Esophageal Foreign Bodies

It's a situation that every parent is afraid of. What should you do if a child swallows a button battery? Or has something lodged in their throat, or accidentally ingest a household cleaner? Today, we are going to talk about the best practices for diagnosing and managing esophageal injuries caused by foreign bodies, caustic ingestions, and traumatic injuries with an expert. Poisonings and ingestions tend to occur in younger kids, those less than five. Those of us that have, uh, children or had children this age, you know, that's the hardest age to keep an eye on them. They can get into things, um, tend to find shiny, uh, objects. That's Dr. Aaron Garrison, he's a pediatric surgeon at Cincinnati Children's Hospital Medical Center, and today he's going to tell us everything we need to know about esophageal injuries. Don't go anywhere. This is the Stay Current podcast. So, as we know, children sometimes swallow things accidentally, like coins or buttons and beads, and most of the time it passes harmlessly through their digestive system. But what do you do when the patient swallows a button battery? When ingested, they can cause damage in several different ways. A single battery can create an electrical current or leak harmful chemicals that can damage or actually erode through the esophageal tissue, and that can cause an aorto-esophageal fistula. But first things first, how can you differentiate between a button battery and a coin on x-ray? They look the same, right? I don't know what you call it. I think there's like a term, but it's like the the rim that you can see on the battery, right? Yep. Good. Close enough. So which is what is that? Coin or battery? It's a coin. Coin. Coin. Okay, the one on the left is a battery because you can see that halo sign, right? So, that's important to to know because if you see that halo sign, it turns into an emergency. If you see that halo, it turns into an emergency. Now, suppose a neighbor who knows you're a doctor calls you to say that her three-year-old may have swallowed a button battery. What should you advise her to do immediately? Maybe even before going to the emergency room, the best thing is to advise them to give their child 10 milliliters of honey every 10 minutes on the way to the hospital, but they should get there immediately. Have them take 10 ml of honey because it will sort of deactivate the or at least minimize the tissue damage. Um, so any signs such as drooling, vomiting, um, unexplained, um, choking and coughing in a child less than five, you really need to think about a foreign body and especially if you if it was unwitnessed. To check out really good algorithms regarding known or suspected battery ingestions in younger or even older children, and what you should do about it, go to the Poison Control website. If you're in the stay current in pediatric surgery app, we'll give you the link below the media player. Check it out. So scoping and removing the object is critically important. You will put the, you know, just like a sword swallower, you really have to get the chest elevated, so putting in a roll so that the whole scope can go down, um, without, you know, meeting the posterior esophagus. Once you've determined that the child has ingested a coin and not a battery, and if the child is asymptomatic, you can wait until the next day to see if it passes. About x-rays, so some objects like steak bones and metallic things are radio opaque and that's easier to visualize. But other objects such as fish bones, wood, plastic, and glass are radio lucent, and those are easy to miss. So a major take-home point, if you have a patient who is symptomatic but has a negative x-ray, you should still take a look. Let's look at another issue, caustic ingestion. Okay, so caustic ingestion. Anything capable of burning and causing destruction of the esophagus can qualify as a caustic ingestion usually, um, due to, um, acids or bases. Uh most commonly in kids they're household cleaning products, so bleach, lies, um, and then, um, basic or alkaline issues or ingestions are much more common than than acid. Um, on up to date there is this, um, uh, graph showing kind of what the pH is of commonly ingested substances. So, I'd surprise that Coca-Cola has a pH of two, but the more dangerous ones such as sodium hydroxide and, um, Drano, those pH are up to 14 and those are quite dangerous. What's the difference between acids and bases, and which is more dangerous? Most people naturally think that acids are worse. If you ask most people, they would probably think acids are cause the worst injury, but they tend not to. They're more superficial. Um, the alkali ingestions cause liquefactive necrosis and more of a deeper penetrating, um, injury and can, that's why those aorto enteric fistulas can happen because it can go all the way through the wall of the esophagus. And so the, um, alkali ingestions tend to be much more damaging to esophagus than, um, acidic. They also tend to be less painful. Um, so kids will tend to spit out the acids because it tastes bad, uh whereas the basic things don't, uh, cause that same reaction. With a caustic ingestion, there's a worsening possibility of perforation over the course of a week. So those patients need to be monitored closely. This is what can be life-threatening in that first day or two as opposed to the esophageal injury, is that patients can have a big reactive, um, injury to the epiglottis and causing airway obstruction. Um, interestingly, if you they aspirate like a powder, if they take in a powder, then there can be a delay such as like one to two hour delay until the symptoms begin it worse, whereas liquids tend to be kind of immediately, um, cause a reaction. Here are some recommendations about what not to do when managing a patient with suspected caustic ingestion. Do not induce vomiting, use neutralizing agents, dilute it with milk or water, and lastly, don't use activated charcoal. Also, don't place an NG tube until you've completely characterized the esophagus, and definitely plan for a scope within the first 24 hours. What about esophageal injuries? Isolated esophageal injuries are pretty rare. As you guys all know, that's the esophagus is protected by a lot of structures, so if your esophagus is injured, chances are a lot of other things are going to be injured too. So your, um, um, in your neck and in your mediastinum, so other things are probably going to be causing issues. Um, these injuries tend to be more penetrating from either, um, knife wounds or gunshot shots. Um, and then very much less frequently, um, blunt trauma. Often, the diagnosis is delayed because we're not looking for esophageal injuries, but once an injury is suspected, we have to determine exactly where that injury is so we can pick an appropriate approach. Let's start with cervical injuries. These you can tend to get away with a little bit, um, less invasive, um, management, just, uh, with drainage. And again, they're rarely isolated. If you're operating on esophageal injury, there's a good chance that you're going to have an airway or a vascular injury as well. Um, your main plan is going to be keeping the patient NPO, and NG antibiotics and a drain if there is an injury to the esophagus. Um, and then exposure, um, you know, anyone who's cannulated ecmo, I think would feel comfortable with this incision, and then just keeping in mind if it's a bilateral incision just, a bilateral injury, making a collar incision above the clavicle and and extending it over. Here's another issue, a not uncommon problem. Suppose a nurse needs to pass an NG tube into a newborn and the cervical esophagus gets perforated. A not uncommon, well, it's uncommon, but it is not uh rare. Um, problem is that a baby is born, the nurse passes an NG tube for whatever reason and it doesn't go all the way down or they they perforate the esophagus, the cervical esophagus in a newborn. And the treatment for that is just take the NG tube out and put them on antibiotics and don't do anything else. This raises the point that nearly 60% of all reported esophageal perforations are iatrogenic. But depending on the cause, perforations can be managed non-operatively, especially if contained and adequately drained. So overall, um, management of principles, you're going to want to just get exposure, knowing which way to, um, where location wise to, um, make your incision, debride non-viable tissue, do a layered closure and then think about, um, uh buttressing with muscle, so swinging a strap muscle down, swinging an intercostal down if needed, um, and then, uh, doing an adequate tube drain. Let's summarize the key points. Button battery ingestion can be fatal, and if this is suspected by parents, they should give their child 10 milliliters of honey every 10 minutes and route to the hospital. Also, the most common type of caustic ingestion is alkaline, and that can cause rapid liquefactive necrosis until the alkali is neutralized or diluted. But you want to avoid vomiting or aspiration because that can make the injury worse. After caustic ingestion, once the patient is stabilized, endoscopy should be performed within 24 hours to evaluate the extent of the injury. We hope you enjoyed our episode on esophageal foreign bodies, ingestions, trauma, and perforations with Dr. Aaron Garrison. Follow us on social media, like and subscribe to our YouTube channel, and if you're listening on a podcast player, go ahead and leave us a comment. Let us know what you like, what you didn't like, and what you want to hear in the future. But until next time, I'm Britney and remember, knowledge should be free.