TABLE 721 Presentations of Esophageal Foreign Bodies Warranting Endoscopy Consultation and Possible Hospital Admission

The offending object can be located in several ways. A radiopaque object will be demonstrated on standard x-ray films of the neck or abdomen. The procedure of choice for finding and then extracting a foreign body in the esophagus is endoscopy. 4 This procedure has a high success rate and thus avoids progression to surgery.5 It is also time-efficient.6 Although many other diagnostic methods are available, they are not as reliable and thorough as endoscopy, so the time spent in arranging for and conducting such tests may not be time well spent for a frightened, uncomfortable patient.

If endoscopic equipment and expertise are not available, an esophagogram can be performed. Consultation with an endoscopist is strongly recommended before initiation of any contrast study, because direct visualization of the foreign body after contrast administration may not be possible because of interference from swallowed contrast medium.

The type of contrast agent must be chosen based on the anticipated clinical findings and course. 7 If perforation is suspected, a water-soluble contrast agent (Gastrograffin) should be used. However, since water-soluble agents are pulmonary irritants, barium should be used if aspiration is possible. The least amount of barium possible should be instilled, because barium will block the endoscopic field. If both perforation and aspiration are possible, a nonionic contrast agent is indicated.

Progress of the object through the gastrointestinal tract must be monitored with repeat abdominal x-ray films, usually 2 to 4 h apart. The use of metal detectors, if available, has been advocated as a means of localizing and tracking the progression of metal objects, thereby avoiding repeated radiation exposure. Abdominal examinations should be done frequently to detect early signs of developing peritonitis should perforation occur. Virtually all symptomatic patients will require observation and esophagoscopy. If a nonfood object becomes lodged in the esophagus or is unable to pass through the pylorus, it must be removed as soon as possible, using esophagogastroscopy. Fatal lead encephalopathy has been reported in a child who ingested a lead curtain weight, which supposedly had been in the stomach for an extended time.8

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