Day: March 28, 2005

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. Mnemonics for radio-opaque foreign objects are:

CHI (o)PPED

  • Chloral hydrate, concretions (aspirin)
  • Heavy metals
  • Iron
  • Opiate packets
  • Phenothiazines
  • Plumbism
  • Enteric coated pills
  • Dental amalgam

COINS

  • Chloral hydrate
  • Opiate packets
  • Iron
  • Neuroleptic agents
  • Sustained release products

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