Most foreign bodies (90 percent) that are ingested enter the
gastrointestinal tract while 10 percent enter the tracheobronchial
tree.1 Approximately 1500 people die annually in the United
States from ingested foreign bodies in the upper gastrointestinal
tract.2 Most objects (80 to 90 percent) usually pass spontaneously
but about 10 to 20 percent must be removed endoscopically. Approximately
1 percent require surgical removal.3 Most (80 percent)
esophageal foreign bodies occur in children followed by edentulous
adults, prisoners, and psychiatric patients.4 Recurrent
episodes of foreign body ingestion occur in 5 to 10 percent of patients,
especially prisoners and psychiatric patients.1
The presentations are best divided according to accidental and
deliberate ingestors.1–5 The accidental ingestor
is usually cooperative and has a single foreign body. Conversely,
the deliberate ingestor is often uncooperative and the foreign bodies
are multiple and unusual. It is important to identify such individuals
at their initial presentation since foreign body removal is usually
performed under conscious sedation or general anesthesia.
The patient’s history is the most important part of
the diagnostic evaluation.3 The identity of the object
ingested is usually known to the patient. Persistent odynophagia,
dysphagia, or foreign body sensation may indicate the presence of
an esophageal foreign body despite negative radiographic results.
A high index of suspicion must be maintained in younger children
and mentally retarded adults.
The physical examination is most likely negative unless complications
are present. Stridor, wheezing, signs of consolidation, and the
absence of breath sounds should be sought. Subcutaneous emphysema
in the neck or chest indicates perforation of the esophagus or the
stomach. The most common sites for a foreign body to get trapped
are where the esophagus is narrow: at the cricopharyngeus muscle,
where the aortic arch crosses the esophagus, and at the gastroesophageal junction.
Radiographic evaluation is often helpful in the evaluation of
an esophageal foreign body.3–6 Obtain plain radiographs
of the neck and chest in the posteroanterior and lateral positions.
Evaluate the radiographs for the presence of a foreign body in all
planes. Air in the subcutaneous tissues, mediastinum, and/or
beneath the diaphragm is indicative of a perforation. Barium studies are
undesirable in patients with a food bolus impaction and obscure
endoscopic visualization. Esophagrams performed using a minimal
amount of thin barium may be necessary in situations where the foreign
body is made of wood, thin metals, aluminum can tops, and plastics.
Meglumine diatrizoate (Gastrografin) is contraindicated in food
bolus impactions because it is highly hypertonic and can lead to
severe chemical pneumonitis if aspirated into the lungs.5 Computerized
tomography may be useful, especially in cases where the foreign
body could not be detected as it may have become embedded in or
penetrated the esophageal wall.6
Endoscopy is important for both the diagnosis and possible removal
of an esophageal foreign body. Extraction with the flexible endoscope
is successful in 84 to 98 percent ...