Foreign body in the esophagus

Disease Description (Causes and Symptoms)

• Definition: A foreign body in the esophagus is a condition in which an intentionally or unintentionally swallowed object becomes lodged in the esophagus. It commonly becomes stuck at esophageal constrictions, especially the first constriction, and is particularly common in children.
• Causes/Pathophysiology:
  • Children: Most cases are accidental aspiration/ingestion of small foreign bodies such as coins, small toys, buttons, and safety pins. It occurs most often in children, especially those aged 1–3 years (approximately 75–80%).
  • Adults: Bone fragments, dentures, and sharp metals such as pins and needles; the risk is increased in psychiatric patients, prisoners, and patients with esophageal disease, including strictures or a history of surgery.
  • Pathophysiology: Mechanical obstruction causes dysphagia and retention of secretions; pressure-induced mucosal ischemia can lead to necrosis and perforation. Batteries, especially button batteries, cause electrochemical and chemical injury, resulting in rapid tissue necrosis.
• Main symptoms:
  • Increased salivation (drooling), difficulty swallowing (dysphagia), a foreign-body sensation in the throat, vomiting, coughing, chest pain, shortness of breath, or wheezing.
  • In children, symptoms may be nonspecific, such as irritability, loss of appetite, or fever, and may be mistaken for an upper respiratory infection or gastrointestinal disease.
  • In severe cases, airway compression can cause shortness of breath and stridor.

Treatment Methods

• Principles: Treatment is determined based on the type of foreign body (battery, sharp object, radiolucent or not), location (in the esophagus or gastrointestinal tract), symptoms (airway obstruction or excessive salivation), and time elapsed.
• Emergency treatment (immediately required):
  • In cases involving a button battery, a strongly corrosive substance, sharp metal such as a pin, needle, or razor blade, suspected airway injury, shortness of breath, or signs of airway obstruction, secure the airway immediately (intubation if necessary), followed by endoscopic removal.
• Endoscopic removal:
  • Direct removal using a flexible or rigid endoscope is the standard treatment (diagnosis and treatment are performed simultaneously). It should be performed as soon as possible, especially for dangerous objects.
• Non-emergency management/observation:
  • If symptoms are mild and the foreign body is small and round, with no risk of harm while passing through the gastrointestinal tract, observation and follow-up with abdominal radiography may be appropriate. However, active removal is recommended if symptoms develop or if the object remains for more than 24 hours, depending on the clinical situation.
  • Balloon catheter technique: May be used under fluoroscopy within 72 hours only for a single, round, radiopaque foreign body. It is contraindicated in cases of esophageal abnormalities, a history of surgery, or shortness of breath.
• Surgical treatment:
  • Surgical treatment is required if endoscopic removal is not possible or if esophageal perforation or serious complications, such as involvement of a major blood vessel, occur.
• Other treatments:
  • If perforation is suspected: nil per os (NPO), antibiotics, fluid replacement, oxygen therapy, and intensive care if necessary.
  • Analgesics and acid suppression with a proton pump inhibitor (PPI) may be considered to relieve pain and inflammation, promote wound healing, and prevent recurrence.
• Precautions (self-care):
  • Do not try to remove the object forcefully with your fingers at home (the blind finger-sweep technique is dangerous).
  • Do not give food to push the object down, especially in the case of a button battery or a sharp foreign body, for which this is contraindicated.
  • Symptoms requiring an immediate emergency-room visit: persistent drooling, severe dysphagia, shortness of breath, persistent chest pain, or hemodynamic instability.

Checklist Before an Outpatient Visit (Including Example Questions)

Items to prepare and information to confirm:

• Time of ingestion (exact time), circumstances at the time of ingestion (as much detail as possible about what was swallowed: size, shape, and material, such as plastic, metal, glass, battery, or bone), and the number of objects
• Current symptoms (drooling, difficulty swallowing, shortness of breath, chest pain, vomiting, etc.) and when they began
• Medical history: esophageal surgery, esophageal stricture, gastroesophageal reflux disease, and the condition of the teeth or dentures
• List of current medications and allergy information
• Results of previously performed radiographic or endoscopic examinations, if available (bring them)
• For children, a guardian should accompany them; if possible, bring photographs of the foreign body or the relevant object and its packaging Example questions to record before the appointment:
• When and what object did you swallow?
• Do you currently have pain when swallowing? Can you swallow food?
• Are you having difficulty breathing or abnormal breathing sounds, such as wheezing or stridor?
• Are you unable to swallow your saliva? Are you vomiting blood or seeing blood?

General Example Questions to Ask the Doctor

• "When is the recommended time for removing the foreign body? Is this an emergency?"
• "Which removal method do you recommend—flexible endoscopy, rigid endoscopy, balloon catheter, or surgery? What are the risks and advantages of each?"
• "How high is the risk of complications such as perforation or infection, and what should be done to prevent them?"
• "What dietary and activity restrictions should I follow after treatment?"

Examples of Disease-Specific Questions

• "The foreign body is a button battery (or sharp metal). Is immediate endoscopic removal necessary? How quickly could injury develop if removal is delayed?"
• "The foreign body is radiopaque (or is a single coin). Under what conditions is observation alone acceptable at your hospital or outpatient clinic, and what is the maximum observation period?"

Additional Reference (Summary)

• Permitted scope of observation: Short-term observation may be possible when the patient has no symptoms, the object is not dangerous, and the foreign body is small and harmless to swallow; however, removal is generally recommended if more than 24 hours have passed or if secretions are excessive.
• The balloon catheter technique may be used under fluoroscopy within 72 hours only for a single, round, radiopaque foreign body; it is contraindicated in cases of esophageal abnormalities, shortness of breath, or a history of surgery.
• In situations requiring an immediate emergency response, such as a button battery, sharp metal, or shortness of breath, the patient must be transferred without delay to the emergency room or endoscopy unit.