pediatric foreign body ingestions kara wong,...

Pediatric Foreign Body Pediatric Foreign Body IngestionsIngestions

Kara Wong, Harvard Medical School Year IVKara Wong, Harvard Medical School Year IVGillian Lieberman, MDGillian Lieberman, MD

Kara Wong, HMS IVGillian Lieberman, MD

October 20, 2008


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AgendaAgenda

Presentation of our patientsPresentation of our patients

EpidemiologyEpidemiology

Symptoms and ComplicationsSymptoms and Complications

Approach to FB IngestionApproach to FB Ingestion

Radiological diagnosisRadiological diagnosis

Therapy: Observation Therapy: Observation vsvs

InterventionIntervention

Special situations (magnets, batteries)Special situations (magnets, batteries)

Management of our patientsManagement of our patients


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Our first patientOur first patient’’s presentations presentation

7 year old boy 7 year old boy p/wp/w accidental ingestion of accidental ingestion of

Monopoly battleship. Monopoly battleship. Denies chest pain, Denies chest pain, abab

pain, or SOB. pain, or SOB.

Vitals AFFS, PE Vitals AFFS, PE unremarkable.unremarkable.

KUB obtained revealing KUB obtained revealing metallic object in metallic object in stomach.stomach.

Supine KUB of FB in stomachCourtesy of Dr. Mark Waltzman, Children’s Hospital Boston

Battle ship


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Our second patientOur second patient’’s presentations presentation

11 month old girl 11 month old girl p/wp/w

accidental ingestion of hair clip. No accidental ingestion of hair clip. No drooling, cough, vomiting, drooling, cough, vomiting, stridorstridor, or respiratory distress. , or respiratory distress.

Vitals AFFS. PE unremarkable. Vitals AFFS. PE unremarkable.

KUB and lateral neck films reveal foreign body in esophagus.KUB and lateral neck films reveal foreign body in esophagus.

Courtesy of Dr. Mark Waltzman, Children’s Hospital BostonLateral neck plain film of FB in esophagus PA CXR of FB in esophagus


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Our third patientOur third patient’’s presentations presentation

3 year old girl 3 year old girl p/wp/w

with fever, abdominal pain, decreased oral with fever, abdominal pain, decreased oral intake. Mother believes she may have swallowed a quarter. intake. Mother believes she may have swallowed a quarter.

PE unremarkable except for refusal to take oral intake. PE unremarkable except for refusal to take oral intake.

KUB reveals round metallic object in esophagusKUB reveals round metallic object in esophagus

Courtesy of Dr. Marc Baskin, Children’s Hospital Boston

PA CXR with FB in esophagus Lateral CXR with FB in esophagus


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Approach to evaluation of FB Approach to evaluation of FB Ingestion: Ingestion:

Questions to ConsiderQuestions to Consider

How are FB ingestions diagnosed and identified ? How are FB ingestions diagnosed and identified ?

Which patients need intervention and which Which patients need intervention and which patients can be observed? patients can be observed?

What are the possible outcomes ?What are the possible outcomes ?


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EpidemiologyEpidemiology

Over 100,000 cases of foreign body ingestion reported per year Over 100,000 cases of foreign body ingestion reported per year in US. Many go unin US. Many go un--reported or unreported or un--discovered. discovered.

80% of cases occur in children and infants, who are prone to 80% of cases occur in children and infants, who are prone to sticking objects in their mouth and less able to control their sticking objects in their mouth and less able to control their oropharnxyoropharnxy

and airways.and airways.

Fatalities have been reported for children under age 4.Fatalities have been reported for children under age 4.

From: Chen, X., S. Chen, X., S. MilkovichMilkovich, et al. (2006). "Pediatric coin ingestion and aspiration." , et al. (2006). "Pediatric coin ingestion and aspiration." IntInt J J PediatrPediatr OtorhinolaryngolOtorhinolaryngol 70(2): 32570(2): 325--99

Diagram showing association of child’s age with incidence of FB ingestion and injury rate


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Menu of FB IngestionsMenu of FB Ingestions

Frequently found objects Frequently found objects include coins (most include coins (most common), safety pins, common), safety pins, batteries, toy parts, batteries, toy parts, magnets, bones.magnets, bones.

Anything a child can Anything a child can possibly grab and possibly grab and swallow is fair game!swallow is fair game!

Supine KUB of child with safety pin and key in jejunum and rubber doll head in descending colon From: Hunter, T. B. and M. S. From: Hunter, T. B. and M. S. TaljanovicTaljanovic (2003). (2003).

"Foreign bodies." "Foreign bodies." RadiographicsRadiographics 2323(3): 731(3): 731--57.57.


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FB ingestions by the numbersFB ingestions by the numbers

At diagnosis, 60% located in stomach, 20% located in At diagnosis, 60% located in stomach, 20% located in esophagus.esophagus.

Older children and male children more likely to Older children and male children more likely to spontaneously pass FB.spontaneously pass FB.

6060--90% spontaneously pass when located in distal 90% spontaneously pass when located in distal esophagus or below GE junction.esophagus or below GE junction.

Only 10Only 10--20% require endoscopic removal.20% require endoscopic removal.

66% of spontaneously passed 66% of spontaneously passed FBFB’’ss

are never found in are never found in stool by parents.stool by parents.

Previous surgery or congenital malformations (Previous surgery or congenital malformations (TEFTEF’’ss) ) increase risk of obstruction and complications.increase risk of obstruction and complications.


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Symptoms of FB ingestionSymptoms of FB ingestion

Most are asymptomatic! History is most important clue. Most are asymptomatic! History is most important clue.

Symptoms most often associated with location in upper Symptoms most often associated with location in upper esophagus.esophagus.

Acute Esophageal: Acute Esophageal: retrosternalretrosternal

pain, cyanosis, pain, cyanosis, dysphagiadysphagia, drooling, wheezing, , drooling, wheezing, stridorstridor, choking, , choking, vomiting, vomiting, hemoptysishemoptysis, decreased PO intake, gagging., decreased PO intake, gagging.

Chronic Esophageal: weight loss, recurrent aspiration Chronic Esophageal: weight loss, recurrent aspiration PNA.PNA.

Stomach or Bowel: Abdominal pain, bloody stool.Stomach or Bowel: Abdominal pain, bloody stool.


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Complications of FB IngestionComplications of FB Ingestion

Aspiration and airway obstructionAspiration and airway obstruction

Stricture or fistula formationStricture or fistula formation

GI obstruction, perforation, or bleedingGI obstruction, perforation, or bleeding

Erosion into esophagus, aorta, or other Erosion into esophagus, aorta, or other structuresstructures

DeathDeath


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Approach to FB IngestionApproach to FB Ingestion

We have our history, now what do we do?We have our history, now what do we do?


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Indications for imaging Indications for imaging

Previous recommendations: asymptomatic children Previous recommendations: asymptomatic children tolerating PO intake do not need radiographs.tolerating PO intake do not need radiographs.

However, 20% of asymptomatic patients had an However, 20% of asymptomatic patients had an esophageal FB.esophageal FB.

28% of esophageal coins pass spontaneously within 24 28% of esophageal coins pass spontaneously within 24 hours.hours.

Risk of complications increases with esophageal FB.Risk of complications increases with esophageal FB.

Current recommendations: ALL suspected foreign Current recommendations: ALL suspected foreign body ingestion patients need radiographs.body ingestion patients need radiographs.

Frontal radiograph of chest, KUB, and lateral Frontal radiograph of chest, KUB, and lateral radiograph of neck needed to image entire length of GI radiograph of neck needed to image entire length of GI tract.tract.


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Diagnosing Foreign BodiesDiagnosing Foreign Bodies

Opaque: glass, most metal except aluminum, Opaque: glass, most metal except aluminum, animal bones, food, soil.animal bones, food, soil.

NonopaqueNonopaque: Fish bones, wood, plastics, : Fish bones, wood, plastics, aluminum.aluminum.

Consider CT, US, or oral contrast for nonConsider CT, US, or oral contrast for non--

opaque objects.opaque objects.

Courtesy of Dr. Mark Waltzman, Children’s Hospital Boston


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Patient with nonPatient with non--radioradio--opaque FB opaque FB

20 month old boy with plastic spear in parapharyngeal space seen on axial CT with contrast.

Courtesy of Dr. Mark Waltzman, Children’s Hospital Boston


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Indications for removal of FB Indications for removal of FB

Patient SymptomaticPatient Symptomatic

Sharp or long (>5cm)Sharp or long (>5cm)

MagnetMagnet

Disk battery in Disk battery in esophagusesophagus

In esophagus >24 hoursIn esophagus >24 hours

In stomach >4In stomach >4--6 wks6 wks


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Techniques for RemovalTechniques for Removal

Choice depends on patientChoice depends on patient’’s s condition, surgeoncondition, surgeon’’s experience, s experience, location and type of FB.location and type of FB.

Flexible or rigid endoscopyFlexible or rigid endoscopy

Most successful methodMost successful method

Allows visualization of object Allows visualization of object (good for sharps)(good for sharps)

Risks: pharyngeal bleeding, Risks: pharyngeal bleeding, bronchospasmbronchospasm, accidental , accidental extubationextubation, , stridorstridor, hypoxia, , hypoxia, esophageal perforation, esophageal perforation, mediastinitismediastinitis

Magill forceps and laryngoscopeMagill forceps and laryngoscope

Allows visualization of object Allows visualization of object (good for sharps)(good for sharps)

Endoscopy and removal of esophageal coin

From: http://www.gastrointestinalatlas.com/ForeignbodyCoin3.jpg

10/18/08

Magill forceps and laryngoscopeMagill forceps and laryngoscope

From: http://www.ispub.com/xml/journals/ijorl/vol4n2/body-fig4.jpg

10/18/08

http://www.gastrointestinalatlas.com/ForeignbodyCoin3.jpg

http://www.ispub.com/xml/journals/ijorl/vol4n2/body-fig4.jpg


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Techniques for RemovalTechniques for Removal

BougienageBougienage

DilaterDilater

used to push object in used to push object in esophagus into stomachesophagus into stomach

No reported complicationsNo reported complications

Foley catheterFoley catheter

Deflated catheter passed Deflated catheter passed distally to FB, inflated, and distally to FB, inflated, and withdrawn under fluoroscopywithdrawn under fluoroscopy

1.8% complication rate: 1.8% complication rate: epistaxisepistaxis, emesis, transient , emesis, transient respiratory distressrespiratory distress

Penny pincherPenny pincher

Grasping object with forceps Grasping object with forceps through NGT under through NGT under fluoroscopyfluoroscopy

Lateral neck fluoroscopy showing Foley catheter

extraction of coin

under fluoroscopy From: Donnelly, L. F. (2001). Fundamentals of Pediatric Radiology. Philadelphia, W.B. Saunders Company.


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ObservationObservation

Acceptable if patient asymptomatic, FB not sharp or Acceptable if patient asymptomatic, FB not sharp or long (>5cm), not magnet, not esophageal battery. long (>5cm), not magnet, not esophageal battery.

2020--30% of esophageal 30% of esophageal FBFB’’ss

pass spontaneously.pass spontaneously.

Most Most FBFB’’ss

pass spontaneously after passing the narrow pass spontaneously after passing the narrow esophagus, pylorus and duodenal sweep.esophagus, pylorus and duodenal sweep.

Repeat radiograph in 8Repeat radiograph in 8--16 hours for esophageal FB. 16 hours for esophageal FB. Serial radiographs weekly for distal FB until it passes.Serial radiographs weekly for distal FB until it passes.

Endoscopic removal of FB if retained in esophagus Endoscopic removal of FB if retained in esophagus >16 hours or retained in stomach >4 weeks, or if >16 hours or retained in stomach >4 weeks, or if patient becomes symptomatic.patient becomes symptomatic.


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Special considerations for magnetsSpecial considerations for magnets

Multiple magnets attract across multiple loops of bowel Multiple magnets attract across multiple loops of bowel and cause pressure necrosis, ischemia, perforation, and cause pressure necrosis, ischemia, perforation, volvulusvolvulus..

From: KircherKircher, M. F., S. , M. F., S. MillaMilla, et al. (2007). "Ingestion of magnetic foreign bodies causing m, et al. (2007). "Ingestion of magnetic foreign bodies causing multiple bowel perforations." ultiple bowel perforations." PediatrPediatr

RadiolRadiol

3737(9): 933(9): 933--6.6.

Serial supine KUB’s

showing three magnets attracting each other across multiple bowel loops and causing a total of 6 perforations of bowel wall.


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Special considerations for magnetsSpecial considerations for magnets

Single magnet shouldnSingle magnet shouldn’’t t cause problems. cause problems.

Difficult to tell whether a Difficult to tell whether a single or multiple magnets single or multiple magnets have been ingested.have been ingested.

Suspect magnet ingestion Suspect magnet ingestion if metallic object fails to if metallic object fails to progress.progress.

Current recommendation: Current recommendation: ANY suspected magnet ANY suspected magnet ingestion should be ingestion should be removed.removed.

Various MagnetsFrom: http://www.global-b2b-

network.com/direct/dbimage/50242200/Alnico_Magnet.jpg


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Special considerations for button Special considerations for button batteriesbatteries

Higher risk of perforation, erosion, Higher risk of perforation, erosion, fistula, fistula, stenosisstenosis

if lodged in the if lodged in the esophagus.esophagus.

Electricity flow between both Electricity flow between both battery poles through contact of battery poles through contact of the tightly surrounding esophageal the tightly surrounding esophageal walls may cause liquefaction walls may cause liquefaction necrosis and perforation.necrosis and perforation.

Leakage of contents: acidic Leakage of contents: acidic environment may erode seal of environment may erode seal of battery and release heavy metals battery and release heavy metals and cause necrosis of membranes.and cause necrosis of membranes.

Lithium cell ingestions associated Lithium cell ingestions associated with most severe outcomes.with most severe outcomes.

Esophageal batteries should be Esophageal batteries should be removed immediately.removed immediately.

Distal batteries can be managed Distal batteries can be managed with observation and weekly with observation and weekly radiographs to ensure passage.radiographs to ensure passage.

Lithium button battery

From: http://img.alibaba.com/photo/10122824/Recharge_Lithium_Ion_Button_Battery.jpg


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Button batteries: Beware the Button batteries: Beware the ““coin coin fake outfake out””

•Look for “Halo Sign”

of button battery

PA CXR of Coin ingestion (left)

courtesy of Dr. Booya

BIDMC and Upright KUB

Battery ingestion (right)

courtesy of Dr. Waltzman

Children’s Hospital Boston


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Button batteries: Beware the Button batteries: Beware the ““coin coin fake outfake out””

On lateral, On lateral, battery shows battery shows ““step off appearance of edgesstep off appearance of edges””

while while coin has sharp coin has sharp edgesedges

Lateral CXR of Battery ingestion

Courtesy of Dr. Marc Baskin, Children’s Hospital BostonLateral neck fluoroscopy of two coin ingestion, Courtesy of Dr. Fargol

Booya, BIDMC


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We have a systematic approach to We have a systematic approach to pediatric FB ingestionspediatric FB ingestions

Now letNow let’’s go take care of our patientss go take care of our patients


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Management of our first patientManagement of our first patient

7 year old 7 year old assymptomaticassymptomatic boy with small, nonboy with small, non--

sharp, gastric metallic toy sharp, gastric metallic toy on KUB.on KUB.

Patient discharged home Patient discharged home with instructions to with instructions to return if he became return if he became symptomatic. symptomatic.

F/u KUB in 1 week.F/u KUB in 1 week.Supine KUB of FB in stomachCourtesy of Dr. Mark Waltzman, Children’s Hospital Boston

Battle ship


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Management of our second patientManagement of our second patient••

11 month old asymptomatic girl with esophageal hair clip on 11 month old asymptomatic girl with esophageal hair clip on CXR.CXR.

••

Admitted to surgery for rigid endoscopic removal of sharp, Admitted to surgery for rigid endoscopic removal of sharp, long object.long object.

Courtesy of Dr. Mark Waltzman, Children’s Hospital BostonLateral neck plain film of FB in esophagus PA CXR of FB in esophagus


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Management of our third patientManagement of our third patient

3 year old symptomatic girl with esophageal FB on CXR.3 year old symptomatic girl with esophageal FB on CXR.

ORL consulted for endoscopic removal and discovered ORL consulted for endoscopic removal and discovered lithium battery surrounded by friable mucosal tissue. lithium battery surrounded by friable mucosal tissue.

Barium swallow normal, no sign of stricture or fistula.Barium swallow normal, no sign of stricture or fistula.

Courtesy of Dr. Marc Baskin, Children’s Hospital Boston

PA CXR with FB in esophagus Lateral CXR with FB in esophagus


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Summary of Approach to Pediatric Summary of Approach to Pediatric FB IngestionFB Ingestion

1.1.

Radiographs are indicated for ALL patients with Radiographs are indicated for ALL patients with suspected FB ingestion. Consider CT or US for nonsuspected FB ingestion. Consider CT or US for non--

opaque opaque FBFB’’ss. . 2.2.

Immediate removal indicated for all symptomatic Immediate removal indicated for all symptomatic patients or for sharp, long (>5cm), magnet, or patients or for sharp, long (>5cm), magnet, or esophageal battery esophageal battery FBFB’’ss. .

3.3.

Patients who do not meet these criteria may be Patients who do not meet these criteria may be observed with repeat CXR in 8observed with repeat CXR in 8--16 hrs for esophageal 16 hrs for esophageal FBFB’’ss

and weekly KUB for distal and weekly KUB for distal FBFB’’ss. .

4.4.

Endoscopic removal indicated if FB remains in Endoscopic removal indicated if FB remains in esophagus >16 hours or in stomach >4 weeks or if esophagus >16 hours or in stomach >4 weeks or if patient becomes symptomatic. patient becomes symptomatic.


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AcknowledgementsAcknowledgements

Dr. Mark Dr. Mark WaltzmanWaltzman

and Dr. Marc Baskin, and Dr. Marc Baskin,

ChildrenChildren’’s Hospital Boston Emergency s Hospital Boston Emergency MedicineMedicine

Dr. Dr. FargolFargol

BooyaBooya, BIDMC Radiology, BIDMC Radiology

Dr. Gillian Lieberman, BIDMC RadiologyDr. Gillian Lieberman, BIDMC Radiology

Dr. Dr. RivkaRivka

ColenColen, Massachusetts General , Massachusetts General

Hospital RadiologyHospital Radiology

Maria Maria LevantakisLevantakis, BIDMC Radiology , BIDMC Radiology

Larry Larry BarbarasBarbaras, BIDMC Webmaster, BIDMC Webmaster


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pediatric foreign body ingestions kara wong,...

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