Open Access Original Article

Upper Gastrointestinal Tract Foreign Bodies Pak Armed Forces Med J 2018; 68 (3): 634-38

UPPER GASTROINTESTINAL TRACT FOREIGN BODIES IN CHILDREN:

PRESENTATION AND MANAGEMENT
Aftab Anwar, Muhammad Almas Hashmi, Samia Khaliq*
Children’s Hospital & Institute of Child Health Lahore Pakistan, *Jinnah Hospital Lahore Pakistan

ABSTRACT
Objective: To describe the presentation and outcome of upper gastrointestinal (GI) foreign bodies in children.
Study Design: Descriptive case series.
Place and Duration of Study: Department of Pediatric Gastroenterology, Hepatology & Nutrition, the Children’s
Hospital & the Institute of Child Health Lahore, from Jan 2016 to Dec 2016.
Material and Methods: Fifty eight children with history of foreign body ingestion were included in the study
through non probability purposive sampling technique. Children underwent upper GI endoscopy flexible
endoscope under general anesthesia. The data such as age, sex, mode of presentation, type of foreign body and
site of impaction was recorded on a specially designed proforma. Qualitative variables including gender, type of
foreign body, clinical features, site of impaction etc were expressed in term of frequencies and percentages while
age was expressed as mean and standard deviation.
Results: Among 58 patients 53.4% (n=31) were male and 46.6% (n=27) were female with age range from 2 months
to 15 years. Majority of cases had developed dysphagia (70.7%). Coins were the most common foreign bodies
encountered (32.8%) followed by button batteries (31%). Lower esophagus was the most common site of
impaction of foreign bodies (65.5%).
Conclusion: Coins and button batteries are the common upper GI foreign bodies with lower esophagus being the
most common site of impaction. Commonest presenting feature was dysphagia. Endoscopic retrieval of foreign
bodies under general anesthesia is a safe mode of treatment.
Keywords: Children, Management, Upper GI foreign bodies.

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INTRODUCTION with ingestion of multiple foreign objects5.

Ingestion of foreign body is a common Esophagus being the narrowest area within the
problem encountered in pediatric gastro- gastrointestinal (GI) tract is the common site of
enterology1. Fortunately, most foreign bodies that foreign body impaction especially the upper third
reach the gastrointestinal tract pass sponta- part6,7. Once beyond stomach, the chances of
neously. About 10 to 20 percent of ingested impaction of foreign body are small.
foreign bodies require endoscopic removal, and Most children with ingested foreign bodies
less than 1 percent requires surgical intervention2. are asymptomatic. They are brought to medical
Although mortality from foreign body ingestion attention by their parents as they witness the
is extremely low, deaths have been reported3. ingestion. Patients may present drooling, refusal
Coins are the most commonly reported foreign to feed or dysphagia, or respiratory symptoms
bodies ingested in children4. Apart from coins including wheezing, stridor, or choking. Children
batteries, magnets, safety pins, toys & their parts, presenting with food bolus impaction usually
bones, marbles, screws and food have been have an underlying pathology (e.g, a stricture)
reported. Developmentally delayed children directly responsible for the impaction4. Long-
present with repeated ingestion episodes and standing esophageal foreign bodies may cause
recurrent aspiration pneumonia and weight loss,
Correspondence: Dr Aftab Anwar, House No 522, Pak Arab
Housing Society Feroze Road Lahore Pakistan
due to aspiration of oral secretions and poor
Email: [email protected] caloric intake, respectively. They can also cause
Received: 18 May 2017; revised received: 11 Jul 2017; accepted: 21 Jul damage to gastrointestinal mucosa and lead to
2017

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Upper Gastrointestinal Tract Foreign Bodies Pak Armed Forces Med J 2018; 68 (3): 634-38

strictures. Sometimes esophageal wall may be calculated using WHO sample size calculator,
eroded, creating a fistula with the trachea or keeping confidence internal 10%, absolute
other structures7. Sharp objects may perforate the precision required 90% and anticipated
esophagus causing neck swelling, crepitus, or proportion of foreign bodies which were coins (P)
pneumomediastinum. Ingestion of gloves, foam, 26.23%5. Fifty eight children with history of
spray foam, bread clip, plastic wires, polystyrene, foreign body ingestion were included in the
polyethylene and vinyl can lead to bezoar study through non probability purposive
formation8. Complications caused by foreign sampling technique. Children underwent
bodies in small bowel include abdominal pain, upper GI endoscopy by a fellow in pediatric
vomiting, altered bowel movements, distension, gastroenterology, with flexible endoscope under
malena, perforation, abscess formation, general anesthesia. The data such as age, sex,
peritonitis and hematochezia9. mode of presentation, type of foreign body and
Radiographic investigation includes a soft site of impaction was recorded on a specially
tissue lateral neck radiograph and a chest designed proforma.
radiograph. Classically, coins are oriented All the data was analyzed using computer
coronally in esophagus. Diagnosis of radiolucent program SPSS version 20. Qualitative variables
foreign bodies, such as plastic, glass and wooden including gender, type of foreign body, clinical
objects involves endoscopic evaluation or features, site of impaction etc were expressed in
contrast radiography. term of frequencies and percentages while age
Treatment for objects visible on a radiograph was expressed as mean and standard deviation.
or not visible can involve endoscopy. Rigid RESULTS
endoscopy with general anesthesia is usually Among 58 patients 53.4% (n=31) were male
employed to retrieve esophageal foreign and 46.6% (n=27) were female with age range
bodies10. For foreign bodies distal to the from 2 months to 15 years with a mean age of
esophagus, surgical removal by laparotomy or 4.38 ± 3.01 years. Presenting complains of the
laparoscopy is required only in rare cases where a patient are shown in table-I, dysphagia being the
foreign body cannot be retrieved by endoscopy, commonest (70.7%).
when a complication such as perforation or
Most of the patients presented to
obstruction has arisen or in cases where large or
emergency department within 24 hours of
sharp objects do not demonstrate progression for
ingestion. Diagnosis was made clinically and/or
weeks11.
radiologically with type of foreign body.
The data on clinical spectrum of upper
Radiological investigations consisted of plain
gastrointestinal foreign bodies in children is
x-ray neck and chest. All the patients underwent
scarce in Pakistan and limited to few case reports.
upper GI endoscopy with flexible endoscope.
Therefore this study has been carried out to
Site of impaction of foreign bodies has been
deduce the clinical spectrum of this entity in
illustrated in table-II. Fifty six patients were
children in our setting.
discharged within 24 hours of admission while 2
PATIENTS AND METHODS were discharged within 48 hours. The common
After Hospital ethical committee approval foreign bodies were coins (32.8%) followed by
and consent from parents/guardians of the button batteries (31%) as shown in table-III.
patients; this descriptive case series was Complications were noted in 7% of patients as
conducted at Department of Pediatric Gastro- respiratory distress.
enterology, the Children’s Hospital & the All patients were successfully managed with
Institute of Child Health, Lahore, from January flexible upper GI endoscopy. Foreign body was
2016 to December 2016. Sample size was

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retrieved in 49 (84.5%) patients while it was study, 78.4% of cases were witnessed by parents
pushed into stomach is remaining 9 (15.5%) or siblings before presentation to emergency
patients. All patients were discharged in stable department.
condition with no endoscopy related Dysphagia has been reported as the most
complications after the procedure. frequent symptom, followed by drooling and
DISCUSSION odynophagia. Foreign bodies coming just inferior
Foreign bodies in upper gastrointestinal tract to the cricopharangeus muscle produce
are usually swallowed accidentally or dysphagia and pain in the suprasternal area
purposefully. After nose and ear, the esophagus during swallowing15. Children may also
is the commonest foreign body which present in complain of sensation of something being stuck
emergency department12. Due to exploratory in the neck, pain in the neck, or chest, salivation,

Table-I: Presenting complaint.

Type No. of patients Percentage (%)
Dysphagia 41 70.7
Odynophagia 8 13.8
Drooling 9 15.5
Table-II: Site of impaction.
Site No. of patients Percentage (%)
Upper Esophagus 12 20.7
Lower Esophagus 38 65.5
Stomach 5 8.6
Duodenum 3 5.2
Table-III: Type of foreign body.
Type No. of patients Percentage (%)
Coin 19 32.8
Button Battery 18 31
Bone 4 6.9
Ornament 6 10.3
Food Bolus 5 8.6
Miscellaneous 6 10.3
nature, foreign body ingestion is common in refusal of food, or respiratory distress after
children and this has been narrated by many ingestion of foreign body16. In our study
studies. While any small object is an ingestion population, dysphagia (70.7%) was the most
hazard, coins, disc batteries, needles, toys parts, common presenting complaint followed by
marbles, ornaments and bottle caps are drooling and odynophagia in order of frequency.
commonly ingested by children. In our study the Respiratory distress or cyanosis was not reported
median age was 3.35 ± 3.01 years with more than in any patient.
half (62.1%) of patients under 4 years of age. A The types of foreign bodies ingested vary
slight male predominance (53.4%) has been from country to country and is in accordance to
recorded in our study. Similar findings have been the culture and feeding habits of it. Several
observed by Dereci and other authors regarding studies found that the coins are most commonly
age and gender distribution4,13. A history of ingested4,17. However, ingestion of button
foreign body ingestion is extremely important to batteries is also very common18. Although our
reach at a quick and definite diagnosis14. In our study concluded coins (32.8%) as the most

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Upper Gastrointestinal Tract Foreign Bodies Pak Armed Forces Med J 2018; 68 (3): 634-38

common foreign body retrieved, button batteries hours, in an otherwise healthy patient may be
(31%) were not much far behind. Button batteries allowed to pass spontaneously into the stomach.
are small, coin-shaped batteries used in toys, However the object should be removed if there is
videogames, hearing aids, watches, and no progression on radiograph after 24 hours, to
calculators. As the use of this small electronic prevent local inflammation. Patients with
gadget has increased, the problem of disk battery respiratory difficulties or those having signs of
ingestion has increased significantly. esophageal perforation should be referred for
Lin et al states that the diagnosis of foreign endoscopy.
body is based upon three elements: eye-witness, Several other removal techniques have been
x-ray and endoscopic findings19. Variable use of employed for retrieval of esophageal foreign
radiology has been documented in diagnosis of bodies. The Foley catheter method involves
foreign body. Imaging studies are commonly inserting the deflated catheter orally, past the
employed for diagnosis of foreign body ingestion object. The balloon is then inflated and the
in children, though negative radiology findings catheter is slowly withdrawn, pulling the foreign
are also common, especially for inorganic foreign body ahead of it. Glucagon relaxes the smooth
bodies. Alternatively, there have been reports muscle of the lower esophageal sphincter
that have suggested the use of a metal detector to allowing passage of the object into the stomach.
locate an ingested coin20. In cases of non radio Success rates using glucagon ranges from 30-
opaque foreign bodies, widening of prevertebral 50%22. Glucagon causes nausea and vomiting.
space is suggestive of foreign body on radiograph These techniques are cost effective as compared
of neck lateral view21. Plain radiology does not to endoscopy but these do not allow direct
have any influence on management of non visualization and also airway is not protected
opaque foreign body, except in delaying while employing these techniques21.
endoscopy. In older children and adults Complications of foreign body ingestion can
posteroanterior and lateral chest radiograph occur throughout the GI tract. These include
provide better localization. In this study we abrasions, perforation, abscess formation,
diagnosed all our patients clinically or on plain obstruction, ulceration, fistula formation,
radiographs of neck/chest. vascular injuries or airway compromise. With
The upper esophagus is the narrowest the advent of endoscopy, more foreign bodies are
portion of gastrointestinal tract and is, therefore, successfully removed resulting in lesser
the most common site for lodging foreign complications.
bodies6,7. However in contrary to most of studies, The best method of removal of an
65.5% of foreign bodies were found in lower esophageal foreign body remains controversial23.
esophagus in our study. Jafari and colleagues also In our country due to lack of pediatric
documented similar findings to our study18. gastroenterologists, adult otolaryngologists and
Management of an esophageal foreign body gastroenterologists perform endoscopies
depends on its type and location. Any sharp, employing rigid endoscopes, which carry a
rigid, or long (>5-6 cm) object should be removed higher complication rate24,25. However due to lack
with endoscope as they are associated with a high of prospective, multicenter trials regarding use of
incidence of esophageal and lower GI tract flexible endoscope in pediatric patients, evidence
perforation22. Objects in the proximal and mid based guidelines have still not been formulated.
esophagus should also be removed since they The purpose of this study was to present our
usually do not pass into the stomach experience with flexible endoscope in removal of
spontaneously. Asymptomatic single blunt object ingested foreign bodies. We note 89% success rate
located in the distal esophagus for less than 24 in our study whereas 11% were pushed down

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