Surgical Emergencies
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Question 66 of 180
A 2 year old child is brought into ED by his parents who tell you they think he may have ingested some small toy magnet balls 2 days ago. They have not yet seen them pass in his stool. His x-ray shows 9 small balls aligned in a row and projecting obliquely anteroposteriorly at the L4/L5 level. What is the most appropriate management?
Answer:
When a single magnet is swallowed, it is likely to pass through the GI tract uneventfully. However, when two or more magnets become separated along their course in the GI tract, these magnets pose the unique danger of being able to attract each other through different loops of bowel, arresting their movement, and potentially causing mural pressure necrosis. This can result in subsequent small bowel obstruction or perforation, volvulus, fistula formation, intraabdominal sepsis, and death. Ingestion of multiple magnets or a single magnet + a metal object require early removal. Removal of the ingested magnets can be retrieved endoscopically if they are in the oesophagus, stomach or proximal duodenum. Once the magnets move further into the small bowel, surgical removal either through an exploratory or a laparoscopic assisted laparotomy is required to localise and remove the magnets.Foreign Body Ingestion
Ear, Nose & Throat / Gastroenterology & Hepatology
Last Updated: 19th September 2022
The majority of foreign body ingestions occur in children between the ages of six months and three years. Most cases are brought to medical attention by their parents because the ingestion was witnessed or reported to them. Many of patients are asymptomatic or have transient symptoms at the time of the ingestion. Accidental foreign body ingestion may also occur in adults with learning difficulties. Intentional foreign body ingestion may occur in patients with psychiatric history or in prison inmates.
Clinical management focuses on identifying and treating the cases at risk for complications, which depends on the location and type of foreign body. Commonly ingested objects include coins (most common), button batteries, toys, toy parts, magnets, safety pins, screws, marbles, bones, and food boluses. The majority of ingested foreign bodies (FBs) are low risk objects and can be managed without imaging or intervention.
Anatomical considerations
Most ingested foreign bodies pass spontaneously. Only 10 to 20 percent require endoscopic removal, and less than 1 percent require surgical intervention.
When foreign bodies are retained:
- Oesophageal foreign bodies tend to lodge in areas of physiologic narrowing, such as the upper oesophageal sphincter (cricopharyngeus muscle), the level of the aortic arch, and the lower oesophageal sphincter.
- Objects that become lodged in the middle portion of the oesophagus are more likely to represent oesophageal pathology, such as an oesophageal spasm or stricture.
- Sections of the oesophagus with prior surgery or congenital malformations (e.g. tracheoesophageal fistula) pose an increased risk as sites for obstruction.
Clinical features
- Most cases are brought to medical attention by their parents because the ingestion was witnessed or reported to them. Many of the children are asymptomatic or have transient symptoms at the time of the ingestion.
- Patients with an oesophageal foreign body may present with:
- Refusal to eat or drink
- Coughing
- Dysphagia
- Drooling
- Respiratory symptoms due to tracheal/airway compression e.g. wheezing, stridor, choking
- Sensation of something stuck in neck or lower chest
- Retrosternal pain
- Objects that reach the stomach are typically asymptomatic, unless they are large enough to cause gastric outlet obstruction, which could present with vomiting and/or feeding refusal.
- Objects that pass beyond the pylorus and into the intestines are usually asymptomatic and pass spontaneously. Occasionally, foreign bodies may be retained in the distal gastrointestinal tract, where they can cause delayed complications. This may present with features such as abdominal pain, vomiting, GI bleeding, and signs of peritonitis or obstruction.
Diagnosis
A careful history and physical examination are the keystones in diagnosing an oesophageal foreign body and to the prevention of its complications. X-rays are unnecessary in an asymptomatic child, with no possibility of button battery or magnet ingestion, a reliable history and no significant past medical history. Imaging is required in: suspected or known button battery, magnet/s, other high-risk radio-opaque object, unknown object, high risk or unwell child.
Imaging can be used to localise the site of the foreign body. 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. This is to evaluate for radiopaque foreign bodies, for indirect evidence of the radiolucent foreign body (such as an air-fluid level in the oesophagus); and for free air representing a perforation.
If the radiograph reveals a radiopaque object, the following features should be noted:
- Oesophageal vs tracheal location
- Flat objects (e.g. coins or button batteries) in the oesophagus usually orient in the coronal plane and appear as a circular object on an anteroposterior projection, whereas objects lodged in the trachea tend to orient in the sagittal plane and are best seen in lateral projection.
- Coins vs button battery
- It may be difficult to differentiate between a button battery and a coin on a radiograph. This distinction is most important when the foreign body is in the oesophagus since batteries require immediate removal, whereas coins may or may not. Radiographic features that can help distinguish between the two include:
- Button batteries have a bilaminar structure, making them appear as a double-ring or halo on plain radiographs.
- On lateral view of the foreign body, the button battery has a step-off at the separation between the anode and cathode; by contrast, the coin has a sharp, crisp edge.
- It may be difficult to differentiate between a button battery and a coin on a radiograph. This distinction is most important when the foreign body is in the oesophagus since batteries require immediate removal, whereas coins may or may not. Radiographic features that can help distinguish between the two include:
Management
Urgent assessment and intervention is indicated:
- When the object is high risk:
- Button batteries in the oesophagus (and, in some cases, in the stomach)
- High-powered magnet or magnet +/- metal object
- Sharp object in the oesophagus
- Large objects (>5 cm long and/or >2 cm wide)
- Superabsorbent polymers
- Toxic objects e.g lead based object
- When the patient shows signs of airway compromise
- When there is evidence of near-complete oesophageal obstruction (e.g. patient cannot swallow secretions)
- When there are signs of symptoms suggesting impending or complete oesophageal perforation (severe neck or chest pain, odynophagia, aphagia or drooling, tachycardia, tachypnoea, pyrexia, surgical emphysema (neck swelling, crepitus), pneumomediastinum)
- When there are signs or symptoms suggesting inflammation or intestinal obstruction (fever, abdominal pain, or vomiting)
- Where objects are lodged in the oesophagus for more than 24 hours or for an unknown duration
Management:
- Objects impacted in the oropharynx require urgent ENT evaluation.
- Button batteries lodged in the oesophagus can erode mucosal surfaces in <2 hours and need immediate removal.
- Ingestion of multiple magnets +/- metal require early endoscopic removal.
- Fish bones may lodge in tonsils and require removal.
- For blunt foreign bodies without the above characteristics that are lodged in the lower oesophagus in an asymptomatic patient who can swallow saliva and where the object has a good chance of passing, observation for 12 to 24 hours is reasonable because spontaneous passage often occurs. If the object does not move, endoscopic removal is indicated.
- Larger objects (>5 cm long and/or >2 cm in diameter) in the stomach require a gastroenterology or surgical opinion due to the increased risk of obstruction.
- If x-ray shows a blunt foreign body is in the stomach or beyond (and it's not a high risk object), the patient can be most likely be discharged.
Complications
- Retained foreign body
- Weight loss due to decreased caloric intake
- Recurrent aspiration pneumonia due to poor handling of oral secretions
- Oesophageal mucosal erosion/ulceration/necrosis
- Oesophageal stricture
- Oesophageal perforation
- Oesophageal fistula e.g. into trachea, aorta
- Button batteries
- Necrosis of the oesophagus may occur due to liquefaction from the electrical current and may lead to ulceration within a few hours of ingestion and perforation as early as eight hours after ingestion. Longer-term retention may lead to pressure necrosis and/or leakage of caustic material, with resultant tissue damage including perforation.
- Multiple magnets (or magnet + metal object)
- These pose the unique danger of being able to attract each other through different loops of bowel, arresting their movement, and potentially causing mural pressure necrosis. This can result in subsequent small bowel obstruction or perforation, volvulus, fistula formation, intraabdominal sepsis, and death.
Rare Earth Magnets
- Rare earth magnets are between five and ten times stronger than ceramic magnets and are sometimes called ‘super strong’ or powerful magnets. They are often brightly coloured and can be of a variety of shapes such as balls, cylinders, discs, ellipses and bars, usually of less than 6 mm in diameter. These inexpensive and readily available magnets can be accidentally swallowed by children with ease.
- The ingestion of a single rare earth magnet is unlikely to cause significant harm, however, if multiple magnets are ingested, or if a magnet is swallowed along with a metal object significant injury can occur. Magnets can attract each other across layers of bowel to cause ischemia and pressure necrosis of the gut and serious complications. The types of injuries have included ulceration, necrosis, perforation, rupture, stricture, fistula, haemorrhage, mediastinitis, gastric outlet or bowel obstruction, volvulus, sepsis and death. Unlike most other ’foreign body’ ingestions, passage of rare earth magnets into the stomach must not be used as an indication that a child is free from any potentially catastrophic underlying injury.
- A symptomatic child or young person who has ingested a rare earth magnet requires urgent discussion with a tertiary paediatric surgical team. The presence of symptoms with a history of rare earth magnet ingestion is highly likely to require surgical intervention. Perforation occurred in 50 to 75% of the symptomatic patients at presentation. Fistula formation may occur within 2 to 5 days. Surgical intervention is indicated when endoscopic removal is not indicated or is not possible because of the location, number of magnets or several bowel loops are attached to each other.
- Do not use metal detectors for the assessment of children with suspected rare earth magnet ingestion. Chest X-ray and abdominal X-ray (with the patient lying down, ideally AP) should be requested to assess both the position of any magnets and the number of magnets. In the case of a single magnet being identified on an abdominal X-ray, a lateral abdominal X-ray should also be requested to confirm that only one magnet has been ingested.
- The progression of the magnet/magnets through the gastrointestinal tract is crucial to determining whether surgical intervention is required. Patients who do not meet discharge criteria e.g. symptomatic patients, signs of deterioration, ingestion of two or more rare earth magnets should be discussed with a specialist regional paediatric surgical centre in the first instance. Admission under the care of a local surgical team maybe appropriate, after discussion with the regional paediatric centre. This admission would enable close observation as well as repeat imaging and in the event of any deterioration, rapid transfer to the regional paediatric centre.
- The following patient should be considered suitable for discharge after rare earth magnet ingestion:
- Single magnet ingestion
- Accidental ingestion
- No comorbidities
- Tolerating oral intake
- Presented within 24 h of ingestion
- Caregiver who can provide close observation
- All patients who are being discharged with rare earth magnet ingestion require follow-up imaging after 6-12 hours, repeated earlier imaging is not indicated. If the child becomes symptomatic before the repeat radiograph urgent surgical review will be required. Follow up abdominal X-ray should be requested (only repeat CXR if magnets seen in the chest on the first image). It is essential that the abdominal radiographs are always performed in the same position (lying down, ideally AP). Interpretation of the abdominal x-ray and the finding of progression of the rare earth magnet through the gastrointestinal tract should be formally confirmed by a radiologist. Follow-up AXRs should continue to be performed until it can be demonstrated (and confirmed by a radiologist) that the magnet has passed through the stomach and serial X-rays (at least 6-12 hrs apart) show that it is progressing through the small bowel or beyond. Failure of the magnet to progress through the gastrointestinal tract, (defined as: the magnet having not moved from the last demonstrated position on AXR irrespective of location in GI tract after a period of 6-12 hrs and confirmed by a radiologist) is an indication for discussion with a specialist regional paediatric surgical centre.
Food boluses
- This is a common emergency presentation to ENT and gastroenterology. The patient is usually in considerable discomfort and may need to go to theatre if this does not improve.
- A food bolus is a semi-solid mass of food (most often meat) not associated with a hard or sharp foreign body. If you suspect that that there may be a hard or sharp foreign body, proceed as for a ingested hard foreign body.
- The food bolus may impact at any level. If the obstruction is in the upper oesophagus, the patient may be spitting out their own saliva, and any attempt to drink something causes immediate regurgitation. They may feel neck pain or point to an area higher in the neck. Lower oesophageal symptoms include discomfort in the suprasternal notch or retrosternally, and delayed regurgitation.
- Consider a lateral soft tissue neck X-Ray and/or a lateral chest X-Ray to look for signs of a hard foreign body (the history is not always accurate), surgical emphysema and signs of obstruction.
- Patients who present to hospital have probably already tried water and waited a few hours to see if their food bolus will pass spontaneously. Offering fizzy drinks to patients with food bolus obstruction appears to be safe and may be effective.
- If the bolus does not pass, patients should be admitted for observation (observation ward, CDU, MAU or SAU) and consideration of medical treatment e.g. IV glucagon, IV buscopan or prokinetics. In uncomplicated cases, admit the patient overnight and give IV fluids and analgesia. Oesophagoscopy (rigid or flexible) is usually performed the following day to allow time for the obstruction to pass spontaneously, as long as there are no worrying features.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
