Pediatric emergency medicine trisk 0678 0678
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ingestion), it is reasonable to allow an observation period of 8 to 16 hours for
spontaneous passage of round, noncorrosive foreign objects such as coins in the
asymptomatic patient with no history of esophageal disease.
Removal techniques for esophageal foreign bodies vary by institution and
depend on the duration of impaction, associated symptoms, and the nature of the
foreign body. Traditional removal methods include flexible endoscopy, rigid
esophagoscopy, and usage of Magill forceps. Endoscopy has been proven to be
safe and effective, is applicable to all types of foreign bodies, allows for direct
examination of the esophageal lumen, and can be used in patients with respiratory
distress. Other less common methods employed for the retrieval of coins and
similar objects include insertion of a balloon-tipped catheter beyond the foreign
body to extract the object, bougienage to advance the object into the stomach, and
fluoroscopic-guided grasping endoscopic forceps covered by a soft rubber
catheter. These alternative removal or advancement methods, though less costly
than endoscopy, carry a risk of complications. They should only be attempted by
clinicians familiar with the techniques for removal of noncorrosive, blunt objects
that have been lodged less than 2 days. The use of glucagon to relax the lower
esophageal sphincter and facilitate foreign-body passage into the stomach is
controversial. Studies have found equivocal results and the use of glucagon is
generally not recommended except in cases of distal esophageal coins when
endoscopy is not readily available.
Stomach and Lower Gastrointestinal Tract
Watchful waiting is appropriate for most foreign bodies of the stomach and lower
GI tract if the patient is asymptomatic. Though most sharp objects will pass
through the GI tract without complications, endoscopic removal should be
considered if the object is within the reach of the endoscope due to the significant
risk of morbidity and mortality. Large (>2.5 cm in diameter) and/or long objects
(>6 cm in length) within the reach of the endoscope should also be removed,
since a large object is unlikely to pass through the pylorus and a long object is
unlikely to either clear the duodenal sweep or pass through the ileocecal valve. If
a large, long, or sharp object has passed out of the stomach of an asymptomatic
patient at the time of evaluation and is not within the reach of the endoscope,
serial abdominal radiographs every 2 to 3 days and serial examinations should be
considered to ensure uneventful passage. Most round objects, such as coins, will
traverse the GI tract in 3 to 8 days without any complications. Some providers
advocate examination of the stool for the foreign body at home, with a follow-up
radiograph in 2 weeks if the foreign body has not passed. Occasionally, innocuous
