Pediatric foreign bodies and their management

Food refusal in 1-year-old child

This is a case report of a 1-year-old, otherwise healthy, girl who presented with the history of refusal of solid foods and vomiting of 1-month duration. She underwent upper gastrointestinal endoscopy, which revealed an eye-catching endoscopic finding and the cause of her symptoms.

Removal of a sewing needle from an occult esophageal ingestion in a 9-month-old

A healthy 9-month-old boy presented with a 1-month history of cough. A chest x-ray showed a linear metallic foreign body (FB) lying transversely in the posterior mediastinum. Computed tomographic scan confirmed the location and size of the metallic FB and also revealed a large pericardial effusion that was corroborated by echocardiogram. The patient underwent a right thoracotomy revealing a normal esophagus without mediastinitis and a 12-mm needle in the posterior mediastinum embedded in the pericardium with the sharp end abutting the left atrium. The needle was extracted uneventfully, and his postoperative course was unremarkable. The diagnosis and treatment for this case are discussed along with a review of the literature.

[Foreign body perforation of the thoracic esophagus]

BACKGROUND

Esophageal perforation due to foreign body (FB) ingestion is an unusual occurrence. This study aims to define diagnostic difficulties of esophageal perforation by FB.

PATIENTS AND METHODS

A chart review of patients on our service with FB esophageal perforation was carried out. Diagnosis of perforation was made by CT scan and/or esophagoscopy. Surgery was indicated when a FB could not be removed endoscopically or on a case-by-case basis according to clinical/laboratory, radiologic, and/or endoscopic findings.

RESULTS

Seven patients (age range: 27 to 80 years) were admitted for esophageal FB perforation. All patients presented with dysphagia. Two patients presented with signs of sepsis more than 24 hours after FB ingestion. Perforation was diagnosed at initial evaluation in five cases (three by endoscopy, two by CT) and after FB extraction in two cases. Six patients underwent surgery (suture repair: n=4; esophageal exclusion: n=1; mediastinal drainage: n=1). Five surgeries were performed at the initial diagnosis and one after failure of medical management. Mortality was zero; one patient developed esophageal fistula.

CONCLUSION

Diagnosis of FB esophageal perforation is difficult and is delayed in up to a quarter of patients. The perforation can be due to the FB itself or may be incurred during endoscopic extraction. Both CT and endoscopy are necessary for diagnosis and treatment. Most patients require surgical intervention.

Selected topics in the evaluation of pediatric gastrointestinal mucosal biopsies

The practice of pediatric gastrointestinal pathology provides specific challenges to the pathologist. Often the clinical information accompanying a biopsy specimen will read simply, "failure to thrive." Other situations, such as the evaluation of a neonate's rectal suction biopsy for Hirschsprung disease, are notorious for providing diagnostic challenges in high-pressure situations. In this review, we will discuss several commonly encountered situations in pediatric pathology: the evaluation of pediatric esophageal eosinophilia, a child who has swallowed a non food item, caustic substance, or hot liquid, the evaluation of a pediatric colorectal biopsy with focal active colitis, and the evaluation of rectal suction biopsies for Hirschsprung disease. With each topic, we will discuss a general approach to the case, diagnostic tips, and how to avoid commonly encountered pitfalls. Finally, we highlight key references pertinent to these issues that can he used to help convey pathologic findings to pediatric gastroenterologists.

[Ingestion of foreign bodies in children. Recommendations of the French-Speaking Group of Pediatric Hepatology, Gastroenterology and Nutrition]

Ingestion of foreign bodies is a common pediatric problem. The majority of ingested foreign bodies pass spontaneously. Management of foreign body ingestions varies based upon the object ingested, its location, and the patient's age and past history. Esophageal foreign bodies should be urgently removed because of their potential to cause complications. Ingested batteries that lodge in the esophagus, sharp or pointed foreign bodies in the esophageal or gastric tract, and ingestion of multiple magnets all require urgent endoscopic removal. Flexible endoscopy is the therapeutic modality of choice for most patients. The use of devices such as a latex protector hood or an overtube may facilitate safer extraction of sharp objects.

Multiple oesophageal foreign bodies: the importance of two radiological views

OBJECTIVES

To demonstrate the importance of two radiological views in the assessment of oesophageal foreign bodies.

CASE REPORT

The case of a child with multiple oesophageal foreign bodies appearing as a single object on an antero-posterior chest radiograph is used to illustrate the need for two radiological views in the assessment of such cases.

CONCLUSIONS

Two radiological views are recommended in the assessment of oesophageal foreign bodies.

Overtubes in gastrointestinal endoscopy

Gastrointestinal endoscopy is an evolving field kindled by technologic advances, scientific discoveries, and the innovative minds of endoscopists. The development and subsequent applications of overtubes in gastrointestinal endoscopy mirror this larger evolution. In this article, we review the development, applications, and complications associated with overtubes in gastrointestinal endoscopy.

Toy magnet ingestion in children: revising the algorithm

The widespread popularity of magnetic toy sets has resulted in increased reports of magnet ingestion and subsequent complications. Traditional algorithms for ingested foreign bodies have advocated passage of these objects through the gastrointestinal tract spontaneously. In regard to magnet ingestion, the unique mechanism of pathogenesis, attraction of 2 or more magnets across multiple loops of bowel, has led to several cases of intestinal perforation caused by bowel wall erosion and necrosis between the magnets. Unfortunately, a misdiagnosis and misconception that a solitary magnet has been ingested may lead to a delay in diagnosis and subsequent severe and possibly preventable complications. We report a case in which a child presented having thought to have ingested a solitary magnetic toy from a magnet construction set. This resulted in the premature discharge from the hospital and the patient's subsequent return with an intraabdominal perforation resulting in an emergency laparotomy. The recent increase of case reports related to magnet ingestion has resulted in proposed treatment regimens for patients ingesting multiple magnets. We would also initiate the magnet algorithm if even presumably a single magnet was ingested. This would include close observation and early intervention, either with endoscopy or surgical exploration, which would theoretically prevent the more severe complications, reported in the literature.

Emergency endoscopic management of dietary foreign bodies in the esophagus

OBJECTIVE

We report our experience of endoscopy in the emergency management of dietary foreign bodies.

METHODS

One hundred thirty-six patients were admitted to the emergency department (ED) between January 1997 and October 2006 for the endoscopic removal of esophageal dietary foreign bodies. They had a mean age of 47.7 years, and 91 (67%) were women.

RESULTS

Most of the ingested materials (98.5%) were successfully extracted using either flexible or rigid endoscope. The objects most frequently ingested were fish bones (48%) and chicken bones (46%). Most of the objects (84%) were lodged in the upper esophagus. Two patients with irretrievable foreign bodies or complicated perforations were taken to surgery.

CONCLUSION

Because most of these foreign bodies lodged in the upper esophagus, physicians should take care of this area to avoid secondary injury or complications, especially with sharp bones.

Emergency endoscopy in children

Endoscopy in children has developed along with pediatric gastroenterology over the last four decades. Introduction of endoscopic techniques in adults precedes application in children, and pediatric endoscopists do fewer procedures than their adult counterparts whether routine or as an emergency. Training for pediatric endoscopists therefore needs to be thorough. This article in particular highlights developments in pediatric gastroenterology of importance to emergency procedures.

Gravel gut: small bowel perforation due to a blunt ingested foreign body

The ingestion of foreign bodies remains a common occurrence in children. Most ingested foreign bodies pass spontaneously, although up to 1% will result in intestinal perforation. Specific foreign bodies such as sharp, pointed, or corrosive objects have been typically associated with perforation. The initial diagnosis of foreign body ingestion may be difficult in the absence of a witness, and the presentation of perforation in this situation difficult to distinguish from other causes of an acute abdomen. We report a case of ileal perforation due to a blunt ingested foreign body in a child in whom the diagnosis was unclear until laparotomy. This case highlights the difficulties in managing pediatric ingested foreign bodies, including the risk of perforation even with a blunt object.

Calcific parasite or surgical miscellany?

This article highlights the difficulties posed by initial radiological investigations that misleadingly interpreted a linear opacity in the ascending colon of a 2-year-old to be a complicating calcified Ascaris. Final surgical management revealed an unusual cause for the tram tracking effect so pathognomonic of Ascaris infestation. Of interest are the images of the abdominal x-ray, ultrasound scan, and barium study.

A surgeon in your corner

The surgical emergencies presented in this article encompass the vast majority of the nontraumatic emergencies seen by a pediatric surgeon but represent only a small proportion of surgical disease in children. Most children seeking outpatient medical care do not need a surgeon, but those who do need one quickly. When one of the processes detailed above is suspected, it is always best to avail oneself of the opinion of a surgeon in a timely manner.