Foreign body and chemical ingestion
Key points
Areas of oesophageal narrowing
Cricopharyngeus sling - between clavicles, zone of change from skeletal to smooth muscle
Aortic arch- mid oesophagus
Lower oesophageal sphincter
Button battery in oesophagus
Current produces sodium hydroxide at anode - causes Liquefactive necrosis
Maximum effects at 6 hours
Neutralised by stomach acid
Lithium batteries have higher voltage and cause same mucosal damage
If object stuck in oesophagus at age >5 - may represent underlying anatomical narrowing
Aspirated foreign bodies
Foreign Body in the airway
Can be anything: Usually liquid in infant and solid in Toddler.
Peanut aspirations are particularly dangerous as oil leak can cause severe reactions in a short period of time and retrieval is difficult
In Adolescents and Adults, right main bronchus is more obtuse with larger diameter and greater airflow and thus foreign bodies are more prone in the right chest
In children, there is an equal chance as the two main bronchi have the same characteristics
Prevention: Legislation, Vigilance, Awareness
Prompt intervention is the key
Look for hyperinflated lung on XR - indicates foreign body in main bronchus - 'ball-valve effect'
Management of Foreign Body Aspirations
Resuscitation
General Anaesthesia
Locate
Retrieve
Recheck
Admit
Observe
Follow up
Resuscitation
Choking Child: If effective cough: Encourage cough and support:
If no effective cough: Conscious: 5 Back blows 5 Chest thrusts
Abdominal thrusts: Unconscious: BLS protocol
Open Airway 5 rescue breaths
15:2 CPR
If all else fails: Needle cricothyroidotomy: Surgical cricothyroidotomy.
General Anaesthesia
Locate the foreign Body
Flexible bronchoscope or Rigid Ventilating Bronchoscope
Retrieve
Optical grasping forceps
Dormia basket
Fogarty Catheter
Difficult retrieval: Cervical tracheotomy, Bronchotomy, Lobectomy
Recheck
For any residual foreign body
May need to aspirate fluid collections
Admit the child.
Child may need Oxygen, Antibiotics and Physiotherapy
Review
Pneumonia, Collapse and Bronchiectasis are possible complications
Follow up.
Any persistent symptoms, chest examination, Chest X ray
Coughing most common symptom
Doezel–Huzly bronchoscope + Hopkins rod-lens telescope or Holinger ventilating bronchoscope is commonly used for retrieval
Learn how to assemble:
Caustic ingestion
A pH >12 or <1.5 is associated with severe corrosive injuries
Oesophageal injury without any evidence of oropharyngeal injury can occur in up to 10% of cases
Acids
Often bad tasting, so only small amounts ingested
Coagulative necrosis - often limited to muscle layer
Most injuries occur in the antrum of the stomach and tend to be worse when the stomach is empty
Causes most damage in the antrum of the stomach - due to pooling after pylorospasm
Alkalis
Often tasteless and odourless - so large quantities can be ingested.
Liquefactive necrosis - may extend through the muscle layer
Sites of most damage at areas of hold up: cricopharyngeal area, level of aortic arch and left main stem bronchus, and immediately proximal to the GOJ
Do not give neutralising chemicals
Management of caustic ingestion
Secure airway
Do pan endoscopy 24-48 hours after injury to allow demarcation, but not so long that perforation is a risk
Only go as far as first significant injury to avoid perforations
Place NG if severe injury
PPI
NBM not necessary if can swallow and no severe injuries
Contrast in 1 week
Follow up for stricture and malignancy
Manage stricture accordingly
Consider fundo if concurrent reflux
Lactobezoar
Neonatal pathology
Happens with all kinds of milk
Treatment is NBM, IV fluids, repeat imaging in several days
Laparotomy and enterotomy is sometimes required
Standard scenario
Button battery in oesophagus
Concern is aorto-enteric fistula
Ensure child is resuscitated A-E
If already evidence of GI bleeding:
Activate major haemorrhage protocol
Inform critical care
Take to theatre for emergency endoscopy
Upper GI bleeding specialist and Cardiothoracic surgery should attend theatre
Ensure Sengstaken-Blakemore/Minnesota tube is available
If no evidence of GI bleeding and short history:
Take to theatre for emergency endoscopy with Upper GI bleeding specialist
Ensure Sengstaken-Blakemore/Minnesota tube is available
Post op
If button battery on posterior wall of oesophgus (near aorta) - ensure MRI aortogram is arranged for 2-4 weeks to ensure no fistula development - discuss with Cardiothoracics if present
If button battery on anterior wall of oesophagus (near trachea) - ensure follow up for tracheo-oesophageal fistula
If found or fistula already present - place NG tube and feed - perform repeat endoscopy/contrast at 4 weeks to check for closure
If remains patent, plan for closure of fistula by cervical/thoracic approach - may need interposition flap
Special scenario - Rectal foreign body
Check for non-accidental injury, inform safeguarding if needed
AXR for position and signs of perforation
May descend - can follow with serial XR
If low, can do EUA +/- endoscopic retrieval with a snare
Laparotomy if perforation or rectal injury +/- colostomy
Special scenario - Trichobezoar
Presents with vomiting + mass
Ask about hair ingestion, ingestion of other materials e.g., textiles
Perform CT to confirm diagnosis and look for hair emboli in rest of bowel
Examination and assessment of nutritional status
Check albumin and iron studies
Amylase - if duodenal extension of hair (Rapunzel syndrome), may get pancreatitis
Manage with upper midline laparotomy + gastrotomy
May need further enterotomies if hair emboli
If malnourished - place central line and start parenteral nutrition
Post op concern is breakdown of gastrotomy - this risk is increased by malnutrition
Follow up should include psychiatric and nutritional support
Page edited by Mrs Charnjit Seehra BSc January 2025
Page edited by Prof. Ashok Daya Ram MBBS, FRCS, FRCPS, FEBPS, FRCS (Paed Surgery), Consultant Paediatric and Neonatal Surgeon, Norfolk and Norwich University Hospital, Norwich, UK. January 2025
References
Dorterler ME, Günendi T. Foreign Body and Caustic Substance Ingestion in Childhood. Open Access Emerg Med. 2020 Nov 4;12:341-352. doi: 10.2147/OAEM.S241190. PMID: 33177894; PMCID: PMC7649222.