Małgorzata Badełek-Izdebska, *Lidia Zawadzka-Głos
Foreign bodies in the oesophagus on the example of patients of the Department of Paediatric Otolaryngology at the Medical University of Warsaw
Ciała obce w przełyku na przykładzie pacjentów Kliniki Otolaryngologii Dziecięcej WUM
Department of Pediatric Otolaryngology, Medical University of Warsaw, Poland
Head of Department: Lidia Zawadzka-Głos, MD, PhD
Wstęp. Ciała obce w przełyku to jeden z częstszych nieinfekcyjnych powodów wizyty dziecka w szpitalnej izbie przyjęć. Dzieci zazwyczaj połykają przedmioty przypadkowo w trakcie zabawy, podczas poznawania świata za pomocą zmysłów, a także w czasie spożywania posiłków. Najczęściej połykane są monety, plastikowe lub metalowe fragmenty przedmiotów i baterie. W przełyku mogą także utkwić twarde kawałki jedzenia.
Cel pracy. Celem pracy była analiza objawów klinicznych oraz postępowania diagnostyczno-leczniczego u pacjentów z podejrzeniem obecności ciała obcego w przełyku.
Materiał i metody. Autorzy przeanalizowali kliniczne dane 49 pacjentów hospitalizowanych w Klinice Otolaryngologii Dziecięcej WUM z powodu podejrzenia lub obecności ciała obcego przełyku, a także proces diagnostyczno-leczniczy, podczas którego potwierdzono lub wykluczono rozpoznanie wstępne.
Wyniki. Przeanalizowano objawy, z którymi pacjenci zgłosili się do szpitala, zastosowane procedury diagnostyczne i lecznicze oraz rezultaty leczenia. Zwrócono uwagę na trudności diagnostyczne, jakie może napotkać lekarz w Izbie Przyjęć, a następnie otolaryngolog kwalifikujący pacjenta do leczenia zabiegowego lub decydujący o postępowaniu zachowawczym. Opisano możliwe powikłania mogące wystąpić podczas wykonywania ezofagoskopii.
Wnioski. Najczęstszymi ciałami obcymi są monety, metalowe lub plastikowe części przedmiotów lub pokarm. Najbardziej niebezpiecznymi ciałami obcymi są baterie dyskowe i ostre, duże przedmioty. Diagnostyka obrazowa obejmuje przeglądowe RTG klatki piersiowej i szyi, a w przypadku ciał niekontrastujących RTG z barytem lub watką nasączoną kontrastem.
Obecność objawów klinicznych i/lub wyników badań obrazowych sugerujących obecność ciała obcego w przełyku jest wskazaniem do endoskopii przełyku w znieczuleniu ogólnym.
Zarówno ezofagoskopia sztywna, jak i wykonywana za pomocą giętkiego fiberoskopu są obarczone pewnym stopniem ryzyka, o czym należy poinformować rodziców przed ich wykonaniem.
Introduction. Foreign bodies in the oesophagus are one of the more frequent non-infectious reasons for a child’s visit to the hospital emergency room. Most often, children swallow items accidentally while having fun, learning about the world with the help of their senses, as well as when eating meals. It is coins, plastic or metal fragments of objects that are usually swallowed. Also, hard pieces of food may stick to the oesophagus.
Aim. The aim of the study was to analyse clinical symptoms as well as diagnostic and therapeutic procedures in patients with suspicion of the presence of a foreign body in the oesophagus.
Material and methods. The authors analysed clinical data of 49 patients hospitalized in the Department of Paediatric Otolaryngology at the Medical University of Warsaw due to the suspicion or presence of a foreign body in the oesophagus. What was also analysed, was the diagnostic and therapeutic process during which the initial diagnosis was confirmed or excluded.
Results. The authors analysed the symptoms with which patients came to the hospital, the diagnostic and therapeutic procedures used and the results of treatment. Attention was paid to diagnostic difficulties that may be encountered by a physician in the Admission Room, and then an otolaryngologist qualifying the patient for interventional treatment or deciding on conservative procedures. Possible complications that may occur during ezophagoscopy are described.
Conclusions. Foreign bodies in the oesophagus are a common problem in the paediatric population. The most common foreign objects are coins, metal or plastic items or food. The most dangerous foreign objects are disc batteries and sharp, large objects.
Diagnostic imaging includes chest and neck X-ray, and in the case of non-contrasting bodies – X-ray with barium or a cotton ball soaked in contrast.
The presence of clinical symptoms and/or imaging results suggesting the presence of a foreign body in the oesophagus is an indication for oesophageal endoscopy under general anaesthesia. Both rigid esophagoscopy and the use of a flexible fiberscope are burdened with a certain degree of risk, of which the parents should be informed before those are performer.
Foreign bodies in the oesophagus are one of the more frequent causes of hospitalization of patients in laryngology units. Most often, foreign objects are swallowed by children accidentally during play, while learning about the outside world with the help of the senses of touch and taste, as well as when eating meals. The youngest children, including infants, are not always able to signal the swallowing of objects; however, vigilant observation by their parents or their presence during an accidental ingestion of the item, is the reason for the carers to contact the doctor and implement appropriate diagnostics. Symptoms may vary in severity, depending on the type of the foreign body, its location, and the time of presence of the body in the oesophagus. Depending on these circumstances, appropriate measures are implemented.
The aim of the study was to analyse clinical symptoms as well as diagnostic and therapeutic procedures in patients with suspicion of the presence of a foreign body in the oesophagus.
Material and methods
The research material was the history of diseases of 49 patients hospitalized in the Department of Paediatric Otolaryngology of the Paediatric Hospital of the Medical University of Warsaw from the end of December 2015 to the beginning of April 2018. A retrospective analysis of the medical data of children admitted to our department due to the suspicion of presence of a foreign body in the oesophagus was conducted. The data from the interview was analysed, as well as the symptoms that the patient reported to the hospital, the results of imaging tests, indications for the performance of esophagoscopy or the reasons for resignation from the treatment, and factors determining the possibility of ending treatment in the hospital ward.
In the analysed period, 49 patients were registered and admitted to the Department of Paediatric Otolaryngology. There were 21 girls and 28 boys in the studied group of patients. The youngest patient at the time of admission to the ward was 6 months old, the oldest – 17 years and 7 months old. The division into age groups was as follows: children up to 12 years old accounted for 14.3%, children from 13 years of age up to 2 years old accounted for 16.3%, patients aged 2-3 years accounted for 24.5%, the remaining 44.9% were patients over 3 years of age. Only one patient was admitted as planned for esophagoscopy due to symptoms lasting for many months, which could suggest, inter alia, the presence of an obstacle in the oesophagus. The remaining 48 patients were admitted to hospital urgently; in 45 children symptoms had appeared within 24 hours before hospitalization, three children had had symptoms for a few days before entering the hospital. In a large part of patients, the interview for the possibility of swallowing a foreign body was positive. This applied to children who reported problems after swallowing an item they were playing with for a short time before the symptoms occurred, as well as situations in which parents or caregivers were convinced that the missing objects or fragments were likely to be in the child’s mouth. These were mostly coins or plastic tokens, as well as plastic elements of toys or decorations. Other situations that caused the parents to report to the hospital were problems with swallowing, directly or shortly after eating a meat meal, fish, pieces of fruit or vegetables and sweets. The aliments presented by the patients were mainly related to problems with swallowing of solid food, but also fluids. Some patients complained about the feeling of an obstacle in the throat or neck, as well as neck pain in the projection of the oesophagus, and the pain was not always associated with the act of swallowing. Other symptoms observed in children included salivation, vomiting, retching or refusal of food intake. One patient had pain in the back. In four patients, a cough was observed, but these children did not present breathing disorders in the form of dyspnoea or stridor.
Upon admission, 7 patients had the results of a chest X-ray carried out in another hospital, of which 6 patients had a review examination, and one X-ray examination with barium pulp. In 40 patients, radiological examination in the form of a chest X-ray was performed in the local hospital emergency ward, in 2 patients the examination was repeated in the ward because of the time that elapsed from the previous imaging examination to the planned esophagoscopy. In 2 patients, radiological examination was aborted upon admission and during further hospitalization. Two patients had a radiological examination with barium pulp carried out upon admission. Imaging studies revealed the presence of a foreign body in the oesophagus projection in 32 cases (31 metallic objects and 1 with bone density); in 5 patients indirect symptoms indicating the possibility of swallowing a foreign body were observed (in 2 examinations, there was an oblong contracting loss (fig. 1) in 1 examination tracheal modelling was described, in one patient the X-ray revealed the stoppage of the barium pulp in the oesophagus, 1 study showed the presence of a unilateral air trap in the pulmonary field). No irregularities were found in 9 X-ray examinations.
Fig. 1. Longitudinal loss of contrasting (a plastic token)
Rigid esophagoscopy under general anaesthesia was performed in 38 patients, 36 of whom were intubated before the procedure, while in the other two cases, the foreign body was first removed from the pharyngeal laryngoscope using Magilla forceps, and then after intubation, the oesophagus was inspected with a rigid esophagoscope. During esophagoscopy, foreign bodies in the oesophagus were seen and removed in 33 patients; in 5 cases the foreign body in the oesophagus was not found. Among the removed foreign bodies there were: 19 coins, 11 metal objects, 6 plastic elements, 1 bone and 1 seed of green peas. Most foreign bodies were removed from the area of the first or second oesophageal stricture. Items removed from the lower throat were: a metal wire (fig. 2) and a plastic star.
Fig. 2. Wire on the border of the lower throat and esophagus
In four patients, due to coughing in the past and a persistent cough, as well as results of imaging examinations indicating the possibility of aspiration of a foreign body to the respiratory tract, simultaneous bronchoscopy was performed. In three cases, there was a thick mucopurulent secretion in the airways, in the fourth patient – the airways were free.
Four patients underwent gastrofiberoscopy: in two patients, foreign bodies dislocated to the gastric cardia, the next patient was suspected of carrying fragments of a glass bauble in the oesophagus or stomach, one patient reported symptoms after eating a tangerine particle. Coins and a piece of tangerine were removed, while fragments of the bauble were not found.
None of the 38 patients was diagnosed with oesophagus perforation during esophagoscopy; in one case (of an ingested open safety pin) – a slight oesophageal wall injury was found (fig. 3); two children showed slight flushing of the oesophagus wall at the foreign body adhesion site; in two patients a red, stained wall of the oesophagus along its entire length was observed and eosinophilic esophagitis was suspected, which was confirmed in the results of a further histopathological examination.
Fig. 3. Safety pin in the esophagus of a 6-month-old child
Seven hospitalized patients were treated conservatively. In three of them the symptoms occurred after eating food (sweets, meat), in two children, the symptoms disappeared quite quickly after admission to the ward, and the X-ray showed no abnormalities, in two patients – metal objects moved to further parts of the gastrointestinal tract, which was confirmed in imaging studies.
In patients who had esophagoscopy with foreign body removal performed, and a scratch or an injury of the oesophageal mucosa was found during the procedure, a control X-ray imaging was carried out, which showed no abnormalities in the form of perforation of the oesophagus or any features of pneumothorax. The girl who had the oesophageal mucosa injured after the removal of the safety pin was hydrated intravenously for 12 hours, then the child was allowed to drink the physiological saline, gradually introducing other fluids to drink, and then food. The remaining patients were able to take oral fluids 2 hours after the procedure, and then their diet was gradually extended.
In all patients, the ailments present at the hospital admission disappeared. Patients without esophagoscopy lesions in the oesophagus mucosa were discharged from the hospital after two days.
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