Management of Foreign Body Ingestions

Transcription

1 Management of Foreign Body Ingestions Gregory P. Conners, MD, MPH, MBA, FAAP, FACEP Chief, Division of Emergency Medical Services Vice Chair of Pediatrics, Emergency and Urgent Care Children s Mercy Hospitals & Clinics Professor of Pediatrics and Emergency Medicine University of Missouri Kansas City School of Medicine Learning Objectives Discuss the epidemiology of foreign body ingestions Identify the various approaches to diagnosis and management of children with potential foreign body ingestions who present to primary care practices or hospital emergency departments Disclosure Statement Who swallows foreign bodies? I have no actual or potential conflict of interest in relation to this program. Basic principles of foreign body ingestion Young children eat the large majority of FBs. The large majority of FBs pass through the GI tract with difficulty. Pay special attention when: The swallower is not a normal, healthy child The ingested FB is long, chemically active, pointed, sharp, or causing symptoms The story is too bizarre to be believed 1

2 Why would we? Because the most common important complication of coin ingestion is esophageal entrapment, which can have severe sequelae when missed, and a radiograph is a good way to diagnose it. Is he symptomatic? If so, probably yes (~15-fold increased risk) But, symptoms may be present in those without esophageal coins, and Esophageal coins may be present without symptoms Does he have a normal esophagus? If not, then probably yes: children with esophageal abnormalities, including previous esophageal foreign body entrapment, also are at increased risk 2

3 Most such kids are generally healthy, and are asymptomatic. For them, the answer depends in large part on the setting in which you are practicing. The risk of complication from foreign body ingestion varies dramatically: lowest in patients seen solely by PCPs, about twice as high in patients self-referred to EDs, and about nine times as high in children referred to an ED by a physician. (Paul RI et al, Pediatrics 1993;91:121-7) Implications: The answer may not be the same for everyone! Foreign body research must be read critically; recommendations must be considered in light of where the data were collected. Researchers must consider this when drawing conclusions. Why a radiograph? What about a handheld metal detector? Why a radiograph? What about a handheld metal detector? Metal Detectors Very high sensitivity, specificity for finding ingested coins. Good at determining whether a swallowed coin is in the esophagus vs. stomach/intestines. Not as well-studied with other foreign bodies. Clearly have some limitations: non-metallic foreign bodies, obese children, etc. Most users will confirm esophageal coins with radiographs. Metal Detectors Some advantages: inexpensive, easy, minimal training required, a crowd-pleaser, radiation-free, can easily repeat over time to document changes Some disadvantages: cannot show results to others, no clear billing code 3

4 What do we do if we find an esophageal coin? Endoscopy (the standard) Foley / Balloon catheter Bougienage Watchful waiting: NPO Watchful waiting: Giving something to eat/drink Medications Back to our classic FB dilemma A normal, asymptomatic 2 year old boy recently swallowed a coin. Should we obtain a radiograph? The answer: in the ED, probably yes, although hand-held metal detectors offer an alternative Back to our classic FB dilemma A normal, asymptomatic 2 year old boy recently swallowed a The answer : in a primary care setting, the answer is less certain, and depends more on other factors: willingness of doctor/patient to take small risk of missing an esophageal coin vs. waiting to allow for spontaneous passage. Some reasonable strategies: Immediate radiography Localize coin with a metal detector Get a radiograph only if the child does not pass the coin in several days (right away if symptoms occur) Home observation: get a radiograph only if symptoms occur Back to our classic FB dilemma A normal, asymptomatic 2 year old boy recently swallowed a coin. Should we obtain a radiograph? What about poison control centers? They got lots of calls about foreign body ingestions. #1: dessicants #2: coins Study: very low complication rate (like primary care) in asymptomatic, otherwise healthy kids. Best to have home observation, follow-up if symptoms arise Special FB case: glass Some special foreign bodies Myth: only leaded glass is radiopaque Fact: Over 90% of different types of glass show up on a radiograph. Radiographs are an effective way to screen for glass. Ultrasound and MRI are also effective for finding embedded glass, but neither is very practical for finding ingested glass. 4

5 Special FB case Teenage girl runs upstairs to the bathroom immediately after dinner. She suddenly begins gagging and drooling, while denying that anything is wrong. She is taken to the ED, where a radiograph is obtained. Swallowed toothbrush Special FB case A sign of either a bizarre accident, or of bulimia Child pulled pop top off soda can, and swallowed it. Seems to be gagging and choking, but radiograph is normal. What is going on? Special FB case: Aluminum Don t assume there is no esophageal foreign body. Aluminum is often radiolucent! Better: metal detector, or contrastenhanced study, or endoscopy Special FB case: zinc pennies Modern pennies are largely zinc, with a thin copper coating In the presence of HCl, zinc produces heat and breaks down. This caused much worry when the new pennies were released, and a 1-2 cases of gastric ulceration in children with penny ingestion were reported. We now clearly know that this is a very unusual, but still possible event. 5

6 Special FB case: child reaching Special FB case: child reaching Special FB case: child reaching Special FB case: child reaching Special FB case: button (disk) battery Within an hour of constant contact with a moist mucous membrane, button batteries begin tissue liquefaction. A button battery left in the esophagus (ear, nose, etc.) overnight can cause extensive damage even a battery that has been discarded because it is dead. Thankfully, button batteries moving along the GI tract rarely cause this sort of damage. Of interest, gastric button batteries seem to do well, at least for a day or two, although they should be removed if they do not progress. Special FB case: toy magnets As small, powerful magnets have become common parts in toys, more and more children have been swallowing them. One small, swallowed magnet passing through the GI tract is typically harmless. When two or more are swallowed, they can powerfully attract each other, and necrose the delicate intestinal lining between. This has resulted in many reports of bowel perforation, and several deaths. Be wary of even single magnet ingestions: radiographs recommended, with referral for multiple magnets Possible alternative: passing a compass over the abdomen, watching for needle deflection from the magnet 6

7 Special FB case: toy magnets Can also see bowel perforation when a patient swallows a magnet and another ferrous object. Especially dangerous is the combination of a swallowed magnet and a button battery. Special FB case: toy magnet and button battery Image compliments of Dr. Nirav Shastri Special FB case: pointed objects Special FB case: pointed objects Thank you! 7