ESOPHAGEAL  FB (see also "ENT" chapter)

Etiology:

  1. Playing with small objects, bones, large food bolus, coins, batteries.
     
  2. Particularly common in pediatric and mentally impaired population
     
  3. Most common sites are:
     
    1. Cricopharyngeal muscle ( C6 level) = 80%
    2. Aortic arch level (T4 level) = 10%
    3. GE junction (T10 level).

S & S:

  1. Vomiting, regurgitation
     
  2. Drooling
     
  3. Dysphagia
     
  4. Choking sensation
     
  5. SQ emphysema will be present in cases of  perforation.

DX:

  1. X-Ray  of neck, chest and abdomen to r/o perforation and to better localize radio-opaque FB. If coin is lodged in esophagus it is  visualized frontally. If it is in trachea coin is oriented sagitally.
     
  2. If  xRay is without any yield or pt is symptomatic,  endoscopy (diagnostic  tool of choice) should be performed.
     
  3. Avoid barium esophagogram since this will interfere with endoscpoy. Also avoid if perforation is a concern.

Treatment:

  1. IV access, O2, suction devise @ bed side, ETT @ bed side in event of respiratory compromise.
     
  2. Consider  inserting NG tube above the FB to avoid aspiration of  unswallowed secretions. If patient is uncomfortable, suction catheter is a good alternative.
     
  3. If  FB is @ Killan's mouth (crycopharyngeal muscle) removal may be attempted with laryngoscope and Magill forceps, otherwise endoscope is employed.
     
  4. It is always a question if  ENT vs. GI is to be called first. The rule of thumb is that if patient c/o pain at the level of the neck, FB is lodged at the level  of crycopharyngeal muscle, and endoscope employed by ENT is adequate for removal. If pain , however is retrosternal, it suggests that  FB is distal to crycopharyngeal muscle and  GI should be consulted to  employ a longer endoscope.
     
  5. If removal with endoscope was unsuccessful, pt is taken to OR to remove FB with rigid endoscope under general anesthesia.
     
  6. If pt can manage secretions, Glucagone 1mg IV (can cause vomiting) or Nifedipine 10 mg SL  can be tried to promote relaxation of  LES.
     
  7. If pointed objects are lodged, surgical  or endoscopic consultations are appropriate.
  8. Alkaline batteries must be removed ASAP.
     
  9. If FB passed pylorus, in 90% of cases, it will exit in 3-5 days, and is followed by Abdominal x-ray.
     
  10. Ingestion of heroin or cocaine bags by "mules" are better removed with surgery, since the perforation and release of the substance into circulation will have deadly  consequences.

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