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Disclosures: Mark A Gilger, MD Consultant/Advisory Boards: QOL [Starch malabsorption (sacrosidase)]. Ajay K Jain, MD Nothing to disclose. Mark E McOmber, MD Nothing to disclose. George D Ferry, MD Nothing to disclose. Jonathan I Singer, MD Nothing to disclose. Alison G Hoppin, MD Employee of UpToDate, Inc.
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INTRODUCTION — Infants put almost everything into their mouths, and toddlers eat just about anything. Of more than 100,000 cases of foreign body ingestion reported each year in the United States, 80 percent occur in children [1-4]. The majority of foreign body ingestions occur in children between the ages of six months and three years [1,5,6]. Fortunately, most foreign bodies that reach the gastrointestinal tract pass spontaneously. Only 10 to 20 percent will require endoscopic removal, and less than 1 percent require surgical intervention [1,5,7]. Although mortality from foreign body ingestion is extremely low, deaths have been reported [5,8,9].
In the United States, coins are the most common foreign bodies ingested by children. Other objects, including toys, toy parts, magnets, batteries, safety pins, screws, marbles, bones, and food boluses have been reported [3,7,10-12]. Ingestion of multiple foreign objects and repeated episodes are uncommon occurrences and usually occur in children with developmental delay [10,13]. The capsules used for capsule endoscopy are occasionally retained in the gastrointestinal tract. This complication is more common in patients with an underlying pathology [14-16] and may require endoscopic or surgical removal [17,18].
The diagnosis and management of foreign bodies in the esophagus are discussed here. Concerns specific to ingestion of button batteries (disk batteries) are discussed in greater detail separately. Management of gastric bezoars is discussed elsewhere. (See "Button and cylindrical battery ingestion" and "Gastric bezoars".)
CLINICAL MANIFESTATIONS — Most children with esophageal foreign bodies are brought to medical attention by their parents because the ingestion was witnessed or reported to them [1,5,19,20]. In these settings, they often are asymptomatic. As an example, in a case series of 325 pediatric patients, only half of the children with an esophageal foreign body displayed symptoms at the time of the ingestion, such as retrosternal pain, cyanosis, or dysphagia, and in many of these cases the symptoms were transient .
When symptoms do occur, they are often related to the location of the foreign body. Older children may localize the sensation of something "stuck" to the neck or lower chest, suggesting irritation in the upper or lower esophagus, respectively. Children with complaints of substernal chest pain are more likely to have mucosal ulceration of the esophagus when evaluated by endoscopy, especially if the foreign body has been present for more than 72 hours, or was found unexpectedly on chest imaging . Patients of any age may present with refusal of feeds or dysphagia, drooling, or respiratory symptoms including wheezing, stridor, or choking. (See "Assessment of stridor in children" and "Approach to wheezing in children".)
Esophageal foreign bodies tend to lodge in areas of physiologic narrowing, such as the upper esophageal sphincter (cricopharyngeus muscle), the level of the aortic arch, and the lower esophageal sphincter [5,19]. Objects that appear in the middle portion of the esophagus are more likely to represent esophageal pathology, such as a stricture. Similarly, children presenting with food bolus impaction commonly have underlying esophageal pathology (eg, a stricture) directly responsible for the impaction [2,23]. Previous surgery or congenital malformations (eg, tracheoesophageal fistula) pose an increased risk as sites for obstruction [24,25].
Longstanding esophageal foreign bodies may cause weight loss or recurrent aspiration pneumonia, due to decreased caloric intake and mishandling of oral secretions, respectively. They also can damage the mucosa and lead to strictures, or erode the esophageal wall, creating a fistula with the trachea or other nearby structures. Sharp objects may perforate the esophagus, resulting in neck swelling, crepitus, or pneumomediastinum . Erosion into the aorta also has been reported, causing life-threatening gastrointestinal bleeding [26,27].
Occasionally, foreign bodies may be retained in the distal gastrointestinal tract, where they can cause delayed complications. Case reports describe cecal retention of a coin mimicking appendicitis , pyogenic liver abscess caused by migration of a sharp object from the gastrointestinal tract to the liver , retention of a long object in the appendix presenting as appendicitis several years later , and perforation of the ileum by ingested gravel .
APPROACH TO MANAGEMENT — A careful history and physical examination are the keystones to diagnosing an esophageal foreign body and to the prevention of its complications . Imaging can be used to confirm the findings and to localize the site of the foreign body. The diagnostic steps and treatment depend on the patient's symptoms, the shape and location of the foreign body, whether it is radio-opaque, and whether it is a strong magnet (algorithm 1 and algorithm 2A) [33,34].
History and physical examination — Airway and breathing always should be examined first. The physical examination of the neck may reveal swelling, erythema, or crepitus, suggesting esophageal perforation has occurred, and surgical consultation is mandatory. The chest examination may reveal inspiratory stridor or expiratory wheezing, suggesting a lodged esophageal foreign body with tracheal compression. The abdominal examination may show evidence of small bowel obstruction or perforation, in which case immediate surgical consultation and abdominal imaging should be obtained.
Imaging — For all patients with suspected foreign body ingestion, the initial diagnostic test should be biplane radiographs (anteroposterior and lateral) of the neck, chest, and abdomen [5,21,35]. Flat objects (eg, coins or disk batteries) usually orient in the coronal plane and appear as a circular object on an anteroposterior projection (image 1), whereas objects lodged in the trachea tend to orient in the sagittal plane and are best seen in lateral projection. However, these associations are not universal [36-38]. The lateral projection radiograph may help to identify the object or establish if more than one foreign body is present, such as stacked coins. Toys made of plastic or wood, some thin metal objects, and many types of bones are not readily seen on plain films [21,39,40]. In a study of 325 children, only 64 percent of the ingested objects were radio-opaque . We suggest that plain radiographs be performed even if the foreign body is thought to be radiolucent. This is to evaluate for the possibility of other swallowed objects, and for indirect evidence of the radiolucent foreign body (such as an air-fluid level in the esophagus).
If the plain radiograph does not reveal any foreign body or abnormalities, management depends on the characteristics of the patient and the suspected foreign body:
●If the patient is symptomatic, or if the suspected foreign body has any dangerous characteristics (large [>2 cm], long or sharp), or if the type of foreign body is not definitively known by the caretakers, we suggest using computed tomography (CT) with 3-dimensional reconstruction as the next diagnostic procedure (algorithm 1) [5,41]. Alternatively, magnetic resonance imaging (MRI) can be used for evaluation of radiolucent foreign bodies, but is contraindicated if any metallic foreign body is present.
●Imaging with CT or MRI is not necessary if the patient is entirely asymptomatic and if the caretakers are certain about the type of foreign body that was ingested and that the object has benign characteristics (small [<2 cm], not sharp or long, and not a magnet or battery). In this case, it is reasonable to discharge the patient after a period of observation in a health care setting, if the patient remains entirely asymptomatic and is able to eat and drink normally.
We avoid gastrointestinal contrast studies when possible. Although the study may help identify the foreign body, barium contrast may obscure visualization on subsequent endoscopy. Moreover, the contrast may be aspirated if the esophagus is obstructed. Because of these concerns, endoscopy may be preferred over contrast even if radiographs are negative [5,40].
A handheld metal detector has been employed with variable success in locating coins, and can detect materials that are metallic but not radio-opaque, such as aluminum [42,43]. This instrument is less reliable in detecting metallic objects other than coins, limiting its use .
Urgent intervention — Urgent intervention is indicated if any of the following warning signs are present (algorithm 1):
●When the ingested object is sharp, long (>5 cm), and is in the esophagus or stomach.
●When the ingested object is a high-powered magnet or magnets (algorithm 2A-B).
●When a disk battery is in the esophagus (and in some cases in the stomach). (See "Button and cylindrical battery ingestion".)
●When the patient shows signs of airway compromise. (See "Emergent evaluation of acute upper airway obstruction in children".)
●When there is evidence of near-complete esophageal obstruction (eg, patient cannot swallow secretions).
●When there are signs or symptoms suggesting inflammation or intestinal obstruction (fever, abdominal pain, or vomiting) [5,40].
Expectant management — For blunt foreign bodies without the above characteristics that are lodged in the esophagus in an asymptomatic patient, observation for 12 to 24 hours is reasonable because spontaneous passage often occurs (algorithm 1) [2,45-49]. In one study, coins lodged in the esophagus passed spontaneously into the stomach in about one-third of patients with a "simple" presentation (defined as no history of esophageal disease or surgery, coin lodged for less than 24 hours, and no respiratory compromise) .
Objects lodged for more than 24 hours or for an unknown duration should be removed promptly . After this period, complications such as transmural erosion, perforation, and fistulae are more likely to occur. As an example, in a case series of 167 children, duration of lodgement for more than 24 hours was the strongest predictor of complications, which included injury to the esophageal mucosa, bleeding, stricture, and obstruction . Complications also were more likely if the foreign body was a sharp or pointed object, disk battery, non-radio-opaque, or located below the upper third of the esophagus.
TECHNIQUES — Various methods have been used to remove esophageal foreign bodies. They include rigid and flexible endoscopy, bougienage, Foley catheterization of the esophagus, and the "penny pincher" technique.
Flexible endoscopy — Flexible endoscopy is preferred in most circumstances because the foreign body can be directly visualized and manipulated, and the surrounding gastrointestinal tract can be examined for potential complications [1,5,10,50-52]. This procedure is performed under conscious sedation or general anesthesia, depending upon the patient's age, ability to cooperate, and the type and number of objects to be removed. The endoscopist should have a complete array of equipment to grasp the foreign object, such as a rat-tooth and alligator forceps, polyp snare, retrieval net, and helical baskets. It is helpful to practice grasping a duplicate of the foreign body using the retrieval tools before beginning the procedure. A foreign body protector hood is the preferred method of protecting the esophagus if the object is sharp or pointed .
Rigid endoscopy — Rigid endoscopy utilizes a non-flexible channeled device that is introduced into the esophagus under general anesthesia. It is most useful for impacted sharp objects that are located in the proximal esophagus, at the level of the hypopharynx and cricopharyngeus muscle . The technique requires considerable skill and may cause complications such as esophageal abrasion and perforation [10,52].
Magill forceps — Magill forceps can be used to extract foreign bodies impacted in the oropharynx or upper esophagus. In some cases, an object impacted in the upper esophageal sphincter is visible at the time of tracheal intubation and can be directly removed with the Magill forceps without the need for intubation. However, in most cases, an endotracheal tube is placed to protect the airway, and a laryngoscope is used to gently open the esophagus and visualize the foreign body . In one case series, esophageal coins were removed in 23 out of 36 patients using Magill forceps. In many of these cases, the extraction was performed easily although the coin was not visible with the laryngoscope. No complications were reported in this study .
Bougienage — Bougienage (passage of a dilator) has been used to push objects into the stomach. Although the procedure is less costly than endoscopy, it does not permit visualization of the esophagus and does not retrieve the foreign body. Therefore, it is most appropriate for foreign bodies that are very likely to pass beyond the stomach without complications, and in situations where there is a low risk of esophageal injury. Thus, the technique has a role only for selected patients, such as those with witnessed coin ingestion of less than 24 hours duration, and many providers do not recommend it at all if endoscopy is available [5,21,51,56].
Foley catheter — For this technique, a deflated Foley catheter is passed beyond the foreign body. The balloon is then inflated using a radio-opaque contrast dye, and the catheter is slowly drawn back under fluoroscopic guidance, to remove the foreign body through the mouth. The technique can be successful with proximal esophageal foreign bodies when performed by an experienced operator. It does not permit visualization of the esophagus and carries the risk of esophageal perforation if the balloon is inflated below a stricture. In addition, this approach may cause aspiration of the foreign body if it is inadvertently dragged into the trachea . For these reasons, many providers do not recommend this technique if endoscopy is available.
Penny pincher technique — The "penny pincher" technique involves insertion of a grasping forceps through a nasogastric tube, under fluoroscopic guidance and usually without anesthesia or endotracheal intubation. This approach is an improvement over the Foley catheter method because it permits direct control of the object, reducing the risk of dropping it into the airway. However, it also does not allow inspection of the esophagus and should only be used for objects that can be firmly grasped and controlled by the forceps .
APPROACHES FOR SPECIFIC TYPES OF FOREIGN BODIES
Coins — Coins are by far the most common foreign body ingested by children [1,22,51,58-60]. A small percentage of the ingested coins become lodged in the esophagus, and these can cause serious complications, including aspiration, if not removed . Approximately two-thirds of ingested coins are in the stomach at the time of initial radiographic evaluation [12,58].
If a coin is visualized in the esophagus and the patient is asymptomatic, the child can be observed for up to 24 hours after ingestion of the coin. (See 'Expectant management' above.) In such patients, 20 to 30 percent of coins will pass into the stomach spontaneously during the observation period (two-thirds of these during the first eight hours). Spontaneous passage is more common in older children and when coins are located in the distal third of the esophagus.
The esophageal coin should be removed promptly if the patient is symptomatic or if the time of ingestion is not known. If the child is asymptomatic and the coin does not pass spontaneously by 24 hours after ingestion, it should be removed. In our practice, we prefer to remove most coins using flexible endoscopy. Rigid endoscopy or Magill forceps are acceptable approaches for proximally located coins, with experienced operators. The penny pincher or Foley catheter techniques are cost-effective alternatives for selected patients, but require fluoroscopy and do not allow direct inspection of the esophagus. (See 'Urgent intervention' above and 'Techniques' above.)
Because coins lack sharp edges and the metal is not toxic, coins that reach the stomach can be managed expectantly, and most will pass out uneventfully within one to two weeks. For these patients, most providers check the location of the coin with a plain radiograph about once a week. If the coin has not passed beyond the stomach by four weeks, endoscopic removal is recommended. If the child develops any signs or symptoms of obstruction, abdominal pain, vomiting, or fever, then the patient is promptly reevaluated with radiographs and the coin is removed endoscopically. Although there have been theoretical concerns about zinc toxicity from retained gastric pennies minted after 1982, evidence demonstrating the need for extraction is lacking [1,21,51,61], except in the case of ingestion of extremely large numbers of post-1982 pennies .
Batteries — The number of ingestions of disk or “button” batteries is increasing substantially . More alarming, when lodged in the esophagus, these batteries are associated with significant morbidity, so they represent a medical emergency. In addition to direct pressure necrosis, contact of the flat esophageal wall with both poles of the battery conducts electricity, resulting in liquefaction necrosis and perforation of the esophagus. Retained batteries also can cause problems through leakage of caustic material (generally batteries contain a heavy metal like mercury, silver, lithium, and a strong hydroxide of sodium or potassium) [5,6,40]. Animal studies have demonstrated mucosal necrosis within one hour of ingestion and ulceration within two hours , with perforation as early as eight hours after ingestion .
It may be difficult to differentiate between a disk battery and a coin on a radiograph. This distinction is most important when the foreign body is in the esophagus, since batteries require immediate removal whereas coins may or may not. Radiographic features that can help distinguish between the two are discussed separately (image 2). (See "Button and cylindrical battery ingestion", section on 'Radiographic localization'.)
Like coins, most disk or cylindrical batteries pass harmlessly once they reach the stomach. However, because of the potential for direct mucosal injury and toxicity, batteries should be removed from the stomach under certain conditions. An overview of the management of battery ingestions is presented separately. (See "Button and cylindrical battery ingestion".)
Sharp-pointed objects — The most common sharp-pointed objects ingested by children are straight pins, needles, and straightened paper clips; these represent 5 to 30 percent of swallowed objects [1,26]. Sharp-pointed objects lodged in the esophagus represent a medical emergency because of a high risk of perforation (15 to 35 percent) [1,26]. When lodged in the hypopharynx, they can cause a retropharyngeal abscess .
Children suspected of swallowing sharp-pointed objects must be evaluated to determine the location of the object. If the history or examination raises concern for a sharp-pointed object, endoscopy should be performed even if the radiologic exam is negative, because many sharp-pointed objects are not readily visible by x-ray.
If the object is in the esophagus, it should be removed immediately. Endoscopic retrieval of sharp objects is accomplished with use of retrieval forceps or polypectomy snare . The risk of mucosal injury during retrieval of a sharp object can be minimized by orienting the object with the sharp-end trailing during extraction and using a protector hood on the end of the endoscope, or (in older children) an overtube [33,66]. Direct laryngoscopy is a reasonable alternative for objects lodged at or above the cricopharyngeus. (See 'Flexible endoscopy' above and 'Magill forceps' above.)
If the object is in the stomach or proximal duodenum, it also should be removed promptly, using a flexible endoscope. The risk of a complication caused by a sharp-pointed object passing through the gastrointestinal tract is as high as 35 percent , although some case series describe lower complication rates from sharp objects (4 percent) . Sharp objects that pass beyond the reach of a flexible endoscope and then cause symptoms will require surgical intervention.
If the object has passed into the small intestine and the patient is asymptomatic, it may be followed with serial radiographs to document its passage. Surgical intervention should be considered for objects that fail to progress for three consecutive days . Parents are instructed to immediately report symptoms of abdominal pain, vomiting, fever, hematemesis, or melena.
Food bolus impaction — Impacted meat or other food bolus is the most common esophageal foreign body in adults, but is relatively rare in children. It usually presents as dysphagia beginning acutely while eating. In children presenting with a food impaction, there is a higher incidence of underlying esophageal pathology (strictures, achalasia, or esophageal motility disorders) as compared to children with other esophageal foreign bodies [2,68,69]. Reflux esophagitis and eosinophilic esophagitis also predispose to food impaction [69-71].
Children who are in acute distress or unable to swallow oral secretions require immediate attention and removal of the impaction. If the patient is comfortable and able to handle oral secretions, endoscopic intervention can be delayed, as many food impactions will pass spontaneously. However, intervention should not be delayed beyond 24 hours.
A proteolytic enzyme, like papain, is not recommended because its use has been associated with hypernatremia, erosion, and esophageal perforation [2,72,73]. Some experts believe that a bolus of intravenous glucagon may promote spontaneous passage of an impacted food bolus by relaxing the esophagus [74,75]. However, two small randomized trials and a large case series suggest that glucagon is no more effective than placebo, except perhaps in patients with a prior history of solid food dysphagia [76-78]. Because of the lack of evidence of efficacy, particularly in children, and because nausea and vomiting are common side effects, we do not recommend the use of glucagon in the management of food impaction or other esophageal foreign bodies in children [77,79].
The optimal approach to removal of a food bolus depends on the location and consistency. Objects in the upper esophagus may be optimally managed with a rigid endoscope, whereas those in more distal locations typically require flexible endoscopy. Some providers find that polypectomy snares or retrieval nets (eg, Roth Net), or a friction-fit adaptor (from a band ligator) fitted to the end of the endoscope are valuable for food bolus removal [50,69,80]. The food bolus can be removed en bloc or in a piecemeal fashion. Once reduced in size, the bolus may be gently pushed into the stomach using the tip of the endoscope. Because food impaction is often caused by an underlying mucosal abnormality such as esophagitis or stricture, we recommend that esophageal mucosal biopsies be obtained at the time of endoscopic disimpaction . (See "Ingested foreign bodies and food impactions in adults", section on 'Food bolus'.)
Magnets — With the increasing use of small magnets in toys and household items, ingestion of magnets has become a serious health hazard in children [82-87]. High-powered magnets composed of neodymium (also known as “rare earth” magnets) are now common components of household appliances. Furthermore, these magnets are commonly available in the form of desk “toys” and “stress relievers” (eg, Buckyballs®), which consist of 200 or more small magnetic balls, cubes, or cylinders. Although these are marketed to adults, they have been involved in many ingestion incidents in children. Many of the children with complications from multiple magnet ingestion had underlying conditions such as developmental delay or autism [82,83]. In some cases, an older child has inadvertently swallowed these magnets while using them to imitate a pierced tongue, so the risk is not limited to young children [85,87]. In 2011, the United States Consumer Safety Product Commission (CPSC) issued an alert describing the safety risks of this type of magnet .
Two or more strong magnets, especially if ingested at different times, may attract across layers of bowel leading to pressure necrosis, fistula, volvulus, perforation, infection, or obstruction; this may result in serious consequences including intestinal resection. It is postulated that intraperitoneal hemorrhage could occur if mesenteric vessels are trapped between attracted bowel loops .
Suspected magnet ingestion requires urgent evaluation. Radiographs of the neck and abdomen should be performed, including a lateral view. In most cases the radiographs cannot determine whether bowel wall is compressed between the magnets, although the finding of magnets that appear to be stacked but are slightly separated (image 3) is suspicious for bowel entrapment. Management depends on the number, location and type of magnets, and on the timing of the ingestion, as described in the algorithms (algorithm 2A-B) .
●Ingestion of a single magnet can generally be managed conservatively, with the following precautions:
•Serial radiographs should be performed to confirm that the magnet progresses through the gastrointestinal tract and to confirm that multiple magnets are not present. Radiographs do not reliably distinguish between single and multiple magnets, since it is possible for magnets to stick together or overlap on a single view and be misdiagnosed as a single magnet [84,85]. To reduce the risk of misinterpreting the radiograph, both AP and lateral radiographs should be performed initially, and all subsequent radiographs should be closely examined for any indication that multiple magnets might be present.
•The child should be kept away from any magnetic or metallic materials (including metallic buttons or buckles in clothing), until the magnet has passed out of the gastrointestinal tract.
•Because even single magnets have some risk, endoscopic removal should be considered if the magnet is accessible.
•Ingestion of a single magnet with another metallic object should be managed using the protocol for multiple magnet ingestion.
•Magnets in the esophagus or stomach should be promptly removed via endoscopy.
•Management of patients with multiple magnets beyond the stomach depends on symptoms and progression. Asymptomatic patients should be followed closely with serial radiographs and examinations every four to six hours. Alternatively, magnets can be removed by enteroscopy or colonoscopy if accessible. Symptomatic patients, or any patient with multiple magnets that do not progress on serial radiographs, should undergo surgery for operative removal of the magnets.
The approach to endoscopic removal of magnets is similar to that for other blunt objects. Magnetic probes have been used to retrieve magnetic and metallic foreign bodies with varying success . A series of podcasts is available to guide endoscopic and surgical management . In addition to the steps outlined above, some experts have suggested administration of polyethylene glycol without electrolytes (PEG 3350, Miralax®) or other laxatives to expedite the progression of the magnetic object through the intestine .
Long objects — Foreign bodies that are long and blunt, such as toothbrushes, batteries, and spoons, are most frequently ingested by older children, adolescents, or adults. Objects longer than 6 to 10 cm generally cannot pass beyond the stomach and should be removed [40,67,93]. Objects of intermediate length (longer than 5 cm) may pass the stomach, but up to 50 percent become impacted in the ileocecal region . Thus, these should be removed promptly if they are in the stomach. If they pass into the small intestine they should be followed by serial radiographs, and surgical removal should be considered if they fail to progress.
The use of a long (greater than 45 cm) overtube that extends beyond the gastroesophageal junction may be beneficial in these older children. The object can be grasped with a snare or basket and maneuvered into the overtube. The entire apparatus, foreign body, overtube, and endoscope then can be withdrawn in one motion, avoiding losing grasp of the object in the overtube itself .
Objects containing lead — Acute lead toxicity may occur in children ingesting objects with high lead content, including the lead weights used for fishing ("sinkers"), curtain weights, air rifle pellets, and some toys or medallions. Fatalities have been reported [95,96]. Markedly elevated lead levels have been measured within 90 minutes of ingestion of a foreign body containing lead [97,98]. The acid environment of the stomach enhances dissolution of the metal.
Acute lead toxicity presents with nonspecific symptoms including lethargy and vomiting. Providers should be alert to this possibility in a child with a retained foreign body and should measure serum lead levels if there is any suspicion of lead toxicity. (See "Childhood lead poisoning: Clinical manifestations and diagnosis".)
Objects suspected to have a high lead content should be removed from the esophagus or stomach as quickly as possible. Administration of proton pump inhibitors may decrease the dissolution of lead . Treatment for acute lead toxicity is described separately. (See "Childhood lead poisoning: Management".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)
●Basics topic (see "Patient information: Swallowed objects (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Many children with esophageal foreign bodies are asymptomatic or had transient symptoms at the time of the ingestion, such as retrosternal pain, cyanosis, or dysphagia. When symptoms do occur, they may include a sensation of something stuck in the chest, refusal of feeds or dysphagia, drooling, or respiratory symptoms including wheezing, stridor, or choking. (See 'Clinical manifestations' above.)
●Patients with long-standing esophageal foreign bodies may present with weight loss, aspiration pneumonia, fever, or signs and symptoms of esophageal perforation including crepitus, pneumomediastinum, or gastrointestinal bleeding. (See 'Clinical manifestations' above.)
●The initial evaluation of a patient with suspected foreign body ingestion should include biplane radiographs (anteroposterior and lateral) of the neck, chest, and abdomen (algorithm 1). Other imaging modalities or direct advancement to upper endoscopy may be helpful in identifying radiolucent foreign bodies. (See 'Imaging' above.)
•When the object is sharp, long, or consists of magnets
•When the object is a disk battery in the esophagus
•If airway compromise, such as tracheal compression, is present
•If there is evidence of esophageal obstruction (eg, the patient is unable to swallow secretions)
•If there are signs or symptoms suggesting inflammation or intestinal obstruction (fever, abdominal pain, or vomiting)
•If the object is in the esophagus and the suspected ingestion occurred 24 or more hours prior to the evaluation, or if the time of ingestion is unknown
●Suspected magnet ingestion requires urgent evaluation. Management depends on the timing, location, type, and number of magnets (algorithm 2A-B). Single magnets can generally be managed conservatively, but with precautions. Ingestion of multiple magnets has a high risk of complications and warrants preemptive removal. (See 'Magnets' above.)
●For patients without the above characteristics who are comfortable and able to handle oral secretions, intervention can be delayed for up to 24 hours. Coins, food impactions, and other blunt objects often will pass spontaneously into the stomach and beyond. Recommendations for removal of disk batteries that are in the stomach depend on the timing of ingestion and composition of the battery, and are discussed separately. (See 'Expectant management' above and 'Batteries' above and "Button and cylindrical battery ingestion".)
●A variety of techniques are used to extract foreign bodies from the esophagus or stomach. We suggest flexible endoscopy for most foreign body extractions (Grade 2C). This preference is because the technique can be adapted to a variety of foreign bodies in the esophagus, stomach, or proximal duodenum, and allows direct assessment of the mucosa for injury. Rigid endoscopy or retrieval with Magill forceps are useful techniques for objects in the hypopharynx or proximal esophagus. (See 'Techniques' above.)
●We recommend prompt removal of any sharp object in the esophagus (Grade 1B) or proximal gastrointestinal tract (Grade 1C). This is because of high rates of complications from sharp objects. For the same reason, we recommend prompt removal of magnets if more than one is present in the proximal gastrointestinal tract (Grade 1C). If these objects have passed beyond the proximal duodenum and the patient is asymptomatic, they can be managed with close observation and serial radiographs. (See 'Sharp-pointed objects' above and 'Magnets' above.)
●Objects that have passed beyond the proximal duodenum are not accessible to the endoscope, and most will pass without complications. The progress of radio-opaque objects down the gastrointestinal tract should be monitored with serial radiographs. (See 'Coins' above.)
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.