Young children often place nonfood items in their mouths. When these items are swallowed, they may become lodged in the esophagus at the thoracic inlet or at the LES. The most common objects are coins. Smaller coins may pass harmlessly into the stomach, where they rarely cause symptoms. Other common esophageal foreign bodies include food items, small toys or toy parts, disk batteries, and other small household items. Children with a prior history of esophageal atresia or with poor motility secondary to GER or eosinophilic esophagitis are more prone to food impactions, which seldom occur in the normal esophagus.
Some children are asymptomatic, but most exhibit some degree of drooling, food refusal, or chest discomfort. Olderchildren usually can point to the region of the chest wherethey feel the object to be lodged. Respiratory symptomstend to be minimal, but cough or wheezing may be present,especially when the esophagus is completely blocked by alarge object, such as a piece of meat, which presses on thetrachea.
Plain chest and abdominal radiographs should be taken when foreign body ingestion is suspected. Metallic objectsare easily visualized. A plastic object often can be seen if thechild is given a small amount of dilute x-ray contrast material to drink, although endoscopy is probably safer and moredefinitive.
Endoscopy is ultimately necessary in most cases to remove an esophageal foreign body. Various devices can be used to remove the object, depending on its size, shape, and location.Coins usually are grasped with special-purpose forceps andremoved. Nets, baskets, and snares also are available. Whenever objects that may threaten the airway are being recovered, endoscopy should be performed with endotrachealintubation and under general anesthesia. Removal is usually not necessary if the object is small and in the stomachas it will most likely pass without complication. Endoscopyis emergent for removal of any esophageal foreign body ifsymptomatic or if the ingested foreign body is a suspecteddisc battery in the esophagus or multiple magnets located inthe upper tract.
Sharp objects may lacerate or perforate the esophagus; smooth objects present for a long time also may result in perforation due to ulceration. Corrosive objects, such as zinc-containing pennies and disc batteries, can cause considerable local tissue injury and esophageal perforation. Magnets can lead to perforation and fistula formation when they connect between adjacent loops of bowel.
In adolescents, caustic ingestion injuries are usually the result of suicide attempts. In toddlers, ingestion of household cleaning products typically is accidental. Injurious agents include drain cleaners, toilet bowl cleaners, dishwasher detergents, and powerful bleaching agents. Childproof lids for commercial products offer some protection, but have not eliminated the problem. Lye-based drain cleaners, especially liquid products, cause the worst injuries because they are swallowed easily and liquefy tissue rapidly. Full-thickness burns can occur in seconds. Granular products are less likely to cause esophageal injury during accidental exposures because they burn the tongue and lips and often are expelled before swallowing. Less caustic agents, such as bleach and detergents, cause less serious injury. Pill ulcers occur when certain medications (tetracyclines and nonsteroidal anti-inflammatory drugs [NSAIDs]) are swallowed without sufficient liquids, allowing prolonged direct contact of the pill with the esophageal mucosa.
Caustic burns cause immediate and severe mouth pain. The childcries out, drools, spits, and usually drops the container immediately. Burns of the lips and tongue are visible almost immediately.These burns clearly indicate the possibility of esophageal involvement, although esophageal injury can occur in the absence oforal burns. Symptoms may not be present; further evaluationby endoscopy usually is indicated with any significant history ofcaustic ingestion. Pill injury causes severe chest pain and oftenprominent odynophagia (painful swallowing) and dysphagia.