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 IMAGING 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