Anjum Bandarkar, MD

Diagnostic Imaging and Radiology,

Children’s National Medical Center, Washington DC
Disclosures

- None
Learning Objectives

1. Review imaging features of a variety of foreign bodies

in children:
ingested
aspirated
traumatic
inserted

2. Discuss clinical management and complications of

foreign bodies
Foreign Body : Mechanisms of entry

Four routes of entry are known:

1. Ingestion - 80%

2. Aspiration

3. Traumatic / iatrogenic injury

4. Insertion
Radioopaque vs Radiolucent FB’s

Radioopaque* Radiolucent
• Glass – all types • Most foods
• Metal – except aluminum • Wood, splinters, thorns
• Most animal bones • Fish bones
• Some foods • Plastics
• Sand, gravel, soil fragments • Aluminum
• Medications

*Tim Hunter, Radiographics 2003; 23:731-757

FB Ingestion: General Principles

• 80%: 6 months – 3 years of age

• 1500 deaths/year *

• Most foreign objects traverse the GI tract without problem

• Esophagus - major hold-up

• 10 – 20% need endoscopic removal

• <1% require surgery

* www.uptodate.com
 FB Ingestion: General Principles

• A retrospective review* of 325 children - 50 % of children

with confirmed FB ingestions were asymptomatic

• High index of suspicion needed when dealing with children

• Never rest after finding one – ‘Happy eyes syndrome’

Always look for second or third FB

*Arana A, Management of ingested foreign bodies in childhood and review of the literature, Eur J Pediatr. 2001;160:468–72
Pharynx and Esophagus : Anatomy

C6
C6

Courtesy : Sciencedirect.com
Pharynx and Esophagus : Anatomy
 Sites of FB impaction in esophagus

Three points of anatomic narrowing in the

esophagus –

1. Just below the cricopharyngeus muscle in

proximal esophagus
– most common place ; in 70% cases

2. Just above the aortic arch in

midesophagus
– in 20% cases

3. Just above the GE junction, at lower

esophageal sphincter
– in 10% cases
 Sites of FB impaction in abdomen

Once beyond the esophagus, FB’s may

get impacted at one of the following
sites in the abdomen –

1. Pylorus

2. Duodenojejunal junction

3. Ileocecal valve
Types of Ingested FB’s

Most commonly ingested FB’s are:

• Coins

• Button Batteries

• Magnets and steel balls

• Food/meat bolus, chicken/ fish bones

• Screws/ needles/ sharp objects

• Caustics

• Miscellaneous/ marbles/ rings/ toys

FB Ingestion: Signs & Symptoms*
• Vomiting
• Gagging
• Coughing
• Drooling
• Dysphagia/odynophagia
• Food refusal
• Foreign body sensation in throat
• Irritability
• Pain in neck, throat, or chest
• Wheezing
• Respiratory distress High index of suspicion
• Stridor
• Tachypnea or dyspnea
• Recurrent aspiration pneumonia
• Failure to thrive
• Fever
*www.aafp.org/afp/2005/0715/p287.html
FB Ingestion: Imaging Studies

• Initial diagnostic test should be biplane radiographs

- Nose to Rectum series,
- AP and Lateral orthogonal views of neck, chest and abdomen

• Esophagram using water-soluble contrast may be performed,

- But contrast may pose a risk of aspiration
- May compromise subsequent endoscopy
- We do not use barium contrast to evaluate FB’s.
Nose to Rectum radiograph series
FB Ingestion : Management

Urgent / Emergent intervention:

• Disc /button battery

• Magnet

• Sharp, >5 cm long

• Airway compromise

• Near-complete esophageal obstruction

• >24 hours/ unknown time

FB Ingestion : Management

Expectant Management
• Coins / blunt objects – Observe 12 hours, repeat x-ray for location

• About 1/3rd objects will have passed into stomach after 8-12 hours

• If it does not move after 24 hours, it is removed even if asymptomatic.

• Flexible endoscopy is the preferred technique

Algorithm for management of suspected
ingestion of radiopaque foreign bodies.
http://www.aafp.org/afp/2005/0715/p287.html
FB Ingestion : Coin

14 month old girl swallowed a penny.

Nose to rectum series shows round
radioopaque FB in cervical/ upper esophagus
at thoracic inlet.
FB Ingestion : Coin

2 ½ yo girl with penny in mid esophagus

FB Ingestion : Coin

3 yo girl swallowed a quarter (2.5 cm diameter), it slipped

down during rigid esophagoscopy, remained in stomach
for 2 weeks, retrieved via net.
FB Ingestion : Coins

2 yo boy with unknown head

injury for trauma CT -

Multiple round radiopaque

foreign bodies picked up
incidentally on CT abdomen,
Remained in stomach for a
week, did not pass.

Sx - 5 coins were removed.

FB Ingestion : Disc Battery

Disc battery in mid/distal esophagus, Double density / halo sign

Coin vs Battery

Battery

Coin
 FB Ingestion : Battery

• Button batteries are commonly found in numerous electronic devices

• Lithium batteries are increasingly used because of their higher charge
density, but they are also larger in diameter and easily get stuck

Mechanism of action –
• Electronic current generated by battery causes hydrolysis
of tissue fluids resulting in hydroxide accumulation and corrosion of
adjacent tissues

• Leakage of chemical contents like NaOH and KOH causes tissue

necrosis

• Pressure necrosis
 FB Ingestion : Button Battery

4 yo boy with button battery in lower esophagus

 FB Ingestion : Button Battery

12 yo boy swallowed a battery. F/U next day documented passage

“Button Battery Ingestion in Children: What the
Radiologist Must Know” by Mariam Kappil, et al
 FB Ingestions - Magnet

3 ½ yo boy told his mom he swallowed a ball.

Website for magnetix.toys says the ball is steel and not magnetic
 FB Ingestion: Magnets

Day 1 Day 2

8 yo boy swallowed a pair of magnets from his toy set, passed without difficulty
 FB Ingestion: Food Bolus

3 yo seen choking while eating sausage, Sx – Direct Laryngoscopy

FB Ingestion: Fish bone

3 yo boy swallowed fish bone

FB Ingestion: Aluminium (soda can flip top)

11 yo boy swallowed a soda can flip top, drooling and throat pain.
Removed urgently.
 FB Ingestion: Sharp Pin

After 10 hours

11 yo female swallowed 4.5 cm sized

scarf pin by mistake,
Taken to OR for removal, but it had
passed distally, it eventually passed
without difficulty
 FB Ingestion: Complications

• Impaction/ obstruction
• Mass effect (tracheal narrowing)
• Perforation / intestinal obstruction (magnets)
• Mucosal injury/ burns (battery)
• Diverticulum formation (chronic retained FB)
FB Ingestion : Esophageal obstruction

7 yo boy with food bolus

impaction and
esophageal
obstruction.

Sx- Bolus slipped down

after general anaesthesia

Food lodges at site of

narrowing from prior TE
fistula repair
FB Ingestion : Complications

9 mo boy with cough and respiratory distress in the ER,

Coin impacted in upper esophagus / tracheal narrowing
FB Ingestion : Mass effect

Tracheoesophageal stripe WNL

Tracheal narrowing and thickening of

the tracheoesophageal stripe
indicating inflammatory change
secondary to foreign body at thoracic
inlet.
FB Ingestion : Button Battery

2 yo girl with button battery in upper esophagus,

causing mass effect on trachea
Double density / halo sign , beveled edge
 FB Ingestion : Tracheal narrowing

6 month old boy with respiratory distress – 2 coins in upper esophagus.

Rigid esophagoscopy – a penny and a dime
FBI – Corrosion and mucosal injury

19mo boy, came to ER with pain, constipation, no h/o swallowing FB,

X-ray and Sx - impacted corroded penny in esophagus
FB Ingestion : Esophageal narrowing

15 mo boy with battery in UGI post removal – 3 m F/U – improved

Cervical esophagus Esoph.narrowing luminal distension
FB Ingestion : Esophageal stricture

17 mo girl drank Drano

UGI – Long segment stricture

of esophagus

Gastric pull-up surgery

 Retained ingested battery : TE fistula

1 yo girl swallowed a
battery, difficult removal,
refusal to take PO feed,
unusual pharyngeal
airway,

UGI - TE fistula positive

 After FB removal

Retained Ingested FB – Diverticulum

6 yo boy with h/o progressive dysphagia, weight loss and coughing up

undigested food
Barium esophagram - large posterior diverticulum, suspicious filling defect ?
FB within
CT – Discoid FB in pseudodiverticulum from esoph.perforation at T1
Sx – plastic coin (school money) removed, mucosal tears, blind pouch.
F/U esophagram – fistulous tract leading to main esophagus
Sx – Multiple serial dilatations for esoph..obstruction, gastrostomy.
 Retained ingested magnets

2 1/2 yo boy swallowed a couple of magnets 5 days ago, came in vomiting,

no progression on 8 hour follow up radiograph.
Surgery – gastrojejunal and jejunojejunal fistula, 4 holes repaired
THE WEEK……
7 strange things found in people's stomachs.
posted on September 18, 2012, at 1:05 PM

1. A perilously growing toy - gel ball had grown to 3.5 centimeters and
blocked her small intestines

2. A felt-tipped pen – a felt tip pen was found in the stomach of a 76 year-old
woman, it had been there for 25 years

3. 78 pieces of cutlery – a 52 yo woman consumed cutlery at the table

4. A 10 pound hairball – in a teenage girl, trichotillomania

5. 8 yo girl swallowed 20 steel balls and 10 magnets – Magnetix toys, got

8 rips in her intestines. She thought they were candy.

6. More than 400 coins in a 28 yo man

7. Twin brother – a case of fetus in fetu

 Magnet Ingestion - Facts

• BB-sized shiny magnetic balls are rare earth super magnets,

called Neodymium magnets/ Bucky balls / Nanospheres
• Their remarkable attractive force allows magnets to find
each other regardless of bowel wall and stick together.
• Once magnetically attached, they do not break apart and
cause bowel perforation and obstruction.

• In 2007, first warning came out after the death of a 20 mo child

• By 2008, US CPSC (Consumer Product Safety Commission)
had >200 cases, many requiring emergency surgery

Failure to document free movement

necessitates emergent removal.
FB Aspiration: General Principles

• 80% FBA - occurs in <3 years

• Leading cause of unintentional-injury mortality in children <1 year
• >3500 deaths per year from 2005 to 2007*

• Location: Right main bronchus 60%

Left main bronchus 23%
Trachea 13%

• Commonly aspirated FB’s –

Infants & toddlers – peanuts, seeds, popcorn, food particles

Older children – coins, paper clips, pins, pen caps, hardware

*National Safety Council. Report on Injuries in America, 2002.

Information online: www.nsc.org/library/report_injury_usa.htm
FB Aspiration: Signs & Symptoms*

• Choking episode

• Triad of wheeze, cough & diminished breath sounds

• Shortness of breath
• Hoarseness
• Hemoptysis

• Severe respiratory distress

• Cyanosis
• Altered mental status
 FB Aspiration: Imaging Studies

• Initial step - Dedicated 2 view chest radiograph

• Inspiratory – Expiratory views / Lateral Decubitus series

• Real time Fluoroscopy – expiratory mediastinal shift away from FB

postobstructive hyperinflation due to air trapping
diaphragmatic movements

• CT scan – radiolucent FB’s, chronic retained FB’s, residual FB’s.

A normal CXR does not rule out FB aspiration

 FB Aspiration: Imaging Studies

14 mo girl with choking episode while eating pecans at home

Rt. Side down

Dedicated AP and Lat. views Lateral decubitus series

Rigid Bronchoscopy – Pecan in Left main bronchus

FB Aspiration: Sharp Pin

10 yo girl accidentally aspirated a pin while adjusting her head scarf

Sx – Rigid bronchoscopy, pin removed from left MSB
 FB Aspiration: Management

• Rigid Bronchoscopy is the standard of care for removal of aspirated FB

• Flexible bronchoscopy is also safe and may be used depending on user

• Antibiotics and systemic corticosteroids help reduce inflammation

Education – a strategy to prevent FB aspiration in children

 FB Aspiration: Complications

Acute vs chronic complications

Acute FBA - can block respiration by obstructing airway and

impairing oxygenation and ventilation

Chronic FBA – can lead to -

atelectasis
postobstructive pneumonia
bronchiectasis

Longer the FB is retained, higher the chances of complications

FB Aspiration - Complications

10 yo boy got a CXR at his

well-child visit and a FB was
incidentally noted in his Left
main bronchus. He had
been seen for wheezing in
the ER 4 months ago. He
had some symptoms of
ADHD.

1st Sx – failed removal, very

snugly fit, granulation++
FB Aspiration - Complications

Push pin/ thumb tack

After 4 days of antibiotics and steroids,

2nd Sx – successfully removed
FB Aspiration - Complications

5 yo boy with several months of coughing and now has fever and
diminished breath sounds
FB Aspiration - Complications

4 yo boy choked while eating grapes, was taken to his primary

care clinic, got resuscitated and transferred to CNMC, but had
severe anoxic brain injury.
FB Injuries – General Principles

Traumatic FB injuries –
• puncture wounds from splinters, thorns, nails
• cuts from glass
• MVA

Iatrogenic FB injuries –
• retained catheter, needle, sponge (gossipyboma)
 FB Injuries - Imaging

• Imaging Diagnosis may be difficult

• X-rays may be negative

• US/CT should be used to identify nonopaque materials

• US has emerged as the study of choice for detection and

localization of radiolucent soft-tissue foreign bodies and can
aid assessment of their associated complications.
 FB injuries - Complications

• Most common complication of traumatic FB injury is soft tissue infection

• In cases of chronic retained FB, osteomyelitis may develop

• Iatrogenic FB injuries prolong and complicate hospital course

FB injuries – Glass piece

Hand laceration, r/o FB

FB injuries – Retained Needle

15 yo boy stepped on a sewing needle

FB injuries – Radiolucent soft tissue FB

2 ½ yo boy stepped on
a nail 3 weeks ago

Foot X-ray – negative

US – 2 linear ecogenic
pieces of FB in the
superficial soft tissues
FB injuries – Iatrogenic FB

Newborn female with

retained piece of UVC

Removed by
Interventional
radiologist using
a vascular snare
FB injuries – Radiolucent FB

14 yo stepped on something sharp ? splinter

FB injuries – Retained FB /Osteomyelitis

3 yo girl stepped on a toothpick

three weeks ago,
US – missed FB
F/U – osteomyelitis 3rd metatarsal
FB injuries – Retained FB /Osteomyelitis

Cor T1

Post Gad Sag T1 fs

Ax T2 fs

5 yo boy stepped on toothpick 2 years ago, now came in with

persistent retained FB and chronic osteomyelitis
FB injuries – Traumatic penetrating FB

4 yo girl
fell while
brushing her
teeth.

Toothbrush
head
impaled the
palate
FB Insertion – General Principles

No matter the body opening, FB insertions are well known

Favorite sites – rectum, vagina, urethra, ear, nose

Predisposed individuals are

• Children, usually out of curiosity
• Mentally challenged individuals
• Some adults (engaging in unusual sexual practices)
 FB Insertion – Complications

• Severe bleeding from mucosal injury

• Edema preventing natural passage or easy removal

• Abscess formation, sepsis

• Retained objects may perforate and travel to remote locations

FB Insertion – Battery in auditory canal

4 yo girl with 2 days h/o pain and

swelling in left ear,
CT to rule out mastoiditis
FB Insertion – Do you see the FB ?

10 yo boy playing with a penny, misplaced it

FB Insertion – Do you see the FB ?

8 yo developmentally delayed girl

told her grandma that she had put
something into her vagina.

Pelvic x-ray showed the FB

FB Insertion – Screws in Penile urethra

14 yo autistic boy brought in by parents because he was walking funny

FB Insertion – Bobby pins in urethra

Same boy a few months later…..

Self Embedding Behaviour

It is a form of self inflicted

injury where the person
intentionally inflicts harm
to his or her body without
suicidal intent.

17 yo girl with self embedding behaviour, also had many ingested FB’s
 Potpourri……..

17 month old girl : single view CXR for cough showed a FB.
Repeat series with 2 views was negative.
The FB was her pinky clip and external.

Orthogonal views are important to confirm location of FB.

Potpourri……..

FB aspiration – screw in trachea

Potpourri……..

FB aspiration – Tiny light bulb in left main bronchus

Potpourri……..

FB in hand –
Glass piece
 Potpourri……..

His brother shot him with a BB gun

Potpourri……..

FB ingestion – Hair clip in esophagus

 Potpourri……..

FB ingestion – Screw in small bowel, passed without difficulty

Potpourri……..

Incidentally noted – undigested mushroom in small bowel

Making a mountain out of a molehill!

15 year old boy presenting with acute RLQ pain. He has mitochondrial
disorder, is on multiple medications, and his mother is a lawyer.
US - 1.6 cm tubular structure within bowel loop,
AXR – FB in RLQ, CT – Pill in cecum. Appendix normal.
Diagnosis – Obstructive 3 mm right VUJ calculus.
 Summary ……..

• Reviewed imaging features of different types of FB’s with a focus on

ingested FB’s.

• Start with a nose to rectum series to localise the FB, adding

orthogonal views as needed.

• It is important to recognise and differentiate battery from coin

because management is different

• Remember the ones that are radiopaque versus radiolucent FB’s.

 Summary ……..

• FB aspiration is less common but can have more complications.

• Normal CXR does not rule out FB aspiration.

• In case of traumatic soft tissue FB’s with negative radiographs,

ultrasound is the study of choice.

• Know the complications of battery and magnet ingestion.

• Recognise when to apply emergent vs expectant management.