Emergency care of esophageal foreign body impactions: timing, treatment modalities, and resource utilization

Resource Utilization and Risk Factors for Esophageal Injury in Pediatric Esophageal Foreign Bodies

OBJECTIVE

While management protocols of pediatric esophageal foreign bodies (EFBs) are well-delineated, resource utilization can be improved. This study's objectives were to explore hospital charges/costs for pediatric patients who present with EFBs and to identify patient risk factors associated with esophageal injury.

METHODS

A retrospective chart review of patients undergoing aerodigestive foreign body removal at a tertiary-care children's hospital from 2018 to 2021 was conducted. Data collected included demographics, medical history, presenting symptoms, EFB type, surgical findings, and hospital visit charges/costs.

RESULTS

203 patients were included. 178 of 203 (87.7%) patients were admitted prior to operation. Unwitnessed EFB ingestion (p < 0.001, OR = 15.1, 95% CI = 5.88-38.6), experiencing symptoms for longer than a week (p < 0.001, OR = 11.4, 95% CI = 3.66-38.6) and the following presenting symptoms increased the odds of esophageal injury: dysphagia (p = 0.04, OR = 2.45, 95% CI = 1.02-5.85), respiratory distress (p = 0.005, OR = 15.5, 95% CI = 2.09-181), coughing (p < 0.001, OR = 10.1, 95% CI = 3.73-28.2), decreased oral intake (p = 0.001, OR = 6.60, 95% CI = 2.49-17.7), fever (p = 0.001, OR = 5.52, 95% CI = 1.46-19.6), and congestion (p = 0.001, OR = 8.15, 95% CI = 2.42-27.3). None of the 51 asymptomatic patients had esophageal injury. The median total charges during the encounter was $20,808 (interquartile range: $18,636-$24,252), with operating room (OR) (median: $5,396; 28.2%) and inpatient admission (median: $5,520; 26.0%) contributing the greatest percentage.

CONCLUSIONS

Asymptomatic patients with EFBs did not experience esophageal injury. The OR and inpatient observation accounted for the greatest percentage of the hospital charges. These results support developing a potential algorithm to triage asymptomatic patients to be managed on a same-day outpatient basis to improve the value of care.

LEVEL OF EVIDENCE

Level 3 Laryngoscope, 2024.

Characteristics and outcomes of emergency department patients with a foreign body that entered through the ear, nose or mouth: a 10-year retrospective analysis

BACKGROUND

Foreign bodies in the ear, nose and throat commonly necessitate emergency department visits.

METHOD

This retrospective study was conducted on emergency department visits from January 2010 to December 2019 to determine characteristics and clinical prognoses of ENT patients. Patients were divided into three groups according to foreign-body entry route; patient characteristics and clinical findings were compared between groups.

RESULTS

Of 676 142 emergency department visits, 10 454 were because of ENT-related foreign bodies. The mean (± standard deviation) age of subjects was 24.0 (± 23.4) years, and 5176 patients were male (49.5 per cent). The most common entry route was the mouth (74.5 per cent). Most patients (97.1 per cent) were discharged after emergency treatment. Intensive care and in-hospital mortality occurred only in the mouth group.

CONCLUSION

Clinical findings differ depending on foreign-body entry route. After emergency treatment, most patients were discharged; some cases presented serious complications.

Ear, nose, and throat foreign bodies in adults: A population-based study in Taiwan

BACKGROUND/PURPOSE

This study performed a population-based analysis in the managements of adult ear, nose, and throat FBs in Taiwan.

METHODS

The Taiwan Longitudinal Health Insurance Database 2000 were used, which comprises 1,000,000 beneficiaries randomly sampled in 2000 with a follow-up period from 2000 to 2013. Patients aged >18 years with ear, nose, or throat FB were identified according to the International Codes of Diseases.

RESULTS

In total, 94,312 adults with ear (n = 21,786), nose (n = 1007), throat (n = 62,986), airway (n = 419), or esophageal (n = 8114) FB were identified. Emergency department visits were most common among patients with esophageal or airway FB (33.3% and 25.1%, respectively). X-rays were most commonly performed for patients with esophageal FB (44.8%), and computed tomography (CT) was most commonly used for those with airway FB (4.3%). Hospitalization rate was the highest among patients with airway FB (7.4%), followed by those with esophageal (3.0%) and nose (0.7%) FB. Patients with airway FBs corresponded with the highest rate of intensive care unit stay (58.1%), longest hospital stay (10.5 days), and highest in-hospital mortality rate (25.8%). A multiple logistic regression model indicated that old age, medical comorbidities, undergoing CT, and airway or esophageal FB were associated with hospitalization among adults with FB.

CONCLUSION

Disparities were identified in the treatment of ear, nose, and throat FB in adults. This study provides population-based data that may serve as a reference for otolaryngologists in clinical FB management.

[Clinical features and prognosis of gastrointestinal injury due to foreign bodies in the upper gastrointestinal tract in children: a retrospective analysis of 217 cases]

OBJECTIVE

To study the clinical features and prognosis of gastrointestinal injury caused by foreign bodies in the upper gastrointestinal tract in children.

METHODS

A retrospective analysis was performed for the clinical data of 217 children who were diagnosed with foreign bodies in the upper gastrointestinal tract complicated by gastrointestinal injury by gastroscopy from January 2011 to December 2016, including clinical features, gastroscopic findings, complications, and prognosis.

RESULTS

Among the 217 children, 114 (52.5%) were aged 1-3 years. The most common foreign body was coin (99/217, 45.6%), followed by hard/sharp-edged food (45/217, 20.7%) and metal (35/217, 16.1%). The most common gastrointestinal mucosal injury was ulceration (43.8%), followed by erosion (33.2%). Compared with other foreign bodies, button cells were significantly more likely to cause esophageal perforation (P<0.01). The esophagus was the most commonly injured organ (207/217, 95.4%). Of all the 217 children, 24 (11.1%) experienced infection. The children with perforation caused by foreign bodies had a significantly higher incidence rate of infection than those with ulceration caused by foreign bodies (P=0.003). Of all the 217 children, 204 (94.0%) underwent successful endoscopic removal of foreign bodies. Among these children, 98 were hospitalized due to severe mucosal injury and were given anti-infective therapy, antacids, and supportive care including enteral nutrition through a nasogastric tube and/or parenteral nutrition. Of all the children, 10 left the hospital and were lost to follow-up, and all the other children were improved and discharged.

CONCLUSIONS

Most cases of foreign bodies in the upper gastrointestinal tract occur at 1-3 years of age. Coin, hard/sharp-edged food, and metal are the most common foreign bodies. Button cells are more likely to cause esophageal perforation. The incidence rate of secondary infection increases with the increasing severity of gastrointestinal mucosal injury. Children undergoing endoscopic removal of foreign bodies and enteral nutrition through a nasogastric tube tend to have a good prognosis.

Eosinophilic Esophagitis: A Comprehensive Review

Eosinophilic esophagitis (EoE) is an emerging chronic atopic clinical-pathologic disease with an estimated prevalence of 1/1000 similar to the one of Crohn's diseases. Usually, EoE is firstly suspected due to symptoms that are caused by esophageal dysfunction and/or fibrosis. EoE diagnosis is confirmed if the esophageal biopsy shows at least 15 eosinophils per high power field (eos/hpf) as a peak value in one or more of at least four specimens obtained randomly from the esophagus. Most of the patients affected by EoE have other atopic diseases such as allergic rhinitis, asthma, IgE-mediated food allergies, and/or atopic dermatitis. The local inflammation is a T helper type 2 (Th2) flogosis, which most likely is driven by a mixed IgE and non-IgE-mediated reaction to food and/or environmental allergens. Recently published genetic studies showed also that EoE is associated with single nucleotide polymorphism (SNP) on genes which are important in atopic inflammation such as thymic stromal lymphopoietin (TSLP) located close to the Th2 cytokine cluster (IL-4, IL-5, IL-13) on chromosome 5q22. When the EoE diagnosis is made, it is imperative to control the local eosinophilic inflammation not only to give symptomatic relief to the patient but also to prevent complications such as esophageal stricture and food impaction. EoE is treated like many other atopic diseases with a combination of topical steroids and/or food antigen avoidance.

A dental nightmare, resolved: what a radiologist needs to know when consulted about ingestion of dental foreign body material

Ingestion of dental foreign bodies, while relatively rare, may cause serious, and occasionally fatal, injuries to the airways and gastrointestinal tract. Numerous case reports are available describing the clinical course of such ingestions. The aim of this paper is to develop concise, practical recommendations to aid radiologists in providing clinically relevant diagnostic information, thereby accelerating detection and management of acute ingestion of dental material.

Esophageal Food Impaction and Eosinophilic Esophagitis: A Retrospective Study, Systematic Review, and Meta-Analysis

BACKGROUND

Esophageal food impaction (EFI) can be the initial presentation of eosinophilic esophagitis (EoE). EoE is characterized by persistent esophageal eosinophilia (EE). Both EFI and EE are related to a variety of conditions. To date, the relationship between EFI, EE, and EoE remains unclear.

AIMS

To review our institutional experience with EFIs and combine our knowledge with the existing literature to conduct a systematic review and meta-analysis for delineating the relationship between EFI, EE, and EoE.

METHODS

We reviewed medical records of 72 children with EFI presenting to our emergency center between 2007 and 2013. PubMed, EMBASE, and Scopus databases were screened from inception until July 2014 to identify studies linking EFI and EoE. Included studies were methodically assessed for the quality and strength of association between EFI and EoE.

RESULTS

Our institutional experience highlighted the possibility of proton-pump inhibitor therapy-responsive EE (PPI-REE) as an underrecognized risk factor for EFI. A systematic review of 14 studies, including ours, revealed that most studies did not eliminate other causes of EFI or EE. The meta-analysis revealed that esophageal biopsies were obtained from 54% (40-68) of individuals presenting with EFI, and the overall EoE-attributable EFI among those who were biopsied was 54% (43-65). Substantial heterogeneity was noted among the studies.

DISCUSSION

PPI-REE is an underestimated risk factor for EFI. The quality of existing evidence linking EFI and EoE is limited by several important factors. Future studies with robust design are warranted to delineate the relationship between EFI, EE, and EoE.

Eosinophilic Esophagitis and Gastroenteritis

Eosinophilic gastrointestinal disease (EGID) can be classified as eosinophilic esophagitis (EoE) when the eosinophilia is limited to the esophagus or as eosinophilic gastritis (EG) if it is limited to the gastric tract, eosinophilic colitis (EC) if it is limited to the colon, and eosinophilic gastroenteritis (EGE) if the eosinophilia involves one or more parts of the gastrointestinal tract. EoE is by far the most common EGID. It is a well-defined chronic atopic disease due to a T helper type 2 (Th2) inflammation triggered often by food allergens. EoE diagnosis is done if an esophageal biopsy shows at least 15 eosinophils per high power field (eos/hpf). Globally accepted long-term therapies for EoE are the use of swallowed inhaled steroids or food antigen avoidance. The treatment of EoE is done not only to control symptoms but also to prevent complications such as esophageal stricture and food impaction. EGE cause non-specific gastrointestinal (GI) symptoms and are diagnosed if esophagogastroduodenoscopy (EGD)/colonoscopy show eosinophilia in one or more parts of the GI tract. They are rare diseases with an unclear pathogenesis, and they are poorly defined in terms of diagnostic criteria and treatment. Before initiating treatment of any EGE, it is imperative to conduct a differential diagnosis to exclude other causes of hypereosinophilia with GI localization. EGE are often poorly responsive to therapy and there is no commonly accepted long-term treatment. EG has many characteristics similar to EoE, including the fact that it is often due to a food allergen-driven Th2 inflammation; transcriptome analysis however shows that it is more a systemic disease and has a different gene signature than EoE. EC is a benign form of delayed food allergy in infant and is instead a difficult-to-treat severe inflammatory condition in older children and adults. EC in the latter groups can be a manifestation of drug allergy or autoimmune disease. Overall EGE, EC, and EG are rare and are a diagnosis of exclusion until more common causes of eosinophilia have been excluded.

Outcomes variability in non-emergent esophageal foreign body removal: Is daytime removal better?

OBJECTIVE

The objective of this study is to investigate differences between esophageal foreign body removal performed during standard operating room hours and those performed after-hours in asymptomatic patients.

METHODS

A retrospective chart review at a tertiary children's hospital identified 264 cases of patients with non-emergent esophageal foreign bodies between 2006 and 2011. Variables pertaining to procedure and recovery times, hospital charges, complications, length of stay, American Society of Anesthesiology (ASA) classification, and presence of mucosal injury were summarized and compared between cases performed during standard operating hours and those performed after-hours.

RESULTS

Cases performed during standard hours had significantly longer average wait times compared with after-hours cases (13.1h versus 9.0h, p<0.001). No other clinical characteristics or outcomes were significantly different between groups. Longer wait times are not associated with mucosal injury or postoperative complications.

CONCLUSION

There were no significant differences in procedure time, charges, or safety in after-hours removal of non-emergent esophageal foreign bodies compared to removal during standard operating hours. OR wait time was about 4h longer during standard hours compared with after-hours. This study could not assess the factors to determine the impact in differences in hospital resource utilization or work force, which may be significant between these two groups.

Etiology and management of esophageal food impaction: a population based study

OBJECTIVE

Esophageal food impaction (FI) is a common clinical problem with limited information on incidence. Previous population based studies are lacking. The incidence, main etiological factors, recurrence and outcome of FI was determined in the present study in a population based setting.

MATERIAL AND METHODS

This was a study of consecutive adult patients who presented with FI from 2008 to 2013 at the National University Hospital of Iceland. The mean crude incidence rate of FI was calculated. Retrospective analysis was undertaken on relevant clinical data such as type of bolus, management, complications, recurrence rate, risk factors for recurrence, and outcome.

RESULTS

Overall 308 patients had endoscopically confirmed FI, males 199/308 (65%), median age 62 years. The mean crude incidence was 25 per 100,000 inhabitants per year. The types of FI was meat (68%), fish (12%), vegetable (4%) and other food/objects (16%). Causes for the FI included: esophageal strictures (45%), hiatal hernia (22%), eosinophilic esophagitis (EoE) (16%) and esophageal carcinoma (2%). Recurrence appeared in 21%, in which 24/48 (50%) had EoE vs. 40/260 (15%) in others (p = 0.0001). The removal of the foreign body was successful in 98% of the cases during the first endoscopy. Endoscopic associated complications included four (1.3%) aspirations, one (0.3%) esophageal perforation and one Boerhaave syndrome at presentation (both had EoE).

CONCLUSIONS

The incidence of FI is the highest reported to date. EoE was strongly associated with recurrence of FI. In a population based setting endoscopy is a safe and effective procedure for removing FI.

Resource utilization patterns of pediatric esophageal foreign bodies

BACKGROUND

Ingested foreign bodies are a frequent presentation in pediatric emergency departments. Although some pass spontaneously through the gastrointestinal tract, the majority of esophageal-ingested foreign bodies (EFB) require removal.

MATERIALS AND METHODS

Kids' Inpatient Database (1997-2009) was used to identify children (aged <20 y) with EFB (International Classification of Diseases, Ninth Revision, Clinical Modification code 935.1). Multivariate logistic regression analyses were constructed to identify predictors of resource utilization.

RESULTS

Overall, 14,767 EFB cases were identified. Most patients were <5 y of age (72%), boys (57%), and non-Caucasian (55%), with a median (interquartile range) length of stay (LOS) of 1 (1) d, and total charges of $11,003 (8503). A total of 11,180 procedures were performed, most commonly esophagoscopy (77%), followed by bronchoscopy (20%), gastroscopy (2%), and rarely surgery (0.8%). By multivariate logistic regression, increased total charges were associated with a diagnosis of esophageal ulceration (odds ratio [OR] = 1.57), esophagoscopy (OR = 1.42), and bronchoscopy (OR = 1.62), all P < 0.001. Total charges also increased with admission to urban nonteaching hospitals (OR = 1.51) versus urban teaching hospitals, P < 0.001. Prolonged LOS (≥1 d) was associated with admission to a hospital in the Midwest (OR = 3.18) and with esophageal ulceration (OR = 2.11) and esophagoscopy (OR = 1.13), P < 0.03. Boys had higher odds of longer hospitalization (OR = 1.21), P < 0.001. Overall hospital mortality was 0.1% (n = 16).

CONCLUSIONS

Most EFB occur in children <5 y of age. Esophageal ulceration, esophagoscopy, and bronchoscopy are associated with increased total charges. Esophageal ulceration, esophagoscopy, and boys are associated with an increased LOS. Surgery and hospital mortality are both extremely rare in children with EFB.

Eosinophilic esophagitis

OBJECTIVE

To review the understanding of the pathogenesis of eosinophilic esophagitis (EoE) and the role of the immune system in the disease process.

DATA SOURCES

Peer-reviewed articles on EoE from PubMed searching for "Eosinophilic Esophagitis and fibrosis" in the period of 1995 to 2013.

STUDY SELECTIONS

Studies on the clinical and immunologic features, pathogenesis, and management of EoE.

RESULTS

Recent work has revealed that thymic stromal lymphopoietin and basophil have an increased role in the pathogenesis of disease. Additional understanding on the role of fibrosis in EoE is emerging.

CONCLUSION

The incidence of EoE is increasing like most atopic disease. Similar to other allergic diseases, EoE is treated with topical steroids and/or allergen avoidance.

Acute obstruction

Acute obstruction of the gastrointestinal or biliary tract represents a common problem for acute care surgeons. It is with appropriate clinical evaluation, planning, and physical examination follow-up that acute care surgeons are able to appropriately diagnose, manage, and resolve this difficult group of surgical problems and minimize the morbidity associated with each.

Update on foreign bodies in the esophagus: diagnosis and management

Foreign body impaction in the esophagus is an important emergency that carries significant morbidity and potential mortality. The most common cause of esophageal foreign body obstruction in adults is meat bolus impaction above a pre-existing distal esophageal (mucosal) ring, peptic or malignant esophageal stricture, or eosinophilic esophagitis. Immediate evaluation of the airway, assessment of the urgency of removal, radiological evaluation to localize the object, endoscopic or surgical retrieval, and subsequent monitoring for complications are essential steps in the management.