Esophageal Foreign Body

Etiology

Esophageal foreign body impaction in children most commonly results from accidental ingestion during exploratory behavior. Young children frequently place objects in the mouth, resulting in ingestion of small objects, such as coins, small toys, beads, button batteries, and magnets. Food impaction also occurs, particularly after ingestion of inadequately chewed food or large food boluses. The risk is highest among toddlers and preschool-aged children because of limited coordination, incomplete dentition, and a tendency to swallow without adequate chewing. Additional risk factors include unsupervised play, access to small household objects, and developmental delays or neurobehavioral conditions that impair judgment or oral motor control.

Unlike adults, children are less likely to have intrinsic esophageal disease, although congenital esophageal anomalies, strictures, and eosinophilic esophagitis predispose some children to recurrent impactions. Button batteries and magnets warrant particular concern because of the risk of rapid tissue injury, including pressure necrosis, perforation, fistula formation, and, in the case of button batteries, systemic toxicity. Pediatric esophageal foreign body impaction primarily reflects behavioral risk factors and environmental exposures, with a smaller contribution from underlying structural or inflammatory esophageal disorders than in adults.

The esophagus is a 20- to 25-cm muscular tube extending from the hypopharynx to the stomach (see Image. Digestive and Respiratory Structures Anatomically Related to the Esophagus). The esophageal wall consists of a mucosal lining and an outer muscular layer, with striated muscle proximally and smooth muscle distally. Natural esophageal narrowing predisposes to foreign body impaction, although most ingested objects that reach the stomach pass without intervention. Foreign body types vary by geographic region and dietary habits. For example, fish bones are a frequent cause in parts of East Asia.[4][5][6]

Epidemiology

Children account for approximately 80% of emergency department visits for esophageal foreign bodies.[7] Incidence is highest among older infants and toddlers, reflecting the tendency to place readily accessible objects in the mouth. Peak risk occurs between 6 months and 6 years of age, with most cases affecting children younger than 3 years.[8]

Esophageal foreign body impactions in children are usually accidental and involve small objects, including coins, pins, needles, button batteries, toy parts, crayons, marbles, bones, large food boluses, and jewelry. Coins are the most commonly ingested object.[9] Most affected children have normal esophageal anatomy. However, underlying conditions, including eosinophilic esophagitis, previous esophageal atresia repair, and prior Nissen fundoplication, increase the risk of impaction.[10]

In contrast, esophageal impaction in adults most commonly results from food boluses, particularly meat, with an estimated annual incidence of 13 per 100,000. Most impactions occur in the distal esophagus at sites of preexisting pathology, including diverticula, webs, rings, strictures, tumors, eosinophilic esophagitis, achalasia, scleroderma, and esophageal spasm. Therefore, adults with a history of food impaction should undergo follow-up esophageal evaluation, even after spontaneous symptom resolution.[11] A subset of adults presents after intentional foreign body ingestion related to self-harm or concealment of substances.

Pathophysiology

The esophagus has 3 physiologic points of narrowing where foreign bodies most commonly become impacted. These sites include the following:

• UES, which contains the cricopharyngeus muscle at the C6 level
• Midesophagus at the level of the aortic arch, at approximately the T4 level
• LES at the T10 to T11 level

Approximately 74% of pediatric foreign bodies become impacted at the UES, whereas about 68% of adult impactions occur in the distal esophagus and are frequently associated with underlying structural pathology.[12] The level of the left mainstem bronchus is another common site of impaction. 

Complications range from local mucosal damage to life-threatening extraluminal injury. Local complications include mucosal abrasions, lacerations, necrosis, and stricture formation. Severe complications include airway compromise, esophageal perforation, tracheoesophageal fistula, vascular injury such as an aortoesophageal fistula, retropharyngeal abscess, mediastinitis, pericarditis, and vocal cord injury.[13]

Button batteries, multiple magnets, and sharp or pointed objects are associated with particularly high complication rates. Button battery ingestion has increased with the widespread use of batteries in household and recreational products.[14] Esophageal impaction allows electrical current to flow between the battery poles through the surrounding mucosa, causing pressure injury and rapid liquefactive necrosis that may progress to perforation. Leakage of corrosive contents further exacerbates tissue injury because button batteries contain heavy metals, such as lithium, mercury, or silver, as well as strong alkaline agents, such as sodium hydroxide or potassium hydroxide. Sharp foreign bodies carry a substantial risk of perforation and generally require urgent removal. The most commonly ingested sharp objects in children include pins, needles, paper clips, and fish bones.[15]

Magnet ingestion has become an increasingly important pediatric safety concern with the widespread use of small magnets in toys and household products.[16][17] High-powered neodymium magnets used in consumer products pose a particularly high risk because of their strong magnetic force. Ingestion of multiple magnets can result in attraction across adjacent bowel loops, causing tissue compression, pressure necrosis, fistula formation, obstruction, or perforation.[18] Even brief delays in diagnosis substantially increase the risk of serious complications, making early recognition and prompt management essential. More than 90% of severe complications occur in children aged 5 years or younger, particularly after ingestion of button batteries measuring 20 mm or larger. Prolonged esophageal impaction further increases the risk of developing complications.

History and Physical

The assessment of patients with ingested foreign bodies should elicit vital information, including the type and number of objects, the location, the time since ingestion, and the presenting signs and symptoms. These factors determine the need for emergent or urgent retrieval versus observation with follow-up. Most adults and older children can provide a history of foreign body ingestion and symptom onset.

The most common symptoms include foreign body sensation and dysphagia. Symptoms typically develop within minutes to hours. Foreign bodies in the upper esophagus are generally localized accurately, whereas middle or distal esophageal impactions often present as vague discomfort, aching, or chest pain. Additional symptoms include hypersalivation, retrosternal fullness, regurgitation, gagging, choking, hiccups, and retching. Odynophagia may indicate more severe forms of injury, such as esophageal laceration or perforation.

Physical examination may reveal anxiety and discomfort with swallowing. Inability to swallow saliva indicates complete esophageal obstruction and warrants more urgent treatment.

Infants, young children, and individuals with cognitive impairment may be unable to provide a reliable history, thus requiring a high index of suspicion. Presenting symptoms may include unexplained cough, gagging, poor feeding, drooling, or irritability in infants and young children. Esophageal foreign bodies may also compress the trachea, causing wheezing, cough, dyspnea, or stridor. Airway foreign bodies should remain in the differential diagnosis. Initial physical examination should focus on airway patency, vital signs, ability to manage secretions, and evidence of complications, including hematemesis, abnormal breath sounds, tenderness of the neck, chest, or abdomen, and subcutaneous emphysema.

Evaluation

Anteroposterior and lateral chest radiographs are the preferred initial diagnostic studies (see Image. Button Battery in the Upper Esophagus of a Child). Radiographs help identify the foreign body, determine its location, and detect complications. Chest radiographs are usually sufficient, although neck and abdominal radiographs may be indicated based on the clinical presentation.

Flat objects, including coins, bottle caps, and disc batteries, typically align in the coronal plane when lodged in the esophagus and appear round on the frontal (posteroanterior) view. In contrast, tracheal foreign bodies align in the sagittal plane and appear round on the lateral view. Circular radiopaque objects require careful evaluation for a halo or double-ring sign, which identifies a button battery and necessitates emergent removal. Chest radiography differentiates coins from button batteries with approximately 80% sensitivity, specificity, and accuracy.

Food, plastic, wood, and aluminum are radiolucent and are not visible on plain radiographs. Bones and glass may or may not be radiographically visible. Diagnostic endoscopy or computed tomography (CT) should be considered when findings from plain radiographs are unremarkable despite persistent clinical suspicion. CT has high sensitivity for detecting foreign bodies and is useful for identifying complications, such as perforation. The strong association between esophageal food impaction and eosinophilic esophagitis warrants consideration of esophagogastroduodenoscopy with biopsy, particularly in patients with recurrent impactions.[19]

Treatment / Management

Management in patients with a stable airway and no evidence of complications depends on the type and location of the foreign body, degree of obstruction, and duration of impaction. Endoscopic removal is the treatment of choice, achieving success rates exceeding 90% with complication rates below 5%. Endoscopic management is categorized according to the urgency of intervention. Categories include emergent (within 2 hours of presentation), urgent (within 24 hours of presentation), and elective or expectant (24 hours or more after presentation).[20][21][22][23](A1)

Indications for emergent removal include the following:

• Airway compromise or respiratory distress
• Inability to manage oral secretions, which often presents with persistent drooling
• Button battery impaction in the esophagus
• Symptomatic sharp foreign body impaction in the esophagus
• Presence of clinical manifestations of gastrointestinal perforation or obstruction, eg, fever, abdominal pain, or vomiting

Urgent removal is indicated for impaction involving the following foreign bodies:

• Multiple high-powered magnets
• Sharp objects in the stomach
• Button batteries in the stomach that produce symptoms
• Superabsorbent polymers in the esophagus or stomach

Endoscopic intervention should be performed within 24 hours for foreign bodies that are retained in the esophagus or have an unknown duration of impaction. In otherwise asymptomatic children, removal is generally recommended when the object remains in the stomach for more than 4 weeks. Selection of the endoscopic approach depends on the foreign body type and location, duration of impaction, patient age, airway status, and local expertise.[24][25][26](B2)

Flexible endoscopy is generally the 1st-line approach for most esophageal foreign body impactions in children because of its high success rate, minimally invasive nature, and ability to provide complete visualization of the esophagus and stomach. Flexible endoscopy is particularly useful for removing impacted blunt objects, such as food and coins. Rigid endoscopy may be preferred in selected situations, including impaction of sharp or large foreign bodies in the proximal esophagus, development of airway compromise, foreign body entrapment at the UES, and cases requiring enhanced airway protection or procedural control. Flexible endoscopy is generally associated with lower morbidity, less extensive instrumentation, and shorter recovery times. Rigid endoscopy provides superior control for dislodging proximal esophageal foreign bodies, particularly sharp objects, and may offer better airway protection. However, rigid endoscopy typically requires general anesthesia and specialized expertise.

Several medical therapies have been evaluated for esophageal foreign body impaction, although routine pharmacologic management is not recommended in children. Agents intended to relax the LES, particularly glucagon, have been used in attempts to facilitate the passage of smooth, blunt foreign bodies into the stomach. Glucagon is administered at a dose of 0.25 to 2 mg intravenously over 1 to 2 minutes in a sitting patient, followed by oral intake of water or a carbonated beverage after approximately 1 minute to promote esophageal distention and LES relaxation. Associated adverse effects include nausea and vomiting, which may dislodge the foreign body but also increase the risk of esophageal rupture. Available studies demonstrate limited efficacy compared with placebo and are constrained by small sample sizes and methodological limitations.[27]

The use of proteolytic enzymes, including papain, is not recommended for food bolus impaction. Reported complications of this approach include hypernatremia, mucosal injury, perforation, aspiration, and a theoretical risk of esophageal injury.[28]

Impaction of a disc battery in the esophagus constitutes a true emergency and requires immediate intervention. The most serious complication is a potentially fatal aortoesophageal fistula, with highest risk in presentations involving children aged younger than 5 years, ingestion of batteries 20 mm or larger, impaction at the level of the aortic arch, prolonged esophageal impaction, and the occurrence of any degree of hematemesis. In these situations, an interprofessional approach may be required, involving pediatric gastroenterology, pediatric surgery, cardiothoracic surgery, anesthesia, and radiology, with management in the operating room or cardiac catheterization laboratory.

Asymptomatic children with a coin impacted in the esophagus may be observed for up to 24 hours without increased risk of complications. Coin location is an important determinant of spontaneous passage, with 10% of proximal esophageal coins, 26% of midesophageal coins, and 43% of distal esophageal coins passing spontaneously within 16 hours of ingestion.

Adults presenting with esophageal food impaction should undergo evaluation for eosinophilic esophagitis, as esophageal food impaction may be the initial manifestation of the disease. Eosinophilic esophagitis is a chronic immune-mediated disorder believed to result from the combination of genetic susceptibility, environmental exposures, and aberrant immune responses to food antigens and, in some patients, aeroallergens. The incidence and prevalence of this condition have increased substantially over the past several decades.

Clinical manifestations often reflect a prolonged history of esophageal dysfunction that precedes the initial impaction. Patients may report intermittent dysphagia, prolonged meal times, excessive chewing, frequent fluid intake during meals, food avoidance or modification, difficulty swallowing pills, and recurrent food impactions. Personal or family histories of atopic disease or eosinophilic esophagitis further increase the likelihood of the diagnosis. Confirmation of eosinophilic esophagitis should prompt disease-specific management with anti-inflammatory therapy, dietary modification, and, when indicated, endoscopic dilation to reduce the risk of recurrent food impaction.[29]

Differential Diagnosis

Esophageal abrasions may produce a persistent foreign body sensation even after passage of the offending object. Reassessment within 12 to 24 hours is appropriate in stable patients who can tolerate oral intake. Persistent symptoms warrant further evaluation with CT imaging or endoscopy. Conditions that may produce a foreign body sensation in the absence of a retained object include infectious esophagitis due to Candida species, herpes simplex virus, or cytomegalovirus; noninfectious esophagitis, including cases secondary to reflux, pill ingestion, and eosinophilic inflammation; esophageal spasm; and globus pharyngeus (globus hystericus), a sensation of a lump or foreign body in the throat of uncertain etiology. Patients who are stable and able to tolerate oral intake should receive treatment of the underlying condition and appropriate follow-up care.

Prognosis

Approximately 80% to 90% of ingested foreign bodies pass spontaneously within 3 to 7 days. Children with esophageal injury from disc batteries require short- and long-term follow-up to assess for complications related to erosion, perforation, and esophageal stricture formation. Adults with food impactions have underlying abnormalities in 85% to 90% of cases and require evaluation and treatment of the underlying disorder.

Complications

Delayed diagnosis of esophageal foreign body can result in serious complications, including stricture formation. Less commonly, perforation may occur with pneumomediastinum, mediastinitis, pneumonia, or life-threatening hemorrhage secondary to major vascular injury.