, 2, and 2.5 cm were 0.824, 0.153, and 0.055, respectively. Under receiver operating characteristic (ROC) curve analysis, the optimal cutoff diameter for regularly shaped FBs, and length for irregularly shaped FBs, to predict a transit time of longer than 72 h were 1.95 and 2.25 cm, respectively. Conclusions: The passage rate of ingested radiopaque FBs is 64.4%. Small FBs that have passed the duodenal curve should be managed conservatively via clinical observation and radiographic surveillance. Our results indicate that the larger an FB is, the longer the transit time will be.

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.

Paediatric GI emergencies

Paediatric GI emergencies constitute a wide range of gut pathologies ranging from those that are common, easily diagnosed and treated to conditions that are rarer, often more severe and challenging to manage. Among a myriad of ordinary clinical symptoms and signs physicians have to identify the child with a serious, life-threatening pathology and initiate the appropriate diagnostic and therapeutic pathway. The aim of the review is to present and discuss a selection of key paediatric GI emergencies that provide challenges in diagnosis and treatment. These conditions are classified by their presentation or pathogenesis and include inflammatory conditions, those presenting with GI obstruction or haemorrhage and the ingestion of foreign bodies or caustic substances. The most recent advances regarding the management of these entities are discussed along with key areas of clinical practice and future research.