Version May 2024
INTRODUCTION — The majority of foreign body ingestions occur in children between the ages of six months and three years. Most cases are brought to medical attention by a child's caregivers following a witnessed or reported ingestion. Many of the children are asymptomatic or have transient symptoms at the time of the ingestion. Clinical management focuses on identifying and treating the cases at risk for complications, which depend on the location and type of foreign body.
The diagnosis and management of foreign bodies in the esophagus and gastrointestinal tract are discussed here. Concerns specific to ingestion of button batteries (disk batteries) are discussed in greater detail separately. Management of gastric bezoars is discussed elsewhere. (See "Button and cylindrical battery ingestion: Clinical features, diagnosis, and initial management" and "Gastric bezoars".)
EPIDEMIOLOGY AND PATHOPHYSIOLOGY — Of more than 100,000 cases of foreign body ingestion reported each year in the United States, >75 percent occur in children [1-4]. The majority of foreign body ingestions occur in children between the ages of six months and three years [1,5,6]. Ingestion of multiple foreign objects and repeated episodes are uncommon occurrences and usually occur in children with developmental delay or behavioral problems [7,8]. Although mortality from foreign body ingestion is extremely low, deaths have been reported [5,9,10].
Common foreign bodies — Commonly ingested objects include coins, button batteries, toys, toy parts, magnets, safety pins, screws, marbles, bones, and food boluses [2,7,11-13].
●Coins – Coins are by far the most common foreign body ingested by children [14-16]. It may be difficult to distinguish a coin from a disk battery on a radiograph, and careful review for distinguishing features is essential. (See 'Coins' below.)
●Button batteries – The number of ingestions of disk or button batteries has increased with expanded use of button batteries in household and recreational products [17]. Serious sequelae (eg, esophageal burn, perforation, or fistula) occur in approximately 3 percent of all button battery ingestions. In addition to direct pressure necrosis, contact of the flat esophageal wall with both poles of the battery conducts electricity, resulting in liquefaction necrosis and perforation of the esophagus. Retained batteries can also cause problems through leakage of caustic material (generally, batteries contain a heavy metal like mercury, silver, or lithium and a strong hydroxide of sodium or potassium) [5,6,18]. (See "Button and cylindrical battery ingestion: Clinical features, diagnosis, and initial management".)
●Sharp objects – The most common sharp-pointed objects ingested by children are straight pins, needles, straightened paper clips, and fish bones; these represent 10 to 15 percent of swallowed objects [4]. In older case series, sharp objects had a high risk of perforation (15 to 35 percent) [1,19]. By contrast, a contemporary case series reported no complications after ingestion of a sharp object [20]. In this series, most of the children were asymptomatic at presentation, a majority of the objects were metal fragments/open earrings or glass, and 14 percent of the objects were removed endoscopically, while the remainder passed through the gastrointestinal tract. When lodged in the hypopharynx, they can cause a retropharyngeal abscess [21]. Ingested toothpicks and bones are likely to perforate [4,22]. (See 'Sharp-pointed objects' below.)
●Food impaction – Impacted meat or other food bolus is the most common esophageal foreign body in adults. Children presenting with food impaction often have underlying esophageal pathology (eosinophilic esophagitis, strictures, achalasia, web or ring, or esophageal motility disorders) [4,23,24]. Reflux esophagitis and eosinophilic esophagitis also predispose to food impaction [24-26].
●Magnets – With the increasing use of small magnets in toys and household items, ingestion of magnets has become a serious health hazard in children [27-32]. High-powered magnets composed of neodymium (also known as rare earth magnets) are common components of household appliances. These magnets are also commonly available in the form of desk toys and "stress relievers" (eg, "Buckyballs" and many other brands), which consist of hundreds or more small magnetic balls, cubes, or cylinders. Although these are marketed to adults, they have been involved in many ingestion incidents in children. Many of the children with complications from multiple magnet ingestion had underlying conditions such as developmental delay or autism [27,28]. In some cases, an older child has inadvertently swallowed these magnets while using them to imitate a pierced tongue, so the risk is not limited to young children [30,32]. (See 'Magnets' below.)
The United States Consumer Safety Product Commission has issued warnings describing the safety risks of this type of magnet [33]. Legislation to restrict the sale of these products has been contentious [34-36]. Marketing of small high-powered magnets was initially restricted by recalls and a 2014 federal safety standard, which was overturned in 2016 but then reinstated as a new safety standard in 2022 [36-39]. Beneficial effects of the safety standards were shown in an analysis of visits to United States emergency departments for magnet ingestion from before the safety standard (3.58 per 100,000 children in 2009-2012), with a decline during the period of the safety standard (2.83 per 100,000 children in 2013-2016), then a rebound after the standard was overturned (5.16 per 100,000 children in 2017-2019) [38]. A separate analysis of national data reported a fivefold increase in children requiring escalation of care (hospital admission or transfer) for magnet ingestions during the period when the safety standard was not in effect [39]. Most children with these magnet ingestions require hospitalization and/or endoscopy, and nearly 10 percent develop a life-threatening morbidity [40].
●Multicomponent objects – Objects that have multiple components require particular attention to ensure that the related hazards are addressed appropriately. As an example, "fidget spinner" toys that have lights or motors include button batteries, with related risks of severe esophageal injury [41-43]. They also contain both radiolucent and radiopaque components, which may break apart and progress separately in the gastrointestinal tract. (See 'Batteries' below and 'Imaging' below.)
●Long objects – Foreign bodies that are long and blunt, such as toothbrushes, batteries, and spoons, are most frequently ingested by older children, adolescents, or adults. The associated risk and the approach to management depend on the length and other characteristics of the object. (See 'Long objects' below.)
●Superabsorbent polymers – Toys and household products made of superabsorbent polymers present a risk for bowel obstruction if ingested [44]. These objects can expand 30 to 60 times in volume when hydrated [4]. Several of these toys were voluntarily removed from the market in the United States in 2012 [45], but other products are still available. (See 'Superabsorbent polymers' below.)
●Objects containing lead – Objects with high lead content include lead weights used for fishing (sinkers), curtain weights, air rifle pellets, and some toys or medallions. Acute lead toxicity may occur after ingestion of these objects, and fatalities have been reported [46,47]. (See 'Objects containing lead' below.)
●Wireless endoscopy capsules – Capsules used for capsule endoscopy are occasionally retained in the gastrointestinal tract. This complication is more common in patients with an underlying pathology [48-50] and may require endoscopic or surgical removal [51,52]. (See "Wireless video capsule endoscopy", section on 'Capsule retention'.)
Anatomic considerations — Fortunately, most ingested foreign bodies pass spontaneously. Only 10 to 20 percent require endoscopic removal, and less than 1 percent require surgical intervention [1,5,11].
Patient risk factors for retention of an ingested foreign body in the esophagus include:
●Younger age (because objects are more likely to be retained in a smaller esophagus)
●Congenital malformations
●Prior surgery of the esophagus [4,23,24,53]
●Gastroesophageal reflux or eosinophilic esophagitis (particularly for food bolus impaction) [4]
●Neuromuscular disease
When a foreign body is retained in the esophagus, it tends to lodge in areas of physiologic narrowing, such as the upper esophageal sphincter (cricopharyngeus muscle), the level of the aortic arch, and the lower esophageal sphincter [5,54]. Objects that become lodged in the middle portion of the esophagus are more likely to represent esophageal pathology, such as an esophageal spasm, anastomosis, or stricture (which, if present, may be related to esophagitis, including eosinophilic esophagitis).
CLINICAL MANIFESTATIONS — Most children with gastrointestinal foreign bodies are brought to medical attention because the ingestion was witnessed or reported [1,5,54,55]. Such children are often asymptomatic. As an example, in a case series of 325 pediatric patients, only one-half of the children with an esophageal foreign body displayed symptoms at the time of the ingestion, such as retrosternal pain, cyanosis, or dysphagia, and in many of these cases, the symptoms were transient [21].
When symptoms do occur, they are often related to the location of the foreign body:
●Esophagus – Patients with an esophageal foreign body may be asymptomatic or may present with refusal to eat, dysphagia, drooling, or respiratory symptoms including wheezing, stridor, or choking. Older children may be able to localize the sensation of something stuck in the neck or lower chest, suggesting irritation in the upper or lower esophagus, respectively. Children with complaints of retrosternal chest pain are more likely to have mucosal ulceration of the esophagus when evaluated by endoscopy, especially if the foreign body has been present for more than 72 hours or was found unexpectedly on chest imaging [15]. Sharp objects may perforate the esophagus, resulting in neck swelling, crepitus, or pneumomediastinum [5]. (See "Assessment of stridor in children" and "Evaluation of wheezing in infants and children".)
Longstanding esophageal foreign bodies may cause weight loss or recurrent aspiration pneumonia due to decreased caloric intake and poor handling of oral secretions, respectively. They also can damage the mucosa and lead to strictures or erode the esophageal wall, creating a fistula with the trachea or other nearby structures. Erosion into the aorta has also been reported, causing life-threatening gastrointestinal bleeding [19,56].
●Stomach – Objects that reach the stomach are typically asymptomatic, unless they are large enough to cause gastric outlet obstruction, which could present with vomiting and/or feeding refusal [57]. In true gastric outlet obstruction, symptoms include marked, nonbilious vomiting and gastric distension. Certain types of gastric objects (sharp or long objects, magnets, and some batteries) may warrant removal even if the patient is initially asymptomatic because of risks for complications. (See 'Approaches for specific types of foreign bodies' below.)
●Intestines – Objects that pass beyond the pylorus and into the intestines are usually asymptomatic and pass spontaneously. Occasionally, they may be retained in the distal gastrointestinal tract where they can cause delayed complications. As examples, case reports describe cecal retention of a coin mimicking appendicitis [58], pyogenic liver abscess caused by migration of a sharp object from the gastrointestinal tract to the liver [59], retention of a long object in the appendix presenting as appendicitis several years later [60], and perforation of the ileum by ingested gravel [61].
EVALUATION — A careful history and physical examination are the keystones in diagnosing an esophageal foreign body and to the prevention of its complications [62]. If symptoms are present, they may suggest a likely location of the foreign body (see 'Clinical manifestations' above). Imaging should be used to confirm the findings and to localize the site of the foreign body. The diagnostic steps and treatment depend on the patient's symptoms, the shape and location of the foreign body, whether it is radiopaque, or whether it has magnetic properties (algorithm 1 and algorithm 2A) [4].
History and physical examination — Airway and breathing should always be examined first. The physical examination of the neck may reveal swelling, erythema, or crepitus, suggesting that an esophageal perforation has occurred, in which case surgical consultation is mandatory [63]. The chest examination may reveal inspiratory stridor or expiratory wheezing, suggesting a lodged esophageal foreign body with tracheal compression. The abdominal examination may show evidence of small bowel obstruction or perforation, in which case immediate surgical consultation and abdominal imaging should be obtained.
A metal detector might be useful to detect materials that are metallic but not radiopaque, such as aluminum [64,65], but this use is limited because the instrument is not reliable in detecting many metallic objects [66,67].
Imaging
Conventional radiograph — For all patients with suspected foreign body ingestion, the initial diagnostic test should be biplane radiographs (anteroposterior and lateral) of the neck, chest, and abdomen [5,21,68]. We suggest including each of these sites even if symptoms suggest a location (eg, esophageal or respiratory symptoms). Similarly, we suggest that conventional radiographs be performed even if the foreign body is thought to be radiolucent. This is to evaluate for the possibility of other swallowed objects, for indirect evidence of the radiolucent foreign body (such as an air-fluid level in the esophagus), and for free air representing a perforation. Toys made of plastic or wood, some thin metal objects, and many types of bones are not readily seen on conventional radiographs [18,21,69]. In a study of 325 children, only 64 percent of the ingested objects were radiopaque [21]. Other objects, such as "fidget spinner" toys, have both radiolucent and radiopaque components, which may have broken apart and progressed separately in the gastrointestinal tract [41-43].
If the radiograph reveals a radiopaque object, the following features should be noted:
●Esophageal versus tracheal location – Flat objects (eg, coins or disk batteries) in the esophagus usually orient in the coronal plane and appear as a circular object on an anteroposterior projection (image 1), whereas objects lodged in the trachea tend to orient in the sagittal plane and are best seen in lateral projection. However, these tendencies are not universal, so the radiograph should be carefully examined for other characteristics that distinguish between an esophageal and tracheal location and correlating the findings with the available clinical information [70-72]. The lateral projection radiograph may help to identify the object or establish if more than one foreign body is present, such as stacked coins.
●Coin versus disk battery – It may initially be difficult to differentiate between a disk battery and a coin on a radiograph. This distinction is most important when the foreign body is in the esophagus since batteries require immediate removal, whereas coins may or may not. Radiographic features that can help distinguish between the two are discussed separately (image 2 and image 3). (See "Button and cylindrical battery ingestion: Clinical features, diagnosis, and initial management", section on 'Radiographic localization'.)
Other imaging — If the plain radiograph does not reveal any foreign body or abnormalities, further evaluation depends on the characteristics of the patient and the suspected foreign body:
●Computed tomography (CT) or magnetic resonance imaging (MRI) – If the patient is symptomatic, or if the suspected foreign body has any dangerous characteristics (large [>2 cm width], long [>5 cm length], or sharp), or if the type of foreign body is not definitively known by the caretakers, we suggest using CT with three-dimensional reconstruction as the next diagnostic procedure (algorithm 1) [5,73]. Alternatively, MRI can be used for evaluation of radiolucent foreign bodies but is contraindicated if any metallic foreign body is present.
Imaging with CT or MRI is not necessary if the patient is entirely asymptomatic, the object has benign characteristics (small [<2 cm], not sharp or long, and not a magnet or battery), and the caretakers are certain about the type of foreign object that was ingested. In this case, it is reasonable to discharge the patient after a period of observation in a health care setting, if the patient remains entirely asymptomatic and is able to eat and drink normally.
●Ultrasonography – Ultrasonography has been used to identify the location and nature of foreign bodies in the esophagus or stomach if appropriate expertise is available [74,75].
●A fluoroscopic upper gastrointestinal study with water-soluble contrast also may be performed to evaluate for a radiolucent foreign body (algorithm 1). Barium contrast studies should be avoided because barium may obscure visualization on subsequent endoscopy.
APPROACH TO MANAGEMENT
Indications for urgent removal — Urgent intervention (ie, removal of the foreign body via endoscopy or other technique) is indicated if any of the following warning signs are present (algorithm 1):
●When the patient shows signs of airway compromise (see "Emergency evaluation of acute upper airway obstruction in children")
●When there is evidence of near-complete esophageal obstruction (eg, patient cannot swallow secretions or is drooling)
●When the ingested object is sharp, long (>5 cm), or a superabsorbent polymer and is in the esophagus or stomach
●When the ingested object is a high-powered magnet or magnets (algorithm 2A-B)
●When a disk battery is in the esophagus (and, in some cases, in the stomach) (see "Button and cylindrical battery ingestion: Clinical features, diagnosis, and initial management")
●When there are signs or symptoms suggesting inflammation or intestinal obstruction (fever, abdominal pain, or vomiting) [5,18].
Objects lodged in the esophagus for more than 24 hours or for an unknown duration also should be removed promptly [5]. After this period, complications such as transmural erosion, perforation, and fistulae are more likely to occur. As an example, in a case series of 167 children, duration of lodgment for more than 24 hours was the strongest predictor of complications, which included injury to the esophageal mucosa, bleeding, stricture, and obstruction [19]. Complications also were more likely if the foreign body was a sharp or pointed object, disk battery, nonradiopaque, or located below the upper third of the esophagus.
Management of potentially caustic objects or substances, including detergent "pods," are discussed separately. (See "Caustic esophageal injury in children".)
Expectant management — For patients without any of the above characteristics (eg, a coin lodged in the esophagus of a patient who can swallow and has no respiratory symptoms), observation for 12 to 24 hours is reasonable because spontaneous passage often occurs (algorithm 1) [4,76-80]. In one study, coins lodged in the esophagus passed spontaneously into the stomach in approximately one-third of patients with a simple presentation (defined as no history of esophageal disease or surgery, coin lodged for less than 24 hours, and no respiratory compromise) [79].
We do not recommend the use of proteolytic enzymes (eg, papain) or glucagon in the management of esophageal foreign bodies, including food bolus impaction, in children. A proteolytic enzyme is not recommended for food impaction, because its use has been associated with hypernatremia, erosion, esophageal perforation, and aspiration pneumonitis [4,81,82]. Glucagon is not recommended for management of food or other esophageal foreign bodies, because of the lack of evidence of efficacy, particularly in children, and because nausea and vomiting are common side effects [83,84]. Some authors have suggested that a bolus of intravenous glucagon may promote spontaneous passage of an impacted foreign body by relaxing the esophagus [85,86]. However, two small, randomized trials and a large case series in patients with esophageal food bolus or coin suggest that glucagon is no more effective than placebo, except perhaps in patients with a prior history of solid food dysphagia [83,87,88].
Objects in the stomach that have benign characteristics (not long or sharp, and not a battery or magnet) can generally be managed expectantly if the patient remains asymptomatic. If the object remains in the stomach for more than four weeks, it should be removed because this means that it is unlikely to pass the pylorus.
APPROACHES FOR SPECIFIC TYPES OF FOREIGN BODIES
Coins — A small percentage of the ingested coins become lodged in the esophagus, and these can cause serious complications, including aspiration, if not removed [89]. Approximately two-thirds of ingested coins are in the stomach at the time of initial radiographic evaluation [13,89]. The radiograph should be carefully examined for features that distinguish between a coin and battery. (See 'Conventional radiograph' above.)
●Esophagus – If a coin is visualized in the esophagus and the patient can swallow and has no respiratory symptoms or other distress, the child can be observed for up to 24 hours after ingestion of the coin (see 'Expectant management' above). In such patients, 20 to 30 percent of coins will pass into the stomach spontaneously during the observation period (two-thirds of these during the first eight hours). Spontaneous passage is more common in older children and when coins are located in the distal third of the esophagus [2].
The esophageal coin should be removed promptly if the patient is symptomatic or if the time of ingestion is not known (see 'Indications for urgent removal' above). If the child is asymptomatic and the coin does not pass spontaneously by 24 hours after ingestion, it should be removed. In our practice, we prefer to remove most coins using flexible endoscopy. Rigid endoscopy or Magill forceps are acceptable approaches for proximally located coins, with experienced operators.
Several large case series have described effective management using bougienage to push the coin into the stomach for selected patients at low risk of complications [90-92]. The penny pincher or Foley catheter techniques are cost-effective alternatives for selected patients but require fluoroscopy and do not allow direct inspection of the esophagus. Patient selection and limitations of nonendoscopic techniques are discussed below. (See 'Techniques' below.)
●Stomach – Coins that reach the stomach can be managed expectantly. Coins are unlikely to cause a complication because they lack sharp edges, the metal is not toxic, and the vast majority will pass out uneventfully within one to two weeks [93]; there are only scattered case reports of retention of a swallowed coin in the stomach (a history of pyloromyotomy may increase the risk [94]) or cecum. For children with a gastric coin who remain asymptomatic, we advise the caregivers to monitor the stools for passage of the coin. If the coin is not identified in the stool, we suggest an abdominal radiograph every one to two weeks until clearance is documented, based on expert consensus [4]. If the coin has not passed beyond the stomach by four weeks, endoscopic removal is recommended. If the child develops any signs or symptoms of obstruction, abdominal pain, vomiting, or fever, then the patient should be promptly reevaluated with radiographs to document that the coin is still in the stomach or duodenal bulb, followed by endoscopic removal. Although there have been theoretical concerns about zinc toxicity from retained gastric pennies minted after 1982, evidence demonstrating the need for extraction is lacking [21,95], except in the case of ingestion of extremely large numbers of post-1982 pennies [96].
Batteries
●Esophagus – When batteries become lodged in the esophagus, they represent a medical emergency. Necrosis of the esophagus may occur due to liquefaction from the electrical current and may lead to ulceration within a few hours of ingestion and perforation as early as eight hours after ingestion [43,97,98]. Longer-term retention may lead to pressure necrosis and/or leakage of caustic material, with resultant tissue damage including perforation. Management, including first aid to minimize the severity of esophageal burns until the battery is removed, is discussed separately. (See "Button and cylindrical battery ingestion: Clinical features, diagnosis, and initial management", section on 'Management'.)
●Stomach – Like coins, most disk or cylindrical batteries pass harmlessly once they reach the stomach. However, because of the potential for direct mucosal injury and toxicity, batteries should be removed from the stomach under certain conditions (eg, age <5 years or large-sized battery) because of the potential for direct mucosal injury and toxicity if the battery is retained in the stomach or if it is lodged in the pylorus. (See 'Common foreign bodies' above and "Button and cylindrical battery ingestion: Clinical features, diagnosis, and initial management", section on 'Gastric location'.)
An overview of the management of battery ingestions is presented separately. (See "Button and cylindrical battery ingestion: Clinical features, diagnosis, and initial management".)
Sharp-pointed objects — Sharp-pointed objects (eg, straight pins, needles, straightened paper clips, or fish bones) lodged in the esophagus represent a medical emergency because of a high risk of perforation (15 to 35 percent) [1,19]. (See 'Common foreign bodies' above.)
Children suspected of swallowing sharp-pointed objects must be evaluated to determine the location of the object (algorithm 3). If the history or examination raises concern for a sharp-pointed object, endoscopy should be performed even if the radiologic examination is negative because many sharp-pointed objects are not readily visible by radiography. Radiography is unlikely to detect fish bones and wood toothpicks [4].
●Esophagus – If the object is in the esophagus, it should be removed immediately. Endoscopic retrieval of sharp objects is accomplished with tools such as a retrieval forceps or polypectomy snare [99]. The risk of mucosal injury during retrieval of a sharp object can be minimized by orienting the object with the sharp end trailing during extraction and using a protector hood on the end of the endoscope or, in older children, an overtube [100,101]. Direct laryngoscopy is a reasonable alternative for objects lodged at or above the cricopharyngeus. (See 'Flexible endoscopy' below and 'Magill forceps' below.)
●Stomach or proximal duodenum – If the object is in the stomach or proximal duodenum, it also should be removed promptly using a flexible endoscope. The risk of a complication caused by a sharp-pointed object passing through the gastrointestinal tract is as high as 35 percent [102], although some case series describe lower complication rates from sharp objects (4 percent) [103,104]. Sharp objects that pass beyond the reach of a flexible endoscope and then cause symptoms will require surgical intervention. The most common sites of intestinal perforation are the ileocecal and rectosigmoid regions.
●Small intestine – If the object has passed into the small intestine and the patient is asymptomatic, it may be followed with serial radiographs to document its passage. Surgical intervention should be considered for objects that fail to progress for three consecutive days [4]. Urgent surgical intervention is indicated for patients with symptoms suggesting obstruction or perforation, which may include abdominal pain, vomiting, fever, hematemesis, or melena. Parents/caregivers should be instructed to report any of these symptoms immediately.
Esophageal food impaction — Esophageal impaction of meat or other food bolus usually presents as dysphagia beginning acutely while eating. In children presenting with a food impaction, there is a higher incidence of underlying esophageal pathology compared with children with other esophageal foreign bodies, including esophagitis, anatomic abnormalities, or motility disorders. (See 'Common foreign bodies' above.)
Children who are in acute distress or unable to swallow oral secretions require immediate attention and removal of the impaction (algorithm 4). If the patient is comfortable and able to handle oral secretions, endoscopic intervention can be delayed as many food impactions will pass spontaneously. However, intervention should not be delayed beyond 24 hours [4].
We do not recommend the use of proteolytic enzymes (eg, papain) or glucagon in the management of food impaction or other esophageal foreign bodies in children. (See 'Expectant management' above.)
The optimal approach to endoscopic removal of a food bolus depends on the anatomic location and consistency of the object. Objects in the upper esophagus may be optimally managed with a rigid endoscope, whereas those in more distal locations typically require flexible endoscopy. Some providers find that polypectomy snares or retrieval nets (eg, Roth Net), or a friction-fit adaptor (from a band ligator) fitted to the end of the endoscope, are valuable for food bolus removal [24,105,106]. The food bolus can be removed en bloc or in a piecemeal fashion. Once reduced in size, the bolus may be gently pushed into the stomach using the tip of the endoscope [107]; excessive force should be avoided to minimize the risk for perforation. Because food impaction is often caused by an underlying mucosal abnormality such as esophagitis or stricture, we recommend that esophageal mucosal biopsies be obtained at the time of endoscopic disimpaction [4,108]. (See "Ingested foreign bodies and food impactions in adults", section on 'Food bolus'.)
Magnets — High-powered magnets composed of neodymium (also known as rare earth magnets) are now common components of household appliances and some toys. They represent a serious health hazard if ingested due to risks for gastrointestinal perforation. (See 'Common foreign bodies' above.)
Two or more high-powered magnets, especially if ingested at different times, may attract across layers of bowel leading to pressure necrosis, fistula, volvulus, perforation, infection, or obstruction; this may result in serious consequences including intestinal resection. It is postulated that intraperitoneal hemorrhage could occur if mesenteric vessels are trapped between attracted bowel loops [109]. In a multicenter report of 574 children with magnet ingestion, 57 children (9.6 percent) had intestinal perforation or other life-threatening morbidity [40]. All cases involved two or more magnets, and almost all were small magnets (<5 cm).
Suspected ingestion of any high-powered magnet requires urgent evaluation to determine a management plan, which depends on magnet number, location, and size. Radiographs of the neck and abdomen should be performed, including a lateral view. In most cases, the radiographs cannot determine whether the bowel wall is compressed between the magnets, although the finding of magnets that appear to be stacked but are slightly separated (image 4) is suspicious for bowel entrapment. Management depends on the number, location, and type of magnets and on the timing of the ingestion, as described in the algorithms (algorithm 2A-B) [4,110].
●Single magnet – Ingestion of even a single high-powered magnet (algorithm 2A) has some risk as the magnet may attach to external metallic clothing, such as a belt buckle, naval body jewelry, or metallic button. Endoscopic removal should be considered if the magnet is accessible (ie, in the esophagus or stomach), especially if the child is at risk for further ingestions. Alternatively, it is reasonable to manage these cases conservatively, with the following precautions:
•Serial radiographs should be performed to confirm that the magnet progresses through the gastrointestinal tract and to confirm that multiple magnets are not present. Radiographs do not reliably distinguish between single and multiple magnets, since it is possible for magnets to stick together or overlap on a single view and be misdiagnosed as a single magnet [29,30]. To reduce the risk of misinterpreting the radiograph, both anteroposterior and lateral radiographs should be performed initially and all subsequent radiographs should be closely examined for any indication that multiple magnets might be present.
•The child should be kept away from any magnetic or metallic materials (including metallic buttons or buckles in clothing), until the magnet has passed out of the gastrointestinal tract.
•Ingestion of a single magnet with another metallic object should be managed using the protocol for multiple magnet ingestion.
●Multiple magnets – Ingestion of multiple high-powered magnets (algorithm 2B) has a high risk of complications and warrants preemptive removal [29,111]:
•Magnets in the esophagus or stomach should be promptly removed via endoscopy.
•Management of patients with multiple magnets beyond the stomach depends on symptoms and progression. Asymptomatic patients should be followed closely with serial radiographs and examinations every four to six hours. Alternatively, magnets can be removed by enteroscopy or colonoscopy, if accessible. Symptomatic patients, or any patient with multiple magnets that do not progress on serial radiographs, should undergo surgery for operative removal of the magnets.
The approach to endoscopic removal of magnets is similar to that for other blunt objects. Magnetic probes have been used to retrieve magnetic and metallic foreign bodies with varying success [21]. A series of podcasts is available to guide endoscopic and surgical management [112]. In addition to the steps outlined above, some experts have suggested administration of polyethylene glycol without electrolytes (PEG 3350, eg, MiraLAX) or other laxatives to expedite the progression of the magnetic object through the intestine [110].
Long objects — Foreign bodies that are long and blunt include toothbrushes, batteries, and spoons. Suggested management depends on the length and location of the object and the size of the child:
●For older children and adolescents, objects 5 cm or longer that are in the stomach should be removed because they have a high probability of becoming impacted in the ileocecal area if they pass the pylorus [103]. Objects longer than 6 cm generally cannot pass beyond the stomach [18,103,113]. If they pass into the small intestine, they should be followed by serial radiographs and surgical removal should be considered if they fail to progress.
●For younger children with a long object in the stomach, a lower threshold might be more appropriate, although there are few data to guide decisions for management of long objects in this age group. For example, we typically recommend removing objects that are longer than 2.5 cm for children <5 years.
During endoscopy, the use of a long (greater than 45 cm) overtube that extends beyond the gastroesophageal junction may be beneficial in children who are large enough to permit passage of this device. The object can be grasped with a snare or basket and maneuvered into the overtube. The entire apparatus, foreign body, overtube, and endoscope can then be withdrawn, avoiding losing grasp of the object in the overtube itself [114].
Superabsorbent polymers — Toys and household products made of superabsorbent polymers present a risk for bowel obstruction if ingested [44,115-117]. These objects can expand 30 to 60 times in volume when hydrated [4].
If ingestion of a superabsorbent object is suspected, it should be removed immediately. The superabsorbent polymer is radiolucent, so radiographic evaluation generally is not helpful. However, the object can sometimes be identified by administering a small amount of water-soluble contrast material (eg, diatrizoate meglumine-diatrizoate sodium [Gastrografin]). If the object has passed beyond the stomach, the patient should be monitored for symptoms of intestinal obstruction.
Objects containing lead — Acute lead toxicity may occur in children ingesting objects with high lead content (eg, sinkers used for fishing or air rifle pellets) (see 'Common foreign bodies' above). Markedly elevated lead levels have been measured within 90 minutes of ingestion of a foreign body containing lead [118,119]. The acid environment of the stomach enhances dissolution of the metal.
Acute lead toxicity presents with nonspecific symptoms including lethargy and vomiting. Providers should be alert to this possibility in a child with a retained foreign body and should measure serum lead levels if there is any suspicion of lead toxicity. (See "Childhood lead poisoning: Clinical manifestations and diagnosis".)
Objects suspected to have a high lead content should be removed from the esophagus or stomach as quickly as possible. Administration of acid-reducing agents (ie, antacid, histamine type 2 receptor blockers [H2RAs], proton pump inhibitors) may decrease the dissolution of lead [120]. Treatment for acute lead toxicity is described separately. (See "Childhood lead poisoning: Management".)
Bezoars — Gastric bezoars are uncommon, cause nonspecific symptoms, and can be found incidentally in patients undergoing upper gastrointestinal endoscopy or imaging. They may be composed of vegetable matter (phytobezoars), hair (trichobezoars), medications (pharmacobezoars), or other material. The management of these types of bezoars is discussed separately. (See "Gastric bezoars".)
Bezoars formed of milk curds (lactobezoars) also are uncommon and are most likely to occur in preterm infants fed concentrated formula. They have also been described in older infants and toddlers presenting with abdominal pain, vomiting, and a palpable abdominal mass [121,122]. Lactobezoars generally respond to conservative management, consisting of bowel rest, with or without saline lavage [121,123]. Case reports describe dissolution of lactobezoars with acetylcysteine [124].
TECHNIQUES — Several methods have been used to remove esophageal foreign bodies. They include rigid and flexible endoscopy, bougienage, Foley catheterization of the esophagus, and the penny pincher technique.
Flexible endoscopy — Flexible endoscopy is preferred in most circumstances because the foreign body can be directly visualized and manipulated, and the surrounding gastrointestinal tract can be examined for potential complications [4,105,125,126]. This procedure is usually performed under general anesthesia with an endotracheal tube in place to ensure that the foreign body does not slip into the airway. However, the procedure also may be performed without endotracheal intubation and/or under procedural sedation, depending upon the patient's age and ability to cooperate, the type and number of objects to be removed, and available resources. The endoscopist should have a complete array of equipment to grasp the foreign object, such as a rat-tooth and alligator forceps, polyp snare, retrieval net, and helical baskets. It is helpful to practice grasping a duplicate of the foreign body using the retrieval tools before beginning the procedure. A foreign body protector hood is the preferred method of protecting the esophagus if the object is sharp or pointed [127].
Rigid endoscopy — Rigid endoscopy utilizes a nonflexible channeled device that is introduced into the esophagus under general anesthesia. It is most useful for impacted sharp objects that are located proximal to the esophagus, at the level of the hypopharynx and cricopharyngeus muscle [128]. The technique requires considerable skill. It can cause complications such as esophageal abrasion and perforation [7,126].
Magill forceps — Magill forceps can be used to extract foreign bodies impacted in the oropharynx at or above the cricopharyngeus. In some cases, an object impacted in the upper esophageal sphincter is visible at the time of tracheal intubation and can be directly removed with the Magill forceps without the need for intubation. However, in most cases, an endotracheal tube is placed to protect the airway and a laryngoscope is used to gently open the esophagus and visualize the foreign body [21]. In one case series, esophageal coins were removed in 23 out of 36 patients using Magill forceps. In many of these cases, the extraction was performed easily although the coin was not clearly visible with the laryngoscope [129]. No complications were reported in this study.
Bougienage — Bougienage (passage of a dilator) has been used to push objects into the stomach. It should only be considered for blunt and small objects (eg, coins) that are likely to pass along the esophagus without causing mucosal injury. The procedure is less costly than endoscopy and can be performed without anesthesia or sedation. It is a reasonable choice for appropriately selected patients, when performed by clinicians experienced with the technique and with endoscopy available should bougienage fail.
Several large case series have described effective use of bougienage in cases meeting all of the following criteria [90-92]:
●Child age >1 year
●Coin in the esophagus, with no radiographic characteristics suspicious for button battery
●Coin located below the clavicles and above the diaphragm
●Witnessed ingestion, presenting within 24 hours of ingestion
●No respiratory distress
●No history of prior foreign body ingestions, esophageal abnormalities, or gastrointestinal surgeries
For cases meeting these criteria managed by personnel trained in the technique, bougienage was successful in approximately 95 percent of cases and had only a few minor complications (emesis, gagging), without needing sedation and with substantially shorter hospital stay compared with endoscopy [90-92].
Potential disadvantages of bougienage are that it does not retrieve the foreign body. Accordingly, it should never be used for objects that might cause injury during passage through the esophagus, stomach, or gastrointestinal tract (eg, sharp or large objects or a battery). Moreover, because bougienage does not permit visualization or biopsy of the esophagus, it will not identify children with undiagnosed esophageal disease (eg, eosinophilic or reflux esophagitis, possibly with a stricture, or the rare situation of a web or ring in the mid-esophagus) that might have predisposed the object to become lodged in the esophagus. Because of these considerations, and/or because of greater familiarity with endoscopy, many clinicians do not recommend bougienage at all if endoscopy is available.
Foley catheter — For this technique, a deflated Foley catheter is passed beyond the foreign body. The balloon is then inflated using a radiopaque contrast dye, and the catheter is slowly drawn back under fluoroscopic guidance to remove the foreign body through the mouth. The technique can be successful with proximal esophageal foreign bodies when performed by an experienced operator. It does not permit visualization of the esophagus and carries the risk of esophageal perforation if the balloon is inflated below a stricture. In addition, this approach may cause aspiration of the foreign body if it is inadvertently dragged into the trachea [5]. For these reasons, many providers do not recommend this technique if endoscopy is available.
Penny pincher technique — The penny pincher technique involves insertion of a grasping forceps through a nasogastric tube, under fluoroscopic guidance and usually without anesthesia or endotracheal intubation. This approach is an improvement over the Foley catheter method because it permits direct control of the object, reducing the risk of dropping it into the airway. However, it also does not allow inspection of the esophagus and may only be used for objects that can be firmly grasped and controlled by the forceps [130].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Esophageal strictures, foreign bodies, and caustic injury" and "Society guideline links: Battery ingestion".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, The Basics and Beyond the Basics. The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on patient info and the keyword[s] of interest.)
●Basics topic (see "Patient education: Swallowed objects (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Clinical manifestations – Many children with esophageal foreign bodies are asymptomatic or have transient symptoms at the time of the ingestion, such as retrosternal pain, cyanosis, or dysphagia. When symptoms do occur, they may include a sensation of something stuck in the chest, refusal of feeds or dysphagia, drooling, or respiratory symptoms including wheezing, stridor, or choking. (See 'Clinical manifestations' above.)
Patients with long-standing esophageal foreign bodies may present with weight loss, aspiration pneumonia, fever, or signs and symptoms of esophageal perforation including crepitus, pneumomediastinum, or gastrointestinal bleeding. (See 'Clinical manifestations' above.)
●Imaging – The initial evaluation of a patient with suspected foreign body ingestion should include biplane radiographs (anteroposterior and lateral) of the neck, chest, and abdomen (algorithm 1). Other imaging modalities or direct advancement to upper endoscopy may be helpful in identifying radiolucent foreign bodies. (See 'Imaging' above.)
●Urgent removal required – Urgent and sometimes emergent intervention to remove a foreign body is indicated in any of the following situations (algorithm 1) (see 'Indications for urgent removal' above):
•Multiple high-powered magnets (in the esophagus or stomach)
•Sharp or long (>5 cm) object, or a superabsorbent polymer (in the esophagus or stomach)
•Disk battery (in the esophagus)
•Any object in the esophagus for >24 hours or time of ingestion unknown
•Symptoms suggesting airway compromise, esophageal obstruction (eg, the patient is unable to swallow secretions), inflammation, or intestinal obstruction (fever, abdominal pain, or vomiting)
●Expectant management – For patients with a foreign body in the esophagus but without the above characteristics, who are comfortable and able to handle oral secretions, intervention can be delayed for up to 24 hours. Coins, food impactions, and other blunt objects often will pass spontaneously into the stomach and beyond. (See 'Expectant management' above.)
Objects that have passed beyond the proximal duodenum are not accessible to the endoscope, and most will pass without complications. The progress of radiopaque objects down the gastrointestinal tract should be monitored with serial radiographs. (See 'Coins' above.)
●Approach by type of object – Certain types of objects warrant special consideration:
•Disk battery – A battery lodged in the esophagus should be removed urgently. Necrosis of the esophagus may occur due to liquefaction from the electrical current. This can result in ulceration within a few hours of ingestion and perforation as early as eight hours after ingestion. Recommendations for removal of disk batteries that are in the stomach depend on the timing of ingestion and composition of the battery, and are discussed separately. (See 'Batteries' above and "Button and cylindrical battery ingestion: Clinical features, diagnosis, and initial management".)
•Magnets – Suspected ingestion of a high-powered magnet(s) requires urgent evaluation. Management depends on the timing, location, type, and number of magnets (algorithm 2A-B). Single magnets can generally be managed conservatively but with precautions. Ingestion of multiple magnets has a high risk of complications and warrants preemptive removal. (See 'Magnets' above.)
•Sharp object – A sharp object in the esophagus or proximal gastrointestinal tract should be removed promptly (algorithm 3). This is because of significant risks for complications from sharp objects and low risks for endoscopic removal. If these objects have passed beyond the proximal duodenum and the patient is asymptomatic, they can be managed with close observation and serial radiographs. (See 'Sharp-pointed objects' above and 'Magnets' above.)
•Food impaction – Patients with a food bolus impaction who are in acute distress or unable to swallow oral secretions require immediate attention and removal of the impaction (algorithm 4). If the patient is comfortable and able to handle oral secretions, endoscopic intervention can be delayed for up to 24 hours. If endoscopy is performed, esophageal mucosal biopsies should be obtained to evaluate for an underlying mucosal abnormality such as esophagitis or stricture. (See 'Esophageal food impaction' above.)
●Extraction techniques – A variety of techniques are used to extract foreign bodies from the esophagus or stomach. We suggest flexible endoscopy for most foreign body extractions (Grade 2C). This preference is because the technique can be adapted to a variety of foreign bodies in the esophagus, stomach, or proximal duodenum and allows direct assessment of the mucosa for injury. Rigid endoscopy or retrieval with Magill forceps are useful techniques for objects in the hypopharynx or proximal esophagus. For blunt and small objects (eg, coins), bougienage is a reasonable choice for appropriately selected patients, when performed by clinicians experienced with the technique and with endoscopy available should bougienage fail. (See 'Techniques' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Mark E McOmber, MD, who contributed to earlier versions of this topic review.
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