Medicosnext
Dr. Dilip Neupane
He is Nepal’s first DM in Pediatric Gastroenterology and Hepatology. He completed his MBBS from BP Koirala Institute of Health Sciences and pursued his master’s in Pediatrics from AIIMS, New Delhi. For super specialization, he earned a DM in Paediatric Gastroenterology and Hepatology from PGIMER, Chandigarh. Currently, Dr. Neupane is an Associate Professor in the Department of Pediatric Gastroenterology and Hepatology at KMC Hospital, making significant contributions to child health in Nepal. He is keenly interested in diagnostic and therapeutic endoscopic interventions for gastrointestinal and liver disorders.
A 7-year-old male autistic child from Kathmandu presented with an alleged history of ingestion of a foreign body (Sewing needle) 1 hour before coming to the Emergency of the Kathmandu Medical College Teaching Hospital. An X-ray of the abdomen was done which showed a sharp radiopaque object around the stomach. Urgent UGIE was done under sedation and the foreign body was removed with the help of the grasping forceps. The child was kept for observation and discharged the other day.
How common is the ingestion of the foreign body in children?
Foreign body ingestion and food bolus impaction occur commonly. Most foreign body ingestions occur in the pediatric population, with a peak incidence between 6 months and 6 years. Children are more vulnerable to foreign body ingestion due to the mouthing habit, curiosity about the foreign body and lack of insight into the effect of the ingestion of the foreign body.
How to diagnose foreign body ingestion?
Older children and non impaired adults may identify the ingestion and localize discomfort. Young children, mentally impaired adults, and those with psychiatric illness may thus present with choking, refusal to eat, vomiting, drooling, wheezing, blood-stained saliva, or respiratory distress. Oropharyngeal or proximal esophageal perforation can cause neck swelling, erythema, tenderness, or crepitus. Radiographs can confirm the location, size, shape, and number of ingested foreign bodies and help exclude aspirated objects. However, fish or chicken bones, wood, plastic, glass, and thin metal objects are not readily seen. With suspected foreign body ingestion, persistent esophageal symptoms should be evaluated by endoscopy, even in the setting of a negative radiographic evaluation
What is the timing of the endoscopic removal of the foreign body?
The need for and timing of an intervention for foreign body ingestion depends on the patient’s age and clinical condition; the size, shape, content, anatomic location of the ingested object(s), and the time since ingestion. Judgment of the risks of aspiration, obstruction, or perforation determines the timing of endoscopy. Most patients who are clinically stable without symptoms of high-grade GI obstruction do not require urgent endoscopy because the object will commonly pass spontaneously. However, esophageal foreign objects and food impactions should be removed within 24 hours because delay decreases the likelihood of successful removal and increases the risk of complications, including perforation.
Timing of endoscopy for ingested foreign bodies
Emergent endoscopy
Patients with esophageal obstruction (ie, unable to manage secretions)
Disk batteries in the esophagus
Sharp-pointed objects in the esophagus
Urgent endoscopy
Esophageal foreign objects that are not sharp-pointed Esophageal food impaction in patients without complete obstruction
Sharp-pointed objects in the stomach or duodenum Objects 6 cm in length at or above the proximal duodenum
Magnets within endoscopic reach
Nonurgent endoscopy
Coins in the oesophagus may be observed for 12-24 hours before endoscopic removal in an asymptomatic patient
Objects in the stomach with diameter 2.5 cm
Disk batteries and cylindrical batteries that are in the stomach of patients without signs of GI injury may be observed for as long as 48 hours. Batteries remaining in the stomach longer than 48 hours should be removed.
What are the various common foreign bodies accounted for in the children?
Sharp pointed objects:
A myriad of ingested sharp-pointed objects have been described. Chicken and fish bones, straightened paper clips, toothpicks, needles, bread bag clips, and dental bridgework ingestions have been associated with complications. Patients suspected of swallowing sharp-pointed objects must be evaluated to define the location of the object. Sharp-pointed objects lodged in the oesophagus are a medical emergency. Although the majority of sharp-pointed objects in the stomach will pass without incident, the risk of a complication caused by a sharp-pointed object is as high as 35%. Therefore, a sharp-pointed object that has passed into the stomach or proximal duodenum should be retrieved endoscopically. Endoscopic retrieval of sharp objects may be accomplished with retrieval forceps, a retrieval net, or a polypectomy snare. The risk of mucosal injury during retrieval can be minimized by orienting the object with its point trailing during extraction, by using an overture, or by fitting the endoscope with a protector hood.
Disk batteries:
Special considerations apply to small disk or button battery ingestions. Children younger than 5 years of age are the most likely to ingest a button battery, and most ingested batteries are from hearing aids, watches, toys, and calculators. While local pressure necrosis, corrosive damage from leakage of battery content, heavy metal toxicity and electric injury all seem to play a role, electrolysis seems to be the most significant mechanism for damage caused by BBI. Batteries in the oesophagus typically pose the highest risk of complications, especially in children <6 years of age and in batteries >20 mm in diameter. Voltage and duration of the impaction are associated with more rapid and severe injury. Following suspected battery ingestion, perform a two-view (anterior-posterior and lateral) X-ray of the entire neck, chest and abdomen to diagnose BBI and localise the battery. Close inspection of the image is necessary to identify a double ring or halo sign, which can distinguish a battery from a coin. Mucosal damage can occur within 2 hours after BB lodgement, even if the development of complications typically takes longer. Perforations are usually diagnosed within 2 days (rarely in the first 12 hours). If the battery is present in the oesophagus for <12 hours, then an urgent endoscopy should be done. But if the patient presented to the hospital after 12 hours of the ingestion then CT scan and surgical consultation should be done before endoscopic removal.
Magnet:
Ingestion of magnets can cause severe GI injury and death. The attractive force between magnets or between a magnet and an ingested metal object can occur, trapping a portion of the bowel wall between the 2 objects. Consequently, the pressure between the 2 objects can lead to bowel wall necrosis with fistula formation, perforation, obstruction, volvulus, or peritonitis. If the patient is asymptomatic with a single magnet, it is advisable to await spontaneous evacuation, even if the magnet position remains unchanged. However, if the patient ingests multiple magnetic beads then urgent endoscopic should be done under the paediatric surgery backup.
Coins:
Ingestion of coins occurs most commonly in young children. If coins become lodged within the oesophagus, they can be observed for 12 to 24 hours if the patient is asymptomatic because they will commonly pass it spontaneously. Patients with marked symptoms including drooling, chest pain, and stridor should have emergent intervention to remove the coin. Coins in the distal oesophagus are more likely to pass spontaneously than those in the proximal oesophagus. Most coins will eventually leave the stomach and pass through the GI tract without obstruction. Serial radiographs should be obtained as with other objects undergoing conservative management.
How should parents care for their children to prevent foreign body ingestion?
Children, especially those under the age of five, are naturally curious and often explore their environment by putting objects into their mouths. This can pose serious risks of foreign body ingestion, which may lead to choking, injury, or other complications. Here are some simple but effective measures to help prevent such incidents. Inorder to prevent from such incidents, parents should always keep a close watch on young children, especially during playtime and mealtime, extra vigilance is necessary when they are around small objects or toys (e.g., coins, buttons, batteries, beads, magnets) and also, the child should be educated about the dangers of putting non-food items in their mouth.
