Foreign Body Ingestion Katharine Hopkins, MD OHSU Departments of Diagnostic Radiology and Pediatrics

Indications for Urgent Intervention Button battery in esophagus Sharp or long (> 5 cm) object in esophagus or stomach High-powered magnets (or magnet and metal object) Airway compromise Near-complete or complete esophageal obstruction Signs of inflammation or intestinal obstruction (fever, abdominal pain, vomiting)

Button (Disc) Batteries

Ingestions on the rise due to increased usage in household products, appliances, and toys ESOPHAGEAL BUTTON BATTERY IS A MEDICAL EMERGENCY Animal studies: mucosal necrosis within 1 hour ulceration within 2 hours perforation as early 8 hours

Button (Disc) Batteries Mechanisms of esophageal injury Electrical discharge Most significant Leakage of battery contents Pressure necrosis

Button Batteries—Imaging Differentiation from coins is key Button batteries require immediate removal from esophagus Coins may not Bilaminar structure double ring or halo appearance en face step-off between anode and cathode in profile.

Coin lodged at lower esophageal sphincter

Button battery lodged at lower esophageal sphincter Halo

Button battery lodged at thoracic inlet Step-off Airway narrowing

Button (Disc) Batteries Misidentification of esophageal button battery as coin can have significant adverse consequences Severity of damage depends on length of time that battery is lodged in place, amount of charge, and battery size Airway compromise from esophageal edema within 3 hours of ingestion Full-thickness esophageal injury within 4 hours, leading to ulceration or perforation

Severe complications may develop even after button battery removal, including: Vocal cord paralysis Esophageal perforation Esophageal stricture TE fistula Aspiration pneumonia MediastinitisSpondylodiscitis Erosion into aorta or other arteries Gastric hemorrhage or perforation Intestinal perforation Death (reported 1-18 days after removal)

Button Battery Management Emergent removal from esophagus Expectant management beyond esophagus unless symptoms or co-ingested magnet Low risk of injury 74% passed in 4 days; 89% passed in 7 days Endoscopic or surgical removal if: Battery in stomach more than 48 hours and unlikely to pass (≥ 15 mm in child under 6 years) Signs/symptoms of GI injury

Cylindrical Batteries Most ingestions are intentional Intact cylindrical batteries pose low risk for caustic injury Most pass through GI tract without sequelae Endoscopic removal recommended if lodged in esophagus or if still pre-pyloric after 48 hours

Sharp-pointed Objects 5-30% of swallowed objects High risk of perforation in esophagus Medical emergency Immediate endoscopic removal

Sharp-pointed Objects Beyond esophagus, reported risk of complications ranges from 4-35% Immediate endoscopic removal from stomach or proximal duodenum Surgical removal if beyond duodenum and symptomatic or failing to progress

Magnets Serious health hazard in children High-powered magnets (neodymium or “rare earth” magnets) are common Marketed to adults (Buckyballs®) Attractive to children

Buckyballs® and Buckycubes®

Ingested Buckyballs®

Magnets—Imaging AP and lateral radiographs Nose to anus Stacked magnets are easily misdiagnosed as a single magnet Some magnets are difficult to distinguish from coins or washers

Ingestion of Multiple Magnets Magnets attract across layers of bowel, leading to pressure necrosis High risk of complications FistulaPerforationVolvulusObstruction Cannot reliably determine whether bowel wall is compressed between magnets with radiographs

Management—Multiple Magnets Prompt endoscopic removal from esophagus or stomach Once beyond stomach, removal by endoscopy/colonoscopy or surgery if causing symptoms or failing to progress

Ingestion of Single Magnets Conservative management Serial radiographs to confirm progression