Oh Where, Oh Where Did That Little Foreign Body Go?

Patient Presentation

A 17 month-old female came to clinic because of 1 week of coughing and upper respiratory symptoms.
The past medical history showed her to have 1 previous pneumonia treated as an outpatient.
The review of systems was negative.
The pertinent physical exam revealed a coarse cough, copious clear rhinorrhea, and a lung examination with slightly prolonged expiration. Her abdominal examination was normal.
A chest radiograph was obtained because of parental anxiety over the previous pneumonia.
The radiologic evaluation revealed a round radio-opaque foreign body in the antrum of the stomach. The parent was further questioned and said that the child liked to play with coins and she had found the child playing with pennies the previous evening.
The diagnosis of incidental radio-opaque foreign body (probably a penny) in the stomach was made along with a viral upper respiratory infection. The mother was told to watch for the object in her stools, and was to return to clinic if the object was not found in 2 weeks or if any gastrointestinal symptoms began.

Figure 13 AP radiograph of the chest showing a round foreign body in the antrum / pylorus of the stomach.

Discussion
Children because of their curiosity of the world and their own bodies often place foreign bodies into orifices. This occurs at all ages, but is more in common younger children, especially 6 months-4 years. Common objects include coins, button batteries, toy parts, screws, paperclips, pins, tacks, etc.
Luckily most objects pass through the GI tract without problems. Children with underlying anatomical abnormalities have increased risk of retaining the foreign body. Retained foreign bodies have increased risks of impaction with possible pain, puncture, bleeding, obstruction, scarring and/or erosion. Previously unknown abnormalities may also present as a retained foreign body.

Foreign bodies can present incidentially or by :

  • Cough or stridor
  • Blood – hematemesis, hematochezia
  • Emesis
  • Fever – unexplained
  • Mental status – altered
  • Pain – abdominal, chest, throat
  • Swallowing difficulty
  • Refusing food

On radiographs the objects can be radio-opaque or radiolucent. Most gastrointestinal foreign bodies are radio-opaque, in contrast to those in the respiratory tract which are often radiolucent. A pneumonic for radio-opaque foreign objects is:

Treatment depends on the location. If removal is indicated, endoscopy is generally used. Other methods include an inflated red rubber catheter to pull the object out of the esophagus, or bougienaging the object into the stomach may also be used. Objects that are in the upper esophagus need to be removed because of the risk of dislodging and moving into the lung.
Once the object is in the stomach it is very likely that the object will pass through the rectum with no problems in a few days. Therefore, watchful waiting is appropriate.
Objects that are toxic, sharp, or too big (i.e. length > 6 cm or width > 2 cm) are generally removed. Button batteries need to be removed if they are retained for more than a few days because of the risk of erosion. Children with underlying abnormalities often will also have the objects removed because of the increased risk of retainment.

Learning Point
Sharp or toxic foreign bodies can become lodged anywhere. Objects that are too big may not pass through the stomach’s pylorus.

Common locations for gastrointestinal foreign bodies to lodge includes:

  • Pharynx/Thorax
    • Thoracic inlet – area between clavicles on chest radiograph – this is the area of change from skeletal muscle to smooth muscle
  • Esophagus
    • Cricopharyngeal sling – at C6 on chest radiograph

    • Midesophagus – aortic arch and carina push upon the esophagus on radiograph
    • Lower esophageal sphincter
  • Stomach and Lower Gastrointestinal tract
    • Stomach pylorus

    • Ileocecal valve

Questions for Further Discussion
1. What are common foreign bodies located in the respiratory tract and where are their common locations?
2. What is the treatment for nasal or aural foreign bodies?

Related Cases

    Disease

      Foreign Bodies

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Choking/Swallowing a Foreign Body.

Connors, GP. Pediatrics, Foreign Body Ingestion. eMedicine.
Available from the Internet at http://emedicine.com/emerg/topic379.htm (rev. 7/4,2004, cited 2/24/2005).

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1397-1399.

Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

Date
March 28, 2005

What Do You Do When An Adolescent Is Out of Control?

Patient Presentation
A 16-year-old female was referred to the inpatient ward for further evaluation of chronic left-sided generalized body pain. She was noted to be continuously crying and intermittantly yelling at her mother so the inpatient physicians were called immediately. Upon arrival, she left the room, walked down the hallway and left the floor. The resident physician tried to convience her to return to the room but she refused and went on an elevator. The resident returned to the floor and called the security staff to help find her. Her family tried to contact her personal cellphone and went to their car without success in locating her.
After 30 minutes she came back to the floor by herself. She continued to be tearful with occasional outbursts. She stated she had no intentions of hurting herself or others, but she “just needed to get out of here for a while.” After a several long discussions with her, she agreed to stay in the hospital for evaluation and treatment. The nursing staff was concerned about her mental health and another episode of elopement.
The past medical history revealed depression treated by counseling.
She was evaluated that evening by psychiatry staff who felt that she had some depressive features consistent with chronic illness, and she was not a risk to herself or others. They also felt her pain was possibly due to a conversion disorder, but this could not be diagnosed until a full medical evaluation had been pursued.
She was placed in a single room close to the nurses station and as far away from the outside ward doors as possible. The patient was closely monitored by the nurses. The healthcare team made contingency plans including security and psychiatry staff in case she eloped again or became out of control.
The patient’s evaluation included reviewing her past medical and psychiatric work-ups, consultation with neurology and rheumatology and some additional laboratory testing. All the testing was negative and
the diagnosis of conversion disorder with depressive symptoms and histrionics was made. The patient had some improvement of her symptoms after learning of these conclusions and she agreed that ‘at least part of this is true.” Outpatient psychiatric treatment and primary care was arranged before discharge.

Discussion
What often is described as adolescent out-of-control behavior can range widely. Normal disputes between adolescents and their family, friends, teachers, etc. may simply get out-of-hand momentarily or the adolescent may be a danger to himself, others or property.
The differential diagnosis may include:

  • Depression

    • Major depression – full depressive picture without episodes of mania
    • Bipolar disorder – full depressive picture with previous episodes of mania
    • Dysthymic disorder – chronic, milder symptoms, often with insidious onset and constitutional factors predisposing
    • Adjustment disorder – stress is identifiable and stopping the stress usually improves or stops the depression. However, stress removal may not simply stop the depression
    • Bereavement – loss is the stress. This can include death but also greiving for other losses such as physical health
    • Suicide – attempt or ideation
  • Impulse Disorders

  • Psychosis

    • Affective – less common in adolescents, constellation includes abrupt onset, congruent mood, usually intelligible thought process
    • Organic – caused by a variety of drugs, e.g. amphetamines, lysergic acid, solvents, etc.
    • Neurological – associated with neurological disorders, e.g. temporal-lobe epilepsy, leukodystrophies, etc.
    • Schizophrenia – onset is often insidious, with bizarre mood, rigid or inappropriate affect and difficult to follow thought process
  • Attacks

    • Histrionic – exaggerated, irrational emotional states sometimes seen with conversion symptoms
    • Panic – tremor, dissociative symptoms or bizarre behavior in respone to feeling of dread or terror
    • Rage

Learning Point
The main consideration in dealing with an out-of control person is to achieve a safe environment for both the patient and the personnel caring for him/her. A calm response to the behavior is essential. Heroics may be unwise and risky and adequate help may require numbers of personnel. Knowing what help is potentially available before an emergency arises is best and often protocols are available. However, every situation is unique and resolution may require on-the-fly problem-solving by all the personnel involved. People who may be helpful in calming the situation may include security staff, psychiatric staff, clergy, previous medical caretakers, and family members.
A general plan should include:

  • Trying to maintain a low profile – do not challenge the patient
  • Trying to achieve a safe environment for care
  • Using eye contact with the patient but do not make it prolonged
  • Talking to the patient in a calming tone using their first name
  • Trying to understand what is precipitating the incident and remove it from the environment if possible until a calm environment is achieved
  • Trying to gain trust with the patient
  • Trying to give the patient choices to increase their sense of control
  • If calm is not attainable or self-injury or injury to others is possible, the patient will need to be physically immobilized
  • Immobilization using medication may also be necessary such as haloperidol or lorazepam which are often given intramuscularly
  • Transferring of the patient to an appropriate location for treatment and monitoring may be necessary
  • Evaluation by psychiatric personnel may be necessary

In this patient’s case, the patient returned by herself and she was fairly calm and reasonable. A psychiatric consultation had been planned as part of her evaluation. Because of this elopement, the consultation was obtained earlier to help assess her mental state at the time and to help providing an appropriate, safe environment for the patient and personnel.

Questions for Further Discussion
1. What criteria need to be met for voluntary and involuntary committment to a psychiatric facility?
2. When an adolescent refuses treatment that her legal guardian wants, what are the legal and ethical issues involved?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Adolescence.

Hofmann AD, Greydanus DE. Adolescent Medicine. 2nd Edit. 1983. pp. 581-591.

Clancy, G. Emergency Psychiatry Service Handbook.
Available from the Internet at http://www.vh.org/adult/provider/emergencymedicine/Psychiatry/TOC.html (cited 2/14/05).

Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

Date
March 21, 2005

What is the Classification of Intraventricular Hemorrhage (IVH)?

Patient Presentation
A 24 4/7 week infant was born by cesarean section for pre-term labor and vaginal bleeding.
The past medical history shows that the pregnancy was complicated by teenage motherhood, little prenatal care, suspected placental previa and prolonged rupture of membranes.
The pertinent physical exam shows him to be 695 grams, appropriate for gestation age, and in respiratory distress.
The radiologic evaluation of a screening head ultrasound on day of life 7 showed a diagnosis of bilateral grade II intraventricular hemorrhage (IVH). The second follow-up examination at day 21 of life showed progression to bilateral grade III intraventricular hemorrhage. He was treated conservatively and monitored closely. Repeat examination at day 42 showed resolving intraventricular hemorrhage and decreasing ventricle size.
The patient’s clinical course was complicated by multiple organ system problems because of his extreme prematurity. At discharge on day of life 121, he was to follow-up in the high risk infant follow-up program for bronchopulmonary dysphasia, retinopathy of prematurity, and neurodevelopmental follow-up and care coordination.

Discussion
Intracranial hemorrage is of 4 major types in a neonate: subdural hemorrhage, primary subarachnoid hemorrhage, intracerebellar hemorrhage and intraventricular hemorrhage (IVH). IVH is the most common and usually of greatest clinical significance as it is a major cause of mortality and morbidity in premature infants.
The incidence of IVH in infants &lt;1500 g or <35 weeks' gestation has been reported to be as high as 50%, but appears to have fallen in recent years. Mortality is 27-50% depending on the group studied with an inverse relationship between grade and survival.

The pathogenesis of IVH is not known but is likely multifactoral. Two major factors that contribute are the loss of cerebral autoregulation and abrupt alterations in cerebral blood flow and pressure. IVH originates in the subependymal germinal matrix adjacent to the lateral ventricle often at the level of the Foramen of Monroe in full-term neonates and further posterior in premature infants < 28 weeks.
Most remain in the germinal matrix. Many hemorrhages are clinically asymptomatic while others are catastrophic.

Presentations include:

    Physical examination

  • Alteration in mentation – seizures, posturing, coma or decreased consciousness
  • Apnea
  • Respiratory distress including tachypnea and retractions
  • Irregular breathing
  • Fontannel – full or bulging
  • Hypotension or blood pressure lability
  • Hypnotic
  • Pallor
  • Poor perfusion
    Laboratory

  • Acidosis
  • Bloody cerebrospinal fluid
  • Hematocrit drop
  • Hypoglycemia

Since IVH may be asymptomatic, all infants &lt; 1500 g should have a scheduled screening head ultrasound examination at day of life 5-7 and again at day of life 28-30. Most IVH occurs in the first week of life, but may be delayed so that the second ultrasound examination is scheduled at 28-30 days.
If IVH is suspected clinically, an emergent ultrasound should be ordered. If IVH occurs, follow-up sonograms often occur weekly to monitor and evaluate for development of hydrocephalus and the rate of ventricular dilatation, or for any periventricular cystic change that occurs.
Fortunately, post-hemorrhagic hydrocephalus is relatively uncommon. Management of post hemorrhagic hydrocephalous needs to be individualized but may require ventricular shunting, serial lumbar punctures or other treatment.

Learning Point
The term intraventricular hemorrhage refers to all 4 grades. The term periventricular hemorrhage refers to a grade IV IVH.

  • Grade I: hemorrhage limited to the subependymal germinal matrix
  • Grade II: hemorrhage in the subependymal germinal matrix with extension into the ventricular system but without lateral ventricular dilation
  • Grade III: hemorrhage in the subependymal germinal matrix with extension into the ventricular system with lateral ventricular dilatation
  • Grade IV: hemorrhage in the subependymal germinal matrix with extension into the brain tissue (i.e. intraparenchymal hemorrhage)

Figure 11
– Images from a head ultrasound performed on day of life seven showing Grade II intraventricular hemorrhage. The image on the left is a coronal image of the brain showing intraventricular hemorrhage in the left germinal matrix. The image in the center is a sagittal image of the left side of the brain showing intraventricular hemorrhage extending from the left germinal matrix into the left lateral ventricle without any ventricular dilation. The image on the right is a sagittal image of the right side of the brain which is normal.

Figure 12
– Images from a head ultrasound performed on day of life twenty-one showing interval development of Grade III intraventricular hemorrhage. The image on the left is a coronal image of the brain showing interval development of ventricular dilation and resorption and retration of the intraventricular clot. The image in the middle is a sagittal image of the left side of the brain showing interval development of ventricular dilation and resorption and retraction of the intraventricular clot and ventricular dilation. The image on the right is a sagittal image of the right side of the brain showing interval development of ventricular dilation.

Determination of ventricular dilation can be difficult on sonography, but is important clinically. Most follow-up studies have found that the neurological outcome is associated with the grading of the IVH.
Grades I and II does not increase the chance of neurologic morbidity measurably.
Grades III and IV have a high rate of morbidity including cerebral palsy, seizures, and mental retardation. Periventricular white matter ischemia often evolve into cystic lesions called periventricular leukomalacia or PVL. The presence of PVL carries a high risk of neurologic morbidity.

Questions for Further Discussion
1. What treatment should be given to infants with symptomatic IVH while an emergent ultrasound is completed?
2. What are the indications for serial lumbar punctures?
3. What kinds of long-term follow-up will patients with Grade III or IV IVH need?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Annibale, DJ.
Periventricular Hemorrhage-Intraventricular Hemorrhage. eMedicine.
Available from the Internet at http://www.emedicine.com/ped/topic2595.htm (rev. 5/14/03, cited 1/31/05).

Acarregui MJ. Intracranial Hemorrhage.
Iowa Neonatology Handbook. Bell EF and Seger JL, eds.
Available from the Internet at http://www.vh.org/pediatric/provider/pediatrics/iowaneonatologyhandbook/neurology/hemorrhage.html (rev. 12/03, cited/31/05).

Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

Date
March 14, 2005