Chapter 15. Gastrointestinal Disorders

Clinical Summary

Ingested foreign bodies (FBs) account for many emergency department visits, and most pass through the gastrointestinal (GI) tract spontaneously. However, in children with prior GI tract surgeries (ie, tracheoesophageal fistula or esophageal strictures), FBs may be dislodged and may require surgical intervention. Small children tend to ingest shiny objects, mainly coins (pennies are the most frequently ingested, followed by quarters, dimes, and nickels), beads, button batteries, toys, or small parts of toys. Most FBs are usually blunt or smooth objects. Adolescents usually ingest FBs other than coins, may eat too fast and have food bolus impaction or suffer from esophageal abnormality, neurologic or psychological disorder, and have intentional ingestion of FBs (ie, pencils, nails, or razors). Patients typically present with drooling, excessive salivation, voice changes, vomiting, or respiratory symptoms.

Emergency Department Treatment and Disposition

Hand-held metal detectors can be used to identify the location of metallic FBs, single radiograph of neck, chest, and abdomen can help locate radio-opaque FBs. Obtain anteroposterior and lateral chest radiographs if the FB is above the diaphragm to determine if it is in the trachea or esophagus and whether there is more than one FB (eg, 2 or more coins stacked together). If the FB is suspected to be radiolucent and perforation is NOT a concern, contrast esophagram may be useful. Consider CT scan with coronal and sagittal reconstructions if FB is thought to have migrated to the extraluminal space, or perforation or fistulas are suspected (see Fig. 15.18). Objects lodged in the proximal esophagus may threaten the airway and should be removed promptly. Use endoscopy to emergently remove FB if it poses a risk of corrosive injury (ie, button battery) or risk of perforation (ie, sharp objects such as open safety pin or razor blades). Prompt endoscopic evaluation is also necessary (even if the radiographs are unrevealing) in symptomatic patients (eg, respiratory distress or difficulty managing secretions). Rigid endoscopy with forceps extraction under general anesthesia is the standard method for removal of objects that may be sharp or are embedded in the mucosa as well as objects that may have been in place for a prolonged period or for patients with previous esophageal disease or GI surgeries. This method provides a controlled setting with airway management and direct visualization of the esophagus (ie, mucosal injury or esophageal pathology). Flexible fiberoptic endoscopy, extraction by Foley catheter, or advancement with a bougie dilator for smooth or blunt objects, in place for <24 hours in patients without respiratory distress are alternative methods. Expectant management may be considered for asymptomatic healthy patients with an FB in the esophagus for <24 hours. Allow the patient to eat or drink and repeat the radiographs in a few hours to ensure spontaneous passage through the lower esophageal sphincter (LES). If the FB fails to progress beyond the LES or food is not tolerated, the patient is a candidate for endoscopic removal of FB.

Pearls

1. Coins are the most commonly lodged esophageal FBs in children. A preceding history of ingestion may or may not be present.

2. Most common symptoms of ingested FB are drooling, excessive salivation, dysphagia (refusing solids), retching, hoarseness, vomiting, or respiratory symptoms.

3. If the FB is lodged in an unusual location (ie, other than the normal anatomic narrowing sites), suspect underlying esophageal disease.

4. If the duration of lodged FB is unknown, it should be removed by rigid endoscopy under GA.

5. Three most common locations for entrapment of a FB are:

   • (1) Proximal esophagus at the cricopharyngeus muscle (C6) or upper esophageal sphincter,
   • (2) Midesophagus at the level of the aortic arch (T4), and
   • (3) Distal esophagus (gastroesophageal junction).

6. Eighty percent of ingested FBs occur in children <5 years of age, with the peak incidence between 6 months and 3 years of age.

The author acknowledges the special contributions of Binita R. Shah, MD, and David Tran, MD, to prior edition.

Clinical Summary

Button batteries are frequently ingested, accidently or intentionally or placed in the nose or ears by children. Common sources of the battery include child’s own hearing aid, remote controls, toys, games, watches, and calculators. Cylindrical battery ingestions are most common among adolescents. Eighty percent of patients remain asymptomatic and 60% to 86% pass the battery within 48 to 96 hours. However, if the battery becomes lodged in the esophagus, it can result in esophageal mucosal injury, ulceration, perforation, stricture, liquefaction necrosis (release of alkali) or direct pressure necrosis, tracheoesophageal fistulas, and exsanguinations after fistulization into a major blood vessel, and death. A button battery impacted in the esophagus may present with drooling, gagging, fever, vomiting, refusing food, or respiratory symptoms (eg, stridor, wheezing, cough). A button battery causing GI tract injury may present with abdominal pain, vomiting, fever, or hematochezia.

Emergency Department Treatment and Disposition

Obtain radiographs of the neck, chest, and abdomen to locate the battery. On an anteroposterior view, the battery will have a “double density shadow” and on the lateral view the edge of the battery will have a “step-off.” Remove batteries in the nasal passage, external auditory canal, or esophagus emergently. Use endoscopy for removal of batteries lodged in the esophagus. However, if the battery has passed the lower esophageal sphincter, manage the patient conservatively with parental education of signs of perforation (pain, vomiting, or blood in stools) and serial radiographs, if clinically indicated. Batteries that remain in the stomach for >48 hours should be removed via endoscopy, and batteries >20 mm in diameter or larger will likely not pass through the pylorus and may require endoscopic retrieval. If the patient presents with signs of perforation (abdominal pain, vomiting, fever, or bleeding), surgical intervention is indicated.

Pearls

1. Button batteries lodged in the esophagus can cause severe tissue damage in 2 hours.

2. Hospitalize all patients with batteries lodged in the esophagus or with evidence of complications related to ingestion.

3. Button batteries lodged in the nose, ear, or vagina can cause tissue necrosis and must be removed emergently.

4. Routine use of steroids or antibiotics is not recommended.

5. Do NOT induce vomiting!

6. Removal via Foley catheter should be avoided (does not allow direct visualization, risk of esophageal perforation may be increased, and the battery may be aspirated during retrograde movement).

Clinical Summary

In countries where fish and chicken are one of the major dietary resources, children commonly swallow fish or chicken bones, and with impacted swallowed bones, patients present with “something” stuck in the throat or throat pain while eating. Symptoms are often due to minor mucosal injury (eg, abrasion or laceration). A lateral plain radiograph with soft tissue technique may show the presence of a bone. Plain radiographs are not always useful. Salmon, mackerel, and trout bones are radiolucent; cod, haddock, and halibut are radio-opaque. However, the radiograph may still be negative and an actual bone is identified in only 20% to 30% of such patients.

Emergency Department Treatment and Disposition

Direct inspection of oropharynx and hypopharynx, indirect laryngoscopy, and/or fiberoptic pharyngoscopy are used to make the diagnosis. Consult otolaryngology. Local anesthetic spray may aid in the evaluation and removal of a retained bone or patients may require sedation analgesia.

Pearls

1. Retained bones commonly become impacted at the tonsils, base of tongue and/or posterior pharyngeal wall.

2. Retained bones rarely pass spontaneously once lodged in the mucosa and usually require removal.

3. Plain radiographs are usually not useful as fish or chicken bones are poorly visualized on radiographs because of their varying degrees of calcification.

Clinical Summary

Foreign body (FB) ingestion is more common in pediatric or psychiatric patients, but can be seen in all age groups. Young children tend to accidently ingest coins, toys, or batteries whereas adolescents present with impaction of bones (eg, fish; see Fig. 15.11) or intentional ingestion of FBs. Anorectal FBs are most often seen in adolescents as a result of retrograde introduction due to sexual practices (see Figs. 15.19, 15.20, and 15.21). “Stuffing” drug packets (hurried ingestion of poorly prepared packages) to avoid law enforcement or carefully “packing” packets to smuggle drugs (heroin and cocaine being the most common drugs) across borders are other examples of ingested FBs. The size and shape of the FB will determine where it might get lodged. Some common narrow sites are pylorus, duodenum, ligament of Treitz, ileocecal valve (most clinically significant), appendix, hepatic and splenic flexures, and the rectum. However, “acquired narrowing” in the GI tract (eg, webs, diaphragms, or diverticula) may also become sites for impaction of the FB.

Patients present with variable symptoms ranging from asymptomatic (history of a swallowed FB or an FB passed in the stool) to abdominal pain, vomiting, fever, abdominal distention, or abdominal mass (ie, bezoars). Patient may also present with sudden onset of choking, coughing, or gagging.

Emergency Department Treatment and Disposition

Most ingested FBs are found below the diaphragm, 20% to 30% in the esophagus and about 10% to 20% cannot be found. Hand-held metal detectors or single-view radiographs of neck, chest, and abdomen may help to locate the FB and identify free mediastinal or peritoneal air. Consider obtaining a CT scan with coronal and sagittal reconstructions to help identify complications (ie, abscess formation).

Use endoscopic removal for sharp FBs (razors or sewing needles) or objects that are unlikely to pass the pylorus because of length [>6 cm], width [>2 cm], or shape [>5 cm in diameter or 2 cm in thickness]). FBs like toothbrush or spoon will have difficulty passing the duodenum. Any FB that has remained in the same location for greater than one week will also need to be removed via endoscopy. However, once an object has passed the ligament of Treitz, it cannot be retrieved endoscopically and if removal is indicated, the patient will require laparotomy.

Expectant management is recommended for all other FBs that have passed the esophagus. Most will pass through the GI tract in 4 to 6 days; however, some may take as long as 3 to 4 weeks. Educate parents about warning signs of obstruction or perforation (eg, abdominal pain, vomiting, fever, or hematemesis). Admit body stuffers and packers to monitor for signs of toxicity as well as for passage of the packets. Whole bowel irrigation and laxatives can be used to facilitate passage; however, endoscopic removal of packets is not advised because of the risk of rupture. Signs or symptoms of obstruction or perforation should prompt emergent surgery consult.

Pearls

1. Coins are the most commonly swallowed FBs by children.

2. Most FBs that pass the esophagus will pass through the remainder of the GI tract without complications.

3. Child neglect should be suspected in a child with repeated history of FB ingestion.

4. Ingestion of unusual FBs may suggest an underlying psychiatric illness.

Clinical Summary

Young children tend to ingest toys and coins, while adolescents intentionally ingest sharp objects such as razors, safety pins, and sewing needles.

Emergency Department Treatment and Disposition

Treatment depends on the location of the foreign body (FB) and patient’s presentation. Consult gastroenterology for any sharp object lodged in the esophagus for emergent endoscopic removal and surgery for possible laparotomy for patients who ingested a sewing needle or have symptoms of perforation (fever, abdominal pain, vomiting, or bleeding). The majority of sharp objects that enter the stomach pass through the remaining GI tract without any problem. However, the risk of complications in such patients is high (about 35%). Remove sharp objects in the stomach or proximal duodenum (before the duodenal sweep) endoscopically if it can be done safely. Manage patients who have ingested other sharp objects (beyond the duodenal sweep) conservatively with daily radiographs over 3 days as long as they remain asymptomatic. If the FB does not progress in 3 days, surgical retrieval by laparotomy is recommended.

Pearls

1. There is an increased risk of intestinal perforation with ingestion of sharp objects.

2. Expectant management is generally recommended for most FBs that have passed the esophagus, except for sharp objects.

Clinical Summary

Anorectal FBs result from retrograde introduction (eg, as a sexual practice or as a “mule” for smuggling) or an FB ingestion that lodges in the lower GI tract after passing through proximally. Patients may present with rectal pain on defecation, rectal bleeding, or constipation rather than providing history of inserting a rectal FB because of embarrassment. Other presenting signs and symptoms include inability to void (because of large FB impinging on the urethra), signs of peritonitis (anorectal perforation), and poor sphincter tone. Approach patients in a very nonjudgmental manner so they may feel comfortable and share the information regarding the events surrounding the FB or any attempts at self-removal.

Emergency Department Treatment and Disposition

Identify the type, size, shape, position, number of FBs, and the length of time/duration of FB prior to attempting its removal. Defer the rectal examination until the location and type of FB is determined (risk of breaking fragile objects like light bulbs or pushing the FB deeper or injury to examining physician from a sharp FB). Obtain plain abdominal or pelvic radiographs to detect radio-opaque FBs. If indicated, additional views may be obtained to detect free air under the diaphragm or along the psoas muscle (suggests anorectal perforation). Treatment depends on the location and type of the FB. Most are in the rectal ampulla and easily palpated with a digital rectal exam or visualized with anoscopy. These can be removed in the ED with procedural sedation by digital extraction or with an anoscope or vaginal speculum for visualization of FB followed by forceps-aided removal. Sphincter relaxation with local anesthetic infiltration is key. The distal end of the FB may adhere to the rectal mucosa, creating a vacuum effect impeding its withdrawal. In these instances, a Foley catheter may be passed beyond the FB, insufflate air to break the vacuum, inflate the Foley balloon, and remove the FB. Once the FB has been removed, a sigmoidoscopy should be performed to look for mucosal tears and perforations and follow up radiographs to exclude free air. Consult gastroenterology or surgery if there is a risk of perforation (glass or object with sharp edges) or the object is difficult to remove. Such patients may require laparotomy or sigmoidoscopy with forceps-aided removal of the FB.

Pearls

1. Anorectal FBs have to be removed to prevent complications like bleeding, intestinal obstruction, perforation, and/or sepsis.

2. Caution: Use of enemas or cathartics to facilitate passage of an anorectal FB may increase the risk of perforation (especially with sharp FBs).

Clinical Summary

Constipation is passing hard or lumpy, large-diameter, or pellet-like stools, fewer than 3 times a week associated with pain or excessive straining and may be a presenting symptom of underlying disease like Hirschsprung disease (HD), hypothyroidism, anal fissure, or spina bifida occulta. Uncommon causes of constipation include anal atresia, hypercalcemia, hypotonia, or lead poisoning. Patients may present with straining, crampy abdominal pain, anorexia, nausea and vomiting, tenesmus, blood-streaked stools, or encopresis (fecal soiling associated with solidified fecal impaction). Constipation may lead to recurrent urinary tract infections. Patients with HD may have delayed passage of meconium, enterocolitis (abdominal distention, fever, vomiting, colonic perforation, or peritonitis and shock), or intestinal obstruction (bilious vomiting, obstipation, and constipation). Rectal exam may reveal tight anal canal with an empty rectal vault.

Emergency Department Treatment and Disposition

The majority of the patients with constipation do not require hospitalization, and can be managed as outpatients. For fecal impaction, medications can be given orally (ie, stimulants such as bisacodyl or osmotic agents such as lactulose) or per rectum (bisacodyl or phosphate enemas). Do not use more than one enema per day, because it can lead to hyperphosphatemia, which can lead to hypocalcemia. Maintenance therapy includes stool softeners and lubricants. Mineral oil is used for children >1 year of age and should be avoided in neurologically impaired children. High-fiber diet should be encouraged, along with drinking a lot of fluids. Refer the patients with suspected HD to a gastroenterologist for a rectal biopsy.

Pearls

1. Abdominal radiographs are not routinely performed.

2. Oral fluids, high-fiber diet, behavioral modification, and treating the underlying aggravating factors are key in treating constipation.

3. Absence of hard stool in the rectal vault and expulsion of foul-smelling liquid stool are features of HD.

Clinical Summary

Gastrointestinal bleeding is divided into upper and lower GI bleeding by the ligament of Treitz. Bleeding proximal to the ileocecal valve usually produces melena (tarry stools) and distal to it hematochezia (bloody stools). In neonates, the most common cause of upper GI bleeding is idiopathic and benign anal or rectal lesions account for the lower GI bleeding. However, necrotizing enterocolitis and midgut volvulus should be suspected in a neonate with bilious emesis, abdominal distention, and GI bleeding. Intussusception is most frequently diagnosed in the infants (30 days to 1 year of age) and usually presents with intermittent abdominal pain, vomiting, and currant-jelly stools. Although esophagitis or peptic ulcer diseases are common causes of upper GI bleed; infectious etiologies (ie, Campylobacter, Salmonella, Shigella, or Yersinia) usually cause hematochezia. Esophageal varices secondary to extrahepatic portal hypertension may cause massive hematemesis in children (1-12 years). The most frequent cause of lower GI tract bleed in this age group is juvenile polyps; however, Meckel diverticulum, Henoch-Schönlein purpura (vasculitis of the GI tract), and hemolytic-uremic syndrome (thrombosis of small mucosal vessels) also cause lower GI bleeding.

In adolescents, peptic ulcer disease and esophagitis are the most common causes of upper GI bleed, whereas anal fissures and juvenile polyps are causes of lower GI bleed. Infectious diarrhea and inflammatory bowel disease should also be considered in this age group with lower GI bleeding.

Emergency Department Treatment and Disposition

The diagnostic workup should focus on the hemodynamic instability of the patient secondary to the bleeding. Hemodynamically unstable patients (eg, abnormal vital signs, orthostatic changes in heart rate and blood pressure, clinical signs of shock-like mental status changes, peripheral vasoconstriction, diaphoresis) require 2 large-bore intravenous lines for boluses of normal saline or lactated Ringer, cardiac and pulse oximetry monitoring, and oxygen therapy. Admit such patients and consult gastroenterology. Obtain CBC, coagulation profile, comprehensive metabolic panel type, and cross match. Stool cultures can help exclude infectious etiology of the bleeding, and the Apt-Downey test can differentiate swallowed maternal blood from the infant’s blood. Abdominal radiographs can help diagnose pneumatosis intestinalis, toxic megacolon, and pneumoperitoneum. Nasogastric lavage (with large-bore Salem-sump tube) identifies blood in the stomach and helps to determine if the bleeding is continuous or has ceased. However, it has no benefit in the control of bleeding. Performing continuous lavage beyond 10 minutes, if nasogastric return is not clearing, is also not beneficial and might not allow fibrin clot formation. There is also no role for iced-saline lavage. Initiate empiric therapy with acid-reducing and cytoprotective medications in cases of upper GI bleeding. Octreotide and vasopressin may be useful in suspected variceal bleed. Use endoscopy for evaluation and treatment of upper GI bleeding and flexible sigmoidoscopy or colonoscopy to determine causes of rectal bleeding. Angiography may be useful for patients with massive bleeding because it helps determine the site of bleeding and permits local injection of vasoconstrictors or thrombotic agents to control the bleeding.

Several conditions may mimic GI bleeding. Hematemesis may be swallowed maternal blood or bleeding from nose or mouth. Ingestion of bismuth, iron preparations, licorice, blueberries, spinach, and beets may be confused with melena. Hematuria, menstruation, or use of antibiotics such as ampicillin, rifampin, or cefdinir may be confused with hematochezia.

Pearls

1. Most GI bleeding in children is minor and self-limited.

2. Conditions that can lead to massive upper GI bleeding include esophageal or gastric varices, perforated ulcer, hemorrhagic gastritis, and vascular malformations.

3. Conditions that can lead to massive lower GI bleeding include Meckel diverticulum, inflammatory bowel disease, Henoch-Schönlein purpura, and vascular malformations.

4. Hematemesis following bouts of vomiting suggests Mallory-Weiss tear.

5. A well-appearing neonate or infant with regurgitation of milk mixed with blood is likely swallowed maternal blood.

6. A well-appearing infant with blood-streaked mucus in stool usually suggests milk protein induced colitis.