Ingested Gastrointestinal Foreign Body in Children: Retrospective Review in a Pediatric Emergency Department

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1 대한응급의학회지제 21 권제 1 호 Volume 21, Number 1, February, 2010 원 저 Ingested Gastrointestinal Foreign Body in Children: Retrospective Review in a Pediatric Emergency Department Department of Emergency Medicine, Seoul National University College of Medicine Sae Won Choi, M.D., Do Kyun Kim, M.D. Purpose: Foreign body ingestion is a commonly encountered problem in the pediatric emergency department (ED). This retrospective review aimed to investigate data gathered on the presentation and management of foreign body ingestions in children presented to ED. Methods: This is a retrospective review of patients presented to the Seoul National University Hospital Pediatric ED between January 2005 and May The hospital electronic medical record database was used to identify children less than 15 years of age who presented with foreign body ingestion. Results: Two hundred and fifteen children were reviewed for this study. The age of the patients ranged from 0 months to 14 years and the median age was 28 months. The most common foreign body ingested was coins (23.3%). At the time of presentation, most of the foreign bodies were located in the stomach (38.6%). One hundred and thirty four patients (62.3%) were managed expectantly and received no other treatment. At endoscopic examination, the foreign body was visible in seventy-one patients and removal was successful in sixty-nine patients (success rate 97.2%). Two patients required surgical removal of the ingested foreign body. One hundred patients (46.5%) were referred to our pediatric ED from other institutions, mostly for endoscopy. Two patients developed significant complications as a result of the ingestion and management of the foreign body. Conclusion: Most children presented with ingested foreign body followed an uneventful course and complications following management were rare. Primary and emergency physicians should be familiar with the recommended guidelines in the management of foreign body ingestion in children. 책임저자 : 김도균서울특별시종로구연건동 28 서울대학교의과대학응급의학교실 Tel: 02) , Fax: 02) birdbeak@naver.com 접수일 : 2009년 8월 19일, 1차교정일 : 2009년 9월 28일게재승인일 : 2009년 11월 10일 88 Key Words: Children, Foreign body, Gastrointestinal tract, Management, Guidelines Introduction A child, especially those younger than 3 years, explores the world by putting it in their mouths and this is a part development process. Thus, foreign body ingestion is a common problem faced in the pediatric emergency department (ED). Of more than 125,000 cases of foreign body ingestion reported in 2007 in the United States, more than 75 percent occurred in children 1). Several published studies investigated gastrointestinal (GI) foreign body ingestions. However, these studies featured mixed populations of children and adults, focused mainly on endoscopic management and outcome or only described their experiences as a specialist 2-12). This retrospective study aims to investigate the general clinical findings of foreign body ingestions exclusively in a pediatric ED in Korea. Materials and Methods This is a retrospective review of patients presenting to the Seoul National University Hospital pediatric ED from January 2005 to May The hospital electronic medical record database was used to identify children less than 15 years of age who had foreign body ingestion via International Classification of Disease (ICD) codes. Demographic data, medical history, clinical presentation, foreign body type, radiographic finding, and ED management and disposition were collected from the chart using a data collection sheet.

2 Sae Won Choi, et al.: Ingested Gastrointestinal Foreign Body in Children: Retrospective Review in a Pediatric Emergency Department / 89 T-test and Mann-Whitney U test were used to examine continuous variables, and chi-square test or Fisher s exact test was used with categorical variables. p values less than 0.05 were considered significant. Data analysis was performed by using SPSS v 13.0 (SPSS Inc, Chicago, USA). Results Records of 215 children, 117 boys and 98 girls, were reviewed for this study. The age of the patients ranged from 0 months to 14 years, the mean 41.0±35.5 months, and the median age was 28 months (Fig. 1). Ninety six (44.7%) children were less than two years old. In all but two cases, the foreign body ingestion was witnessed, reported, strongly suspected by a caregiver, or suggested by history and symptoms. The two incidental cases, a 10 month old girl and a 23 month old boy respectively ingested a 23 mm screw and a zipper fragment, both located in the abdomen, were discovered Fig. 1. Age distribution. by coincidence following evaluation for symptoms unrelated to the foreign body. The median time from ingestion to presentation to the pediatric ED was 167 minutes (range: 11 minutes to 3 months). One hundred thirty four children (62.3%) were asymptomatic on presentation. The most common presenting symptoms were vomiting (14.8%), foreign body sensation (7.4%), cough (6.0%), and neck pain (5.6%). The physical examination was unremarkable in 207 children (96.3%). Five patients had a history of esophageal disease (3 trachea-esophageal fistula, 1 esophageal atresia and 1 both) and three patients had a previous history of foreign body ingestion. The spectrum of ingested foreign bodies is shown in Table 1. The most common foreign body ingested Table 1. Types of ingested foreign body Type of foreign body Number of case (%) Coin 50 (23.3) Toy 39 (18.1) Marbles 21 (09.8) Go stones 07 (03.3) Others 11 (05.0) Sharp metal objects 31 (14.5) Pin/nail/needle 12 (05.6) Screw 06 (02.8) Thumbtack 03 (01.4) Other sharp metal 10 (04.7) Button battery 25 (11.6) Other non sharp metal objects 18 (08.4) Plastics 14 (06.5) Jewelry 12 (05.6) Magnet 05 (02.3) Food bolus 04 (01.9) Button 02 (00.9) Glass 02 (00.9) Bone (chicken) 01 (00.4) Miscellaneous 12 (05.6) Table 2. Locations of ingested foreign body Location Number of case (%) Stomach 83 (38.6) Esophagus 55 (25.6) Intestine/Colon 52 (24.2) Unknown 25 (11.6) Table 3. Management of ingested foreign body Management Number of case (%) Observation 134 (62.3) Endoscopic removal 069 (32.1) Transferred to another facility 005 (02.3) Removal with Foley catheter 004 (01.9) Surgery 002 (00.9) Bougination 001 (00.5)

3 90 / 대한응급의학회지 : 제 21 권제 1 호 2010 was coins (23.3%), followed by toys (18.1%), which include 21 marbles (9.8%) and 7 Go stones (3.3%), and sharp metal objects (14.4%). In 184 patients (85.6%), the ingested objects were radioopaque, and nine patients ingested multiple foreign bodies. In 12 patients, computed tomography imaging was taken for further evaluation. Foreign bodies were radiologically or endoscopically proven in 190 (88.4%) patients. At the time of presentation, most of the foreign bodies were at the stomach (38.6%), followed by 25.6% in the esophagus, and 24.2% was distal to the stomach (Table 2). Esophageal foreign body was mostly located in the thoracic inlet (37 of 55 patients). Treatment options are listed in Table 3. One hundred thirty four (62.3%) patients were managed expectantly. Coins in the upper esophagus in four patients were extracted using a Foley catheter and one case of coin in upper esophagus by bougienage technique. At endoscopic examination, the foreign body was visible in 71 patients and removal was successful in 69 patients (success rate 97.2%). In two patients, the foreign body was removed surgically. In a 14-year-old female swallowed an 18- centimeter long metal chopstick, endoscopic removal failed and the chopstick was removed surgically. An 18-month-old girl ingested a cylindrical 23mm long magnet 6 days prior to presentation. Her physical exam was unremarkable. However, on endoscopy, the foreign body was located at the gastroesophageal junction and had punctured the esophagus; it was removed surgically. Comparing the patients who were observed to the patients who were managed invasively (removal with Foley catheter, bougienage technique, removal with endoscopy, or surgical removal), there were significant differences in the presence of symptoms, size of foreign body, and location of the foreign body (Table 4). Patients who managed invasively were more symptomatic, had ingested larger foreign bodies, and were more likely to be lodged in the esophagus than those who were observed. Twenty six patients (15 erosions, 9 ulcerations, 1 stenosis, 1 perforation) developed complications resulting from ingestion or management of the foreign body. Although gender, presence of symptoms, Table 4. Characteristics of children managed expectantly vs. children managed invasivel Expectant management (n=134) Invasive management (n=76) p value Mean age±sd*, months 38.9± ±43.9 NS Gender, n (%) 0.08 Male 080 (59.7) 36 (47.4) Female 054 (40.3) 40 (52.6) Symptom, n (%) Asymptomatic 102 (76.1) 32 (42.1) Symptomatic 032 (23.9) 44 (57.9) History of esophageal disease, n (%) 001 (0.01) 04 (05.3) 0.06 Shape of foreign body, n (%) NS Sharp 018 (13.4) 07 (09.2) Smooth 083 (62.0) 52 (68.4) Irregular 033 (24.6) 17 (22.4) Location of foreign body, n (%) <0.001 Esophagus 003 (02.2) 49 (64.5) Stomach 054 (40.3) 27 (35.5) Intestine/Colon 052 (38.8) 0 (0) Unknown 025 (18.7) 0 (0) Object size, mean±sd, mm Length 18.2± ±19.4 <0.013 Width 11.9± ±7.80 < * SD: standard deviation NS: not significant Fischer s exact test

4 Sae Won Choi, et al.: Ingested Gastrointestinal Foreign Body in Children: Retrospective Review in a Pediatric Emergency Department / 91 shape and location of object were not significant for presence of complications, younger patients were more likely to have complications (Table 5). However, only in 2 patients did the complications alter the clinical outcome. The patient who underwent surgery to remove a magnet that perforated her esophagus developed gastro-esophageal reflux and a hiatal hernia. A 4-year-old girl developed esophageal stenosis from ingestion of a button battery that was lodged in her esophagus for 19 hours before coming to our ED. Although full assessment of outcome was incomplete due to poor follow-up, no perforation, bleeding, obstruction, or mortality was recorded during the follow up period. Discussion We reviewed 215 cases of pediatric foreign body ingestions over a period of 4 years. In accord with previous studies, the majority of our patients were younger than 6 years old, and were asymptomatic 2-5,8-12). Male to female ratio was 1.19:1 in our study which matches previous reports of a male preponderance 8-12). Coins were the most frequent foreign body, and fortunately, complications were uncommon. Radiologic documentation of foreign bodies varies from 14% to 100% 6). In our study, 184 patients (85.6%) had ingested foreign bodies that were radioopaque. The percentage of patients with positive radiologic finding was high in our study because many of our patients were referred to our institution after diagnosis elsewhere. Therefore, our patients with definitive evidence of foreign bodies but who had negative radiologic findings were only three percent. Blunt objects lodged in the esophagus, most commonly coins, can be managed by several methods. Endoscopic removal is an option; however in asymptomatic patients with a single object lodged in the esophagus for less than 24 hours, with no history of esophageal abnormality or prior foreign body ingestions, removal with a Foley catheter or the bougienage technique is also acceptable 13). Although they do not provide control of the object as it is being removed, they have been reported to be successful with a low complication rate 14). A recent randomized controlled study has shown that observing the patient for 8 to 16 hours is also acceptable, based on a spontaneous passage rate of 25% to 30% 15). This is useful for it may avoid the inconvenience of mobilizing emergency endoscopy teams and transfers to referral centers. In this series, there were 31 cases of coins lodged in the esophagus. Of Table 5. Characteristics of children without complications vs. children with complications No complication (n=58) With complication (n=26) p value Mean age±sd*, months 3.5± ± Gender, n (%) NS Male 25 (43.1) 11 (42.3) Female 33 (56.9) 15 (57.7) Symptom, n (%) NS Asymptomatic 26 (44.8) 12 (46.2) Symptomatic 32 (55.2) 14 (53.8) Shape of foreign body, n (%) NS Sharp 12 (20.7) 05 (19.2) Smooth 31 (53.4) 16 (61.6) Irregular 15 (25.9) 05 (19.2) Location of foreign body, n (%) NS Esophagus 29 (50.0) 15 (57.7) Stomach 23 (39.6) 11 (42.3) Intestine/Colon 03 (05.2) 0 (0) Unknown 03 (05.2) 0 (0) * SD: standard deviation NS: not significant Fischer s exact test

5 92 / 대한응급의학회지 : 제 21 권제 1 호 2010 these, four were removed with a Foley catheter, one case by bougienage, 25 were removed by endoscopy and one case of spontaneous passage while preparing endoscopy. The rate of endoscopic removal is high in our institution due to the relative speed in activating the endoscopy team and the conservative approach in management of esophageal coins. Most foreign bodies pass uneventfully, but several studies have shown that about 10% to 20% will require non-operative intervention, and less than 1% will require surgical intervention 2,3,16-19). In our series, 34.8% of the children underwent some form of intervention; this higher percentage may be due to a large proportion of the cases being referred to our hospital for invasive management, such as endoscopy. Of the 215 patients included in this study, 100 (46.5%) were referred from other facilities. Thirty one (31.0%) patients referred to our ED did not have any indication for emergent endoscopy 11). Nineteen patients were asymptomatic and the object was distal to the stomach on initial diagnosis. In the other asymptomatic 12 patients; the ingested object was small, non-sharp, non-toxic, in the stomach and the time of ingestion was known to be less than 3 weeks. These patients could have been safely followed up in the outpatient department and the transfers to the ED could have been avoided. Since the timing of endoscopic intervention is determined by the perceived risk of complications, standard practice for the management of ingested foreign bodies may differ by institutions 14). There are instances where urgent endoscopic removal is mandated: a disk or button battery or a sharp object lodged in the esophagus, patient with signs of respiratory compromise, evidence of esophageal obstruction and the patient is unable to manage his or her secretions 5,14). Also, failure to visualize the object with radiologic studies in a symptomatic patient warrants endoscopy 18). At our institution, the decision and timing of activating the endoscopy team is decided by a pediatric gastrointestinal specialist. However, clinical consideration may justify a management plan at variance with known recommendations. In this series, upon comparing the characteristics of children managed expectantly versus children managed invasively, the differences of symptom, size and location of the foreign body were found to be statistically significant while age, gender, and the general shape of the object were not. These results were as fully expected because symptoms and locations of the foreign body are important factors when deciding the treatment plan. Jung, et al 20) has reported esophageal location of the foreign body being a risk factor in the development of complications for pediatric patients. However in our series, younger patients were more likely to have complications, and location of the foreign body was not significant. Because the risk of complications is a factor taken into account when deciding the treatment plan, further studies to elucidate the risk factors for complications in the pediatric population is needed. Our study has some limitations. First, although the decision to proceed with endoscopy was chosen by a pediatric gastrointestinal specialist, who will be aware of the current guidelines, as a retrospective review, there were no specific rules to be applied. This may have introduced bias to this review. Second, as a retrospective review this study is limited by the accuracy of the medical records. Also, full assessment of outcome is incomplete for followup data was only acquired by documented outpatient department follow-up. However, when taking into consideration that patients were observed for some time after invasive management and that complications would have been referred back to our institution if they occurred, data loss would be probably minimal. Third, not all patients underwent endoscopy and some complications due to foreign bodies may have been missed. Fourth, a large percentage of the patients were referred for our institution being a referral center with full time endoscopic coverage. The patient pool of this study cannot be considered representative of the general population. Conclusion Most children with ingested foreign body had a benign course and clinically significant complications were rare. Younger patients were more likely to develop complications. Although the mode of management were selected according to the patient s condition, physician s experience and available

6 Sae Won Choi, et al.: Ingested Gastrointestinal Foreign Body in Children: Retrospective Review in a Pediatric Emergency Department / 93 equipments as well as the location and type of foreign body, some cases that were referred to our ED for endoscopic removal did not meet the indication for such invasive management. Primary physicians and emergency physicians should be familiar with recommended guidelines available that guide the clinician in the management of foreign body ingestion in children. More studies are required to further evaluate the risk factors in developing complications. REFERENCES 01. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Heard SE Annual Report of the American Association of Poison Control Centers National Poison Data System (NPDS): 25th Annual Report. Clin Toxicol (Phila) 2008;46: Olives JP. Ingested foreign bodies. J Pediatr Gastroenterol Nutr 2000;31:S Arana A, Hauser B, Hachimi-Idrissi S, Vandenplas Y. Management of ingested foreign bodies in childhood and review of the literature. Eur J Pediatr 2001;160: Ayantunde AA, Oke T. A review of gastrointestinal foreign bodies. Int J Clin Pract 2006;60: Cheng W, Tam PK. Foreign body ingested in children: experience with 1,265 cases. J Pediatr Surg 1999;34: Binder L, Anderson WA. Pediatric gastrointestinal foreign body ingestions. Ann Emerg Med 1984;13: Kim JK, Kim SS, Kil JI, Kim SW, Yang YS, Cho SH, et al. Management of foreign bodies in the gastrointestinal tract: an analysis of 104 cases in children. Endoscopy 1999;31: Lee YS, Kang KW, Choi WK. Gastrointestinal foreign bodies in children. experiences of 60 Cases in Kangwon, Korea. Korean J Pediatr Gastroenterol Nutr 2001;4: Park SM, Chung MS, Choi JY, Yoon JG, Kim SS, Chae HS, et al. Gastrointestinal foreign bodies: review of 118 cases. Korean J Gastroenterol 1999;33: Choe BH, Park GS, Hwang JB. Endoscopic removal of foreign bodies from the upper gastrointestinal tract in children: management of 78 cases in Taegu, Korea. Korean J Gastrointest Endosc 2000;20: Lee JH, Nam SH, Lee JH, Lee HJ, Choe YH. Spontaneous passage of gastrointestinal foreign bodies in children. Korean J Pediatr Gastroenterol Nutr 2007;10: Lee MH, Kang KS, Jung HS, Seo JH, Lim JY, Park CH, et al. Gastrointestinal foreign bodies: review of 96 cases. Korean J Pediatr Gastroenterol Nutr 2002;5: Calkins CM, Christians KK, Sell LL. Cost analysis in the management of esophageal coins: endoscopy versus bougienage. J Pediatr Surg 1999;34: Eisen GM, Baron TH, Dominitz JA, Faigel DO, Goldstein JL, Johanson JF, et al. Guideline for the management of ingested foreign bodies. Gastrointest Endosc 2002;55: Waltzman ML, Baskin M, Wypij D, Mooney D, Jones D, Fleisher G. A randomized clinical trial of the management of esophageal coins in children. Pediatrics 2005;116: Uyemura MC. Foreign body ingestion in children. Am Fam Physician 2005;72: Wyllie R. Foreign bodies in the gastrointestinal tract. Curr Opin Pediatr 2006;18: Kliegman R, Behrman RE, Jenson HB. Nelson Textbook of Pediatrics. 18th ed. Philadelphia: Saunders; 2007; Litovitz T, Schmitz BF. Ingestion of cylindrical and button batteries: an analysis of 2,382 cases. Pediatrics 1992;89: Jung SH, Paik CN, Lee KM, Chung WC, Lee JR, Chang UI, et al. Risk factors predicting the development of complications after foreign body ingestion. Korean J Gastrointest Endosc 2009;39:

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