Foreign bodies
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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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Foreign bodies

Foreign Bodies

Tintinalli Chapter 76, 82


Population

Population

  • Children 80%

    • Toys, coins

  • Edentulous adults

    • Bones, packaging

  • Prisoners

    • Utensils, razor blades

  • Psychiatric patients

    • Utensils, razor blades


Pathophysiology

Pathophysiology

  • Most (80%) pass without intervention

  • Few (1%) require surgery

  • Objects traversing pylorus usually pass through to stool


Pathophysiology1

Pediatrics

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)

Adult

Most obstructions in distal esophagus

Arise from preexisting disease

97% of adults with meat impaction have underlying disease process.

Pathophysiology


Clinical presentation

Pediatrics

Refusal to eat

Coughing

Vomiting

Stridor

Increased salivation

Drooling

Anxiety

Palatal abrasion

Reddened throat

Adults

Anxiety

Discomfort

Retrosternal pain

Choking

Vomiting

Drooling

Clinical Presentation


General care

Objects past the pylorus

Expectant care

X-ray

Possibly serial

Esophagram

Endoscopy

Metal detectors

Esophageal FBs warranting endoscopy

Sharp or elongated

Multiple

Button batteries

Evidence of perforation

Coin at level of cricopharyngeus muscle

Airway compromise

Presence >24 hours

General Care


Food impaction

May wait expectantly up to 12 hours if the patient can handle secretions

Do not use meat tenderizer

IV glucagon

Relaxes esophageal smooth muscle

Test dose then 1mg and 2mg 20 minutes later if needed

Not effective in recent study compared to placebo

Nifedipine

Reduces LES pressure without changing esophageal body contraction strength

10mg sublingually

Food Impaction


Coin ingestion

Children

35% asymptomatic

Esophagus

Frontal plane

Trachea

Sagittal plane

Coin Ingestion


Coin ingestion1

Treatment

If coin past LES – expectant observation

Endoscopy

Foley catheter technique while intubated

Coin Ingestion


Button battery ingestion

Button batteries

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

Button Battery Ingestion


Button battery ingestion1

Treatment

Past LES: no removal necessary unless it remains in the stomach after 48 hours

Must be removed from the esophagus

Document on X-Ray

Endoscopy

Button Battery Ingestion


Ingestion of sharp objects

Objects to remove

Longer than 5cm and wider than 2cm rarely will pass the stomach

Pointed objects

15-35% will cause perforation

Ingestion of Sharp Objects


Ingestion of sharp objects1

Management

Document on X-ray

Symptomatic or sewing needle

Surgical consultation

Asymptomatic

Expectant management

Serial x-rays

May need contrast film

Any sign perforation – surgical consultation

Ingestion of Sharp Objects


Cocaine ingestion

One condom can hold 5 grams of cocaine

Surgical removal recommended

May observe for spontaneous passage.

Cocaine Ingestion


Rectal foreign bodies

History

What was it?

How long ago was it inserted?

May not volunteer information – “belly hurts”

Treatment

X-ray

Position

Number

Shape

Free air?

Rectal Foreign Bodies


Rectal foreign bodies1

Treatment

Occassionally may be removed in the ED

Follow up x-rays and exam to rule out perforation

12 hour observation

Otherwise surgical consult

Removal technique

IV sedation

Lithotomy position

Local anesthesia a 6 and 12 o’clock

Then internal sphincter anesthesia circumferentially

Can use foley catheter to break vacuum

Rectal Foreign Bodies


Rectal foreign bodies2

Treatment

Risk of perforation or significant manipulation?

Antibiotics – aerobic and anerobic coverage.

Rectal Foreign Bodies


Guess the foreign body

Guess the Foreign Body

Ready?


Foreign bodies

Paper clip x 2

That was easy!

It gets tougher!


Foreign bodies

Good – it’s a spoon


Foreign bodies

Two needles,

Necklace

Charm

Notice anything else?


Foreign bodies

Esophagus packed with a week’s worth of food


Foreign bodies

Iron tablet overdose


Foreign bodies

A case of iron deficiency?


Foreign bodies

78 pieces of cutlery


Foreign bodies

This is why you do not use narrow necked bottles to collect urine samples.


Foreign bodies

Electric rolling pin


Foreign bodies

Yet another reason, not to play naked billiards in the rain


Foreign bodies

Concrete enema


Foreign bodies

Dr Beight


Foreign bodies

This is why you should always have a non-slip mat in the shower

Dr. Beight


Foreign bodies

Gives new meaning to “explosive diarrhea”


Foreign bodies

Last one to leave, please close the door


Questions

Questions?


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