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Esophageal Foreign Bodies

By Aaron E. Walfish, MD, Beth Israel Medical Center;Mount Sinai Medical Center

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Food and a variety of other swallowed objects can become impacted in the esophagus. Esophageal foreign bodies cause dysphagia and sometimes lead to perforation. Diagnosis is clinical, but imaging studies and endoscopy may be needed. Some objects pass spontaneously, but endoscopic removal is often required.

The esophagus is the most common site of foreign body impaction. Food impactions cause most esophageal foreign bodies. Large, smooth food pieces (eg, steak, hot dogs) are particularly easy to swallow inadvertently before being chewed sufficiently. Bones, particularly fish bones, may be swallowed if the meat in which they are embedded is not chewed sufficiently.

Infants and toddlers do not have fully mature oropharyngeal coordination and often inadvertently swallow small, round foods (eg, grapes, peanuts, candies), which may become impacted. In addition, infants and toddlers often swallow a wide variety of inedible objects (eg, coins, batteries), some of which become impacted in the esophagus. Impacted disc batteries are particularly worrisome because they may cause esophageal burns, perforation, or tracheoesophageal fistula.

Foreign bodies in the esophagus usually lodge in areas where physiologic or pathologic luminal narrowing exists. Luminal narrowing may be caused by webs, rings, strictures, benign and cancerous tumors, achalasia, and eosinophilic esophagitis.

Complications

The main complications of esophageal foreign bodies are

Obstruction may be partial (eg, patient can swallow liquids or at least their oral secretions) or complete. Partial obstruction is less emergent unless it involves a sharp object embedded in the wall, which can lead to perforation. Complete obstruction is poorly tolerated clinically, and even a smooth object, if tightly impacted, may cause pressure necrosis and risk of perforation if allowed to remain in the esophagus for more than about 24 h.

Complications also depend on the nature of the object involved. Despite their small size, impacted disk or button batteries are objects of particular concern because liquefaction necrosis and perforation can occur rapidly.

Symptoms and Signs

The main presenting symptom is acute dysphagia. Patients with complete obstruction of the esophagus hypersalivate and are unable to swallow oral secretions. Other symptoms include retrosternal fullness, regurgitation, odynophagia, blood-stained saliva, and gagging and choking. Hyperventilation resulting from anxiety and discomfort often gives the appearance of respiratory distress, but actual dyspnea or auscultatory findings of stridor or wheezing strongly suggest the foreign body is in the airway rather than the esophagus.

Sometimes, foreign bodies scratch the esophagus but do not become lodged. In such cases, patients may report a foreign body sensation even though no foreign body is present.

Diagnosis

  • Clinical evaluation

  • Sometimes imaging studies

  • Often endoscopic evaluation

Many patients give a clear history of ingestion; those with significant symptoms suggesting complete obstruction should have immediate therapeutic endoscopy. Patients with minimal symptoms who are able to swallow normally may not have an impacted foreign body and can be observed at home for resolution of symptoms. Other patients may require imaging studies.

Some patients, such as young children, mentally impaired adults, and those with psychiatric illness, may not be able to give an adequate history of ingestion. These patients may present with choking, refusal to eat, vomiting, drooling, wheezing, blood-stained saliva, or respiratory distress. Imaging studies also may be needed in these patients.

Some foreign bodies can be detected with plain x-rays (2 views preferred). These x-rays are best for detecting metallic foreign objects and steak bones as well as for detecting signs of perforation (eg, free air in the mediastinum or peritoneum). However, fish bones and even some chicken bones, wood, plastic, glass, and thin metal objects can be difficult to identify on plain x-rays. If there is any suspicion at all of a sharp or dangerous esophageal foreign body, imaging studies, such as CT, should be done to identify the foreign body. However, endoscopic evaluation is required in patients with suspected foreign body ingestions and ongoing symptoms despite negative imaging results. A contrast study typically should not be done because of the risk of aspiration and concern about the presence of residual contrast material making subsequent endoscopic retrieval more difficult.

Treatment

  • Sometimes trial of observation and/or IV glucagon

  • Often endoscopic removal

Some foreign bodies pass spontaneously into the stomach, after which they typically pass completely through the GI tract and are expelled. Patients without symptoms of high-grade obstruction and without ingestion of sharp objects or disk or button batteries typically can safely be observed for up to 24 h to await passage, which is indicated by relief of symptoms. Administration of glucagon 1 mg IV is a relatively safe and acceptable option that sometimes allows for spontaneous passage of a food bolus by relaxing the distal esophagus. Other methods, such as use of effervescent agents, meat tenderizer, and bougienage, are not recommended.

Foreign bodies that do not pass within 24 h ( 1) should be removed because delay increases the risk of complications, including perforation, and decreases the likelihood of successful removal.

Endoscopic removal is the treatment of choice. Removal is best achieved using a forceps, basket, or snare, preferably with an overtube placed in the esophagus or orotracheal intubation to prevent aspiration and protect the airway.

Emergent endoscopy is required for sharp-pointed objects, disk or button batteries, and any obstruction causing significant symptoms.

Follow-up care for the evaluation of structural and functional abnormalities is recommended for patients with esophageal food impaction.

Treatment reference

1. ASGE Standards of Practice Committee, Ikenberry SO, Jue TL, Anderson MA, et al : Management of ingested foreign bodies and food impactions. Gastrointest Endosc 73:1085–1091, 2011. doi: 10.1016/j.gie.2010.11.010.

Key Points

  • The esophagus is the most common site of ingested foreign body impaction.

  • The main presenting symptom is acute dysphagia; patients with complete obstruction of the esophagus hypersalivate and are unable to swallow oral secretions.

  • Complete obstruction may cause pressure necrosis and increases the risk of perforation if present for more than about 24 h.

  • Emergent endoscopy is required for sharp-pointed objects, disk or button batteries, and any obstruction causing significant symptoms.

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* This is the Professional Version. *