Foreign Bodies. Tintinalli Chapter 76, 82. Population. Children 80% Toys, coins Edentulous adults Bones, packaging Prisoners Utensils, razor blades Psychiatric patients Utensils, razor blades. Pathophysiology. Most (80%) pass without intervention Few (1%) require surgery
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Tintinalli Chapter 76, 82
Most obstructions are in the proximal esophagus
Areas of constriction
Cricopharyngeal narrowing (C6)
Thoracic narrowing (T1) most common
Aortic arch (T4)
Tracheal bifurcation (T6)
Hiatal narrowing (T10-11)
Most obstructions in distal esophagus
Arise from preexisting disease
97% of adults with meat impaction have underlying disease process.
Refusal to eat
Objects past the pylorus
Esophageal FBs warranting endoscopy
Sharp or elongated
Evidence of perforation
Coin at level of cricopharyngeus muscle
Presence >24 hours
May wait expectantly up to 12 hours if the patient can handle secretions
Do not use meat tenderizer
Relaxes esophageal smooth muscle
Test dose then 1mg and 2mg 20 minutes later if needed
Not effective in recent study compared to placebo
Reduces LES pressure without changing esophageal body contraction strength
If coin past LES – expectant observation
Foley catheter technique while intubated
Burns within 4 hours
Perforations in as little as 6 hours
Lithium cell worst
Mercuric oxide cells
Check blood and urine mercury levels if cell splits
Past LES: no removal necessary unless it remains in the stomach after 48 hours
Must be removed from the esophagus
Document on X-Ray
Objects to remove
Longer than 5cm and wider than 2cm rarely will pass the stomach
15-35% will cause perforation
Document on X-ray
Symptomatic or sewing needle
May need contrast film
Any sign perforation – surgical consultation
One condom can hold 5 grams of cocaine
Surgical removal recommended
May observe for spontaneous passage.
What was it?
How long ago was it inserted?
May not volunteer information – “belly hurts”
Occassionally may be removed in the ED
Follow up x-rays and exam to rule out perforation
12 hour observation
Otherwise surgical consult
Local anesthesia a 6 and 12 o’clock
Then internal sphincter anesthesia circumferentially
Can use foley catheter to break vacuum
Risk of perforation or significant manipulation?
Antibiotics – aerobic and anerobic coverage.
Paper clip x 2
That was easy!
It gets tougher!
Good – it’s a spoon
Notice anything else?
Esophagus packed with a week’s worth of food
Iron tablet overdose
A case of iron deficiency?
78 pieces of cutlery
This is why you do not use narrow necked bottles to collect urine samples.
Electric rolling pin
Yet another reason, not to play naked billiards in the rain
This is why you should always have a non-slip mat in the shower
Gives new meaning to “explosive diarrhea”
Last one to leave, please close the door