Updated: 12/28/2021

Foreign Body Ingestion

Review Topic
  • Snapshot
    • A mother witnessed her 9-month-old daughter swallow a stray watch battery from the opposite side of the room. She rushed her daughter to the emergency department immediately after the incident. On evaluation, the child appears to be in no acute distress without any evidence of respiratory compromise or gastrointestinal tract obstruction.
  • Introduction
    • Ingestions are often unwitnessed and child may not develop symptoms
    • Most common in children 6 months - 3 years of age
    • Majority of foreign bodies will pass spontaneously without ill effects; however, complications can occur
      • bowel perforation
      • bowel obstruction
    • Typically, radio-opaque objects are swallowed - coins, screws, button-batteries, small toy parts
  • Presentation
    • Esophageal foreign body:
      • may be asymptomatic
      • symptoms, when present, may include: bloody saliva, coughing, drooling, dysphagia, failure to thrive, decreased feeding, gagging, irritability, neck/throat/chest pain, recurrent aspiration pneumonia, respiratory distress, stridor, tachypnea, vomiting, wheezing
    • Once beyond esophagus, objects typically pass but with increased risk of complications:
      • bowel obstruction, perforation, erosion to adjacent organs - abdominal pain, nausea/vomiting, fever, hematochezia, melena
      • common obstruction locations:
        • cricopharyngeal
        • middle 1/3 esophagus
        • lower esophageal sphincter
        • pylorus
        • lleocecal valve
    • 1st test - Radiographs of the chest, neck, upper abdomen
      • consider possibility of radio-lucent foreign body if no abnormality seen on radiograph (wooden, plastic, or glass items; fish/chicken bones)
    • Other imaging studies may be used - US, CT, MRI
    • Endoscopy - definitive diagnostic modality
  • Differential
    • Must rule out foreign body aspiration - confirm object is NOT in trachea or respiratory tree
    • Esophagitis
    • Gastroenteritis
    • Bowel obstruction
    • Intussception
    • Appendicitis
  • Treatment
    • Prevention - parental education and good safety practices at home - not allowing children to play with toys containing small, removable parts
    • If the object is thought to be in the esophagus (based on imaging and clinical presentation):
      • observe for 24 hours with serial radiographs and remove endoscopically if the object does not pass distally within that time-frame
      • if object causes symptoms or time-point of ingestion is unknown - attempt immediate endoscopic removal
      • if the ingested item appears relatively benign and has already progressed inferior to the diaphragm on imaging, observe and wait for spontaneous passage
      • if ingested object is sharp - remove immediately with endoscopy
      • batteries in esophagus have potential to cause severe tissue damage and should be removed immediately with endoscopy
      • consider using a foley catheter to remove retrograde from esophagus or bougienage to pass the object distally into stomach
    • Object distal to esophagus (in stomach most commonly)
      • symptomatic - remove immediately with endoscopy
      • asymptomatic
        • small blunt object - follow with serial radiographs; remove endoscopically if does not advance past pylorus in 3-4 weeks
        • large object (> 3 cm) - beyond pylorus then monitor with serial imaging; in stomach then remove endoscopically
        • sharp object - before pylorus then remove endoscopically; beyond pylorus monitor with serial imaging and remove if no progress for 3 days
    • Always remove button/disc batteries
    • If an acid/alkali is ingested
      • do NOT induce emesis
      • monitor ABC's
      • endoscopy 2-3 weeks later to assess damage
  • Complications
    • Bowel obstruction
    • Bowel perforation
    • GI tract mucosal abrasion
    • Abscess or infection
  • Prognosis
    • The majority of foreign body ingestions will pass spontaneously without intervention
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(M2.PD.15.95) A 7-year-old girl with no significant past medical history is brought to her pediatrician for persistent, blood-stained, foul-smelling vaginal discharge. This has been an ongoing issue for the last 2.5 months. The patient and her mother have been managing it at home with conservative treatments and improved hygiene, without improvement. They only recently received approval for health insurance, allowing them access to a pediatrician. Physical examination is significant for an anatomically normal vagina, mucosal erythema, and foul-smelling discharge with no sign of feculent material present. Pelvic imaging is obtained and is shown in Figure A. What is the best initial step in managing this patient?

QID: 104542

Warm fluid irrigation



Broadened antibiotic coverage



Exam under general anesthesia



Watchful waiting



Beginning a trial of topical corticosteroids



M 7 E

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(M2.PD.14.12) A 2-year-old girl is brought to the hospital after her mother witnessed her swallow a small toy. The patient is irritable, but otherwise is not gagging, reporting chest or throat pain, or vomiting. She is generally healthy and is up to date on her vaccinations. Her temperature is 99.0°F (37.2°C), blood pressure is 80/54 mmHg, pulse is 100/min, respirations are 25/min, and oxygen saturation is 99% on room air. On exam, she is in no respiratory distress and is tolerating her oral secretions. A radiograph is obtained as seen in Figure A. Which of the following is the best next step in management?

QID: 105410

Endoscopic removal



Observation and monitoring only



Oral fluids to advance the object



Serial radiographs



Surgical removal



M 7 E

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Evidence (3)
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