1. Swallowed Foreign Body
Presentation
Parents bring in a young child shortly after he has swallowed a coin, safety pin, toy,
etc. The child may be asymptomatic or have recurrent or transient symptoms of
vomiting, drooling, dysphagia, pain or a foreign body sensation. Disturbed adults may
be brought from mental health facilities to the hospital on repeated occasions, at times
accumulating a sizeable load of ingested material.
What to do:
• Ask about symptoms and examine the patient, looking for signs of airway
obstruction (coughing, wheezing) or bowel obstruction or perforation (vomiting,
melena, abdominal pain, abnormal bowel sounds).
• Obtain two plain x ray views of throat to at least the mid abdomen to determine
if indeed anything was ingested or if the foreign body has become lodged
someplace or produced an obstruction. A barium swallow may occasionally be
necessary to locate a nonopaque foreign body in the esophagus.
• A foreign body with sharp edges or a blunt FB lodged in the esophagus for more
than a day should be removed endoscopically, because it is likely to cause a
perforation, and is still accessible.
• When a coin or other smooth object has been lodged in the upper esophagus for
lsee than 24 hours, it can usually be removed using a simple Foley catheter
techique. When available, it should be performed under fluoroscopy, although it
can be done as a blind procedure. With the patient mildly sedated (e.g.,
midazolam (Versed) 0.5mg/kg per rectum, intranasally or po, with half an hour
allowed for absorption) position with the head down (Trendelenberg) to minimize
aspiration. Restrain uncooperative patients. Have a functioning larygoscope,
forceps and airway equipment at hand. Test the balloon of an 8 to 12 French
Foley catheter to ensure that it inflates symmetrically. Lubricate the catheter
with water-solubile jelly and insert it through the nose into the esophagus to a
point distal to the FB. Inflate the balloon with 5ml of air and apply gentle traction
on the catheter until the FB reaches the base of the tongue. While encouraging
the patient to cough or spit out the FB, further traction will cause involuntary
gagging and expectoration. Immediately defflate the balloon and remove the
catheter. If a first attempt at removal fails, make a second and third try, then
consult an endoscopist. When removal is successful, discharge the patient after a
period of observation.
• When a FB has passed into the stomach and there are no symptoms which
demand immediate removal, discharge the patient with instructions to return for
reevaluation in seven days (or sooner if he develops nausea, vomiting,
abdominal pain, rectal pain, or rectal bleeding). Pediatricians have a saying that
objects larger than two inches will not pass the second portion of the duodenum
in a child under two years old. Having parents sift through stools is often
unproductive (one missed stool negates days of hard work). It may be helpful to
give a bulk laxative to help decrease the intestinal transit time.

2. What not to do:
• Do not use ipecac for FB ingestions. Emesis is effective for emptying the stomach
of liquid and dissolved drugs, but not for removing FBs from the esophagus or
stomach.
• Do not forcefully remove an esophageal FB, especially if it is causing pain. This
may lead to injury or perforation.
• Do not automatically assume that an ingested FB should be surgically removed.
The vast majority of potentially injurious FBs pass through the alimentary tract
without mishap. Operate only when the patient is actually being harmed by the
swallowed FB or when there is evidence that it is not moving down the
alimentary tract..
• Do not attempt to push an foreign body blindly down the esophagus with a
nasogastric tube or other such device. Use an endoscope.
• Do not miss additional coins after removing one from the proximal esopahgus.
Take a repeat x ray after removal of one.
Discussion
The narrowest and least distensible strait in the gastrointestinal tract is usually the
cricopharyngeus muscle at the level of the thyroid cartilage. Next narrowest is usually
the pylorus, followed by the lower esophageal sphincter and the ileocecal valve. Thus,
anything which passes the throat will probably pass through the anus as well. In
general, foreign bodies below the diaphragm should be left alone. A swallowed foreign
body can irritate or perforate the GI tract anywhere, but does not require treatment
until complications occur.
A significant portion of children with esophageal foreign bodies are asymptomatic and
therefore any child suspected of ingesting a foreign body requires an x ray to document
whether or not it is present and if so where it is located. Children with distal esophageal
coins may be safely observed up to 24 hours before an invasive removal procedure,
since most will spontaneously pass the coins. Even safety pins and razor blades usually
pass without incident.
Large button batteries (the size of quarters) have become stuck in the esophagus,
eroded through the esophageal wall, and produced a fatal exsanguination; but the
smaller variety, and batteries which passed into the gut, have not been such a danger.