What Is the Esophagus?
The esophagus spans approximately 20 to 25 cm long in adults, stretching from the hypopharynx to the stomach. It comprises an inner mucosal layer and a muscular layer consisting of circular and outer longitudinal muscles. The upper third comprises voluntary striated muscles that facilitate the initiation of swallowing, while the lower third consists of involuntary smooth muscles.
What Are the Causes of the Foreign Body in the Esophagus?
The esophagus stands out as the primary location for acute foreign body obstructions or food impactions in the gastrointestinal tract, and it's worth noting that 80 to 90 percent of ingested objects that make their way to the stomach will ultimately pass through without requiring any intervention. Although a diverse range of objects can be accidentally ingested, typical esophageal foreign body ingestion involves food boluses (often meat), fish or chicken bones, dentures, and coins. The specific types of objects ingested can vary significantly based on geographical regions and cultural practices. For instance, fish bones were Southern China's most prevalent cause of esophageal foreign body impactions.
Roughly 80 percent of individuals who visit emergency departments for issues related to esophageal foreign bodies are children. These incidents typically involve accidental ingestion of small objects like coins, sharp items such as pins and needles, batteries, components of toys, crayons, fish and chicken bones, large pieces of food, jewelry, and similar items. Among these objects, coins were the most commonly ingested foreign body by children. Most of these children have a normal esophageal structure. However, the risk of blockage is greater in cases with underlying abnormalities such as eosinophilic esophagitis, a history of esophageal atresia repair, or prior Nissen fundoplication.
Similarly, accidental foreign body ingestions can also occur in adults, with the primary cause of blockage being huge food clumps. The estimated annual incidence of food blockages is 13 cases per 100,000 adults. A substantial majority, ranging from 80 percent to 90 percent, of these incidents occur in the lower part of the esophagus and are frequently associated with structural or functional abnormalities. These abnormalities may encompass diverticula, webs, rings, strictures, tumors, eosinophilic esophagitis, achalasia, scleroderma, or esophageal spasms.
What Are the Symptoms of the Foreign Body in the Esophagus?
1. Esophageal foreign body (FB) disease symptoms include the following:
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Sensation of a foreign body.
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Dysphagia (difficulty swallowing).
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Odynophagia (painful swallowing).
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Retrosternal pain (discomfort behind the breastbone).
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Retching.
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Vomiting.
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Early-stage FB disease often presents with FB sensation and localized pain as primary complaints.
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As complications progress, localized inflammation or systemic symptoms may become apparent.
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Patients can typically identify the act of ingestion and locate the discomfort.
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However, the location of discomfort sometimes varies from the site of FB impaction.
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Upper esophageal or above impactions are easier for patients to identify accurately.
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Below this region, symptoms become less distinct, making localization challenging.
2. Complications can lead to severe and systemic symptoms such as:
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Neck swelling.
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Crepitus (crackling sensation) in the neck.
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Hematemesis (vomiting blood).
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Increased dysphagia.
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Dyspnea (breathing difficulties).
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Fever.
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Chest and back pain.
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Esophageal abrasions from ingested FBs can mimic impaction, and FB sensations may persist even after the FB has passed through the esophagus or been removed endoscopically.
How Is Foreign Bodies in the Esophagus Diagnosed?
History and Physical Evaluation:
In assessing individuals with ingested foreign bodies in the esophagus, the doctor will evaluate the key considerations, including the type and number of objects, their location, time since ingestion, and presenting symptoms, which help determine the urgency of retrieval or if observation and follow-up suffice. The doctor will inquire from the adult and older children's history and time of onset, with common symptoms being foreign body sensation and dysphagia, typically developing within minutes to hours.
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Upper esophageal foreign bodies are more precisely localized, while mid-to-lower esophageal impactions may cause vague discomfort or chest pain alongside symptoms like hypersalivation, regurgitation, and retching.
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Painful swallowing (odynophagia) may indicate more serious issues like esophageal laceration. In cases where patients cannot provide history (e.g., infants, young children, mentally impaired, prisoners), a high suspicion level is crucial, with symptoms varying from gagging to respiratory distress. The doctor will perform a physical exam prioritizing airway patency, vital signs, secretions, and signs of complications.
Imaging:
The doctor will then advise routine X-rays, especially for radioopaque objects, to help identify the object, location, and potential complications. Button batteries require special attention due to their appearance on X-rays, while non-radioopaque materials may necessitate diagnostic endoscopy or CT scans for detection and assessing complications like perforation.
How Is Foreign Bodies in the Esophagus Treated?
In managing foreign body ingestion in the esophagus, the approach hinges on factors such as the type of foreign body, its location, the extent of obstruction, and duration. Endoscopic removal is the preferred method, boasting a success rate exceeding 90 percent with minimal complications (less than five percent). The process is categorized into emergency, urgent, and nonurgent scenarios.
Emergency (Requires Immediate Attention):
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Esophageal obstruction leads to an inability to manage oral secretions.
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Disk batteries are lodged in the esophagus.
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Sharp-pointed objects in the esophagus.
Urgent (Addressed Within 12 to 24 Hours):
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Blunt or rounded esophageal objects.
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Food impactions without complete blockage.
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Sharp-pointed objects found in the stomach or duodenum.
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Objects longer than 6 cm are located above the duodenum.
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Multiple magnets within endoscopic reach or a single magnet and another ferromagnetic object.
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Coins stuck in the esophagus.
Nonurgent:
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Objects in the stomach larger than 2.5 cm in diameter.
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Disk batteries in the stomach for up to 48 hours if asymptomatic.
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Blunt objects failing to pass through the stomach within 3 to 4 weeks.
The doctor may use various medical approaches, for example, medications like Glucagon, intended to relax the Lower Esophageal Sphincter (LES) muscles, which may aid the spontaneous passage of smooth, blunt objects into the stomach. However, the effectiveness of glucagon remains inconclusive due to limitations in many studies. Papain, found in meat tenderizers, is not recommended for meat bolus impactions due to potential complications and the theoretical risk of esophageal damage.
In cases of esophageal disc battery impaction, the doctors advise immediate removal due to the high risk of aortoesophageal fistula, particularly in certain scenarios. In the case of asymptomatic children with esophageal coin impaction, the doctor may observe the child for up to 24 hours, with coin location influencing the likelihood of spontaneous passage within 16 hours.
Conclusion
Most individuals who seek evaluation for an esophageal foreign body typically do so following the accidental ingestion of a known object. These individuals often exhibit mild symptoms and are in stable condition. The challenges arise when individuals are unable or unwilling to provide information about the ingested object or the timing of the incident. Examples of such individuals include infants, children, those with mental impairments, individuals with psychiatric conditions, and incarcerated individuals. Additionally, the broad spectrum of possible symptoms, clinical presentations, and the wide possibilities of potential complications can make this condition challenging to assess and address.
