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Esophageal foreign bodies by drtbalu

Introduction:

Esophageal foreign bodies are not so dangerous as air way foreign bodies.  But this is a very common problem among children and
elderly.  Anatomically these foreign bodies  are commonly found at the various natural constrictions of oesophagus (i.e. cricopharynx,
at the cross over of the aortic arch at the level of mid esophagus, and at the lower end of esophagus). 

Classification of patients with esophageal foreign bodies:

1. Pediatric patients
2. Psychiatric patients
3. Patients with underlying esophageal disorders like malignancy
4. Edentulous patients (elderly)



Figure showing coin at the level of cricopharynx

Clinical presentation:

This depends on whether the patient is a child or adult.  Adults usually describe the event clearly and acknowledge the possibility
of the presence of foreign body in the food passage.  Children tend to be pretty vague about their complaints, and invariably even
asymptomatic. 
In children symptoms include:
1. Irritability
2. Poor feeding
3. Drooling
4. Chest pain
5. Coughing

In most paediatric patients foreign bodies in the food channels are incidental findings in a routine chest radiograph.  If the foreign body is
entrapped at the level of cricopharynx, patient may be able to accurately localize the location of it, where as lower esophageal foreign bodies
do not cause definable symptoms like chest pain or pressure.

Respiratory symptoms due to esophageal foreign body is common in children because of their small and compressible tracheal lumen.  These
symptoms include stridor, coughing, and labored breathing.

Physical examination:

This does not play an important role in establishing the diagnosis.  Children with oesophageal foreign body tends to drool.  Clinical examination
is usually unremarkable in most of these patients. 

Role of radiography:

Main diagnostic tool in oesophageal foreign bodies is radiography.  Commonly these foreign bodies tend to be radio opaque.  coins are commonly
ingested by children.  Food products are the other commonly encountered foreign body.  Plain radiographs in these patients may demonstrate
bone / cartilage present in the food elements. 

Both antero posterior and lateral views must necessarily be performed to localize the foreign body.  If plain films are not diagnostic then barium swallow
should be performed.
     *Caution:  Gastrograffin should not be used because it may cause severe chemical pneumonitis if aspirated.




Figure showing radio opaque foreign body at the level of cricopharynx (chicken bone)

Treatment:

Following factors should be considered in the management of foreign body oesophagus - less urgent cases:

a. Type / location of the ingested foreign body
b. Interval between ingestion and presentation
c. Age of the patient

Ingestion of caustic foreign bodies like button batteries should be considered as an emergency.  Delay in these patients may lead to esophageal
perforation.

Sharp metallic objects like pins, needles, razor blades, and nails should always be removed under controlled operating room conditions.



Figure showing safety pin at the level of cricopharynx

Endoscopic removal of foreign bodies:

Foreign bodies impacted at the level of cricopharynx should be removed using an upper esophageal speculum.  This can be performed
either under local / general anesthesia.  Foreign bodies of esophagus can be removed using an oesophagoscope.  General anesthesia
is preferred in these patients because it can cause adequate relaxation making the passage of oesophagoscope smooth and atraumatic. 
Local anesthesia can be used if flexible oesophagoscope is used. 

Balloon catheters can be used to extract impacted foreign body in the oesophagus.  This method can be used only if the foreign body
ingested is single, smooth and radio opaque.  These patients should have no history of esophageal disorder / injury.
This procedure is performed by placing the patient in head down position.  The catheter is passed nasally or orally under fluroscopic
guidance past the foreign body.  The balloon is inflated with a radio opaque solution and is slowly pulled out along with the foreign body
under fluoroscopic guidance.

Complications of oesophagoscopy:

1. Oesophageal trauma
2. Mediastinitis
3. Aorta oesophageal fistula
4. Pneumothorax
5. Tracheo oesophageal fistula






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