6 
Foreign Bodies in the Esophagus
Neil R. Floch
More than 100,000 cases of ingested foreign bodies occur in the pediatric
population each year. Although most are accidental, intentional inges-
tion starts in adolescence. Children under 5 years of age are often exposed
to random household objects, and they often swallow coins; such cases
were as high as 76% in one large study. Children also swallow toy parts,
jewels, batteries, sharp objects (needles, pins, fish or chicken bones),
metal objects, food, seeds, plastic material, magnets, buttons, nuts, hard
candy, and jewelry, which can become lodged in the esophagus. Sharp
objects such as a safety pin can become impacted in the esophagus of
an infant or small child. Batteries represent less than 2% of foreign
bodies ingested by children. Ingestion of multiple magnets can cause
esophageal obstruction and perforation.
Foreign bodies become entrapped as frequently in adults as in chil-
dren (Fig. 6.1). Psychiatric patients and prisoners may intentionally
swallow objects for ulterior motives. In adults, the foreign body most
often entrapped is food, usually meat (33%). Hasty eating may result
in the swallowing of chicken or fish bones. Tacks, pins, and nails held
between the lips may be swallowed and may attach to the esophageal
wall or descend into the stomach and beyond. Pill ingestion may also
be a cause of impaction.
In the esophagus, obstruction typically occurs at the three narrowest
areas, including the upper esophageal sphincter, compression by the
aortic arch in the esophagus, and at the lower esophageal sphincter. Of
the 40% to 60% that become lodged in the esophagus, ingested objects
are found above the cricopharynx in 57% to 89% of patients, at the
level of the thoracic esophagus in approximately 26% of patients, and
at the gastroesophageal junction in 17% of patients. A large propor-
tion (30%–38%) of these people may have an underlying esophageal
disease. Along their way, foreign bodies can cause destruction in the
form of impactions, ulcerations, and perforations. The presence of
other lesions in the esophagus—such as rings, strictures, diverticula,
and tumors—may form a nidus for impaction. Impaction is also more
likely in the presence of a dysmotility disorder such as achalasia. Most
foreign bodies, or 80%, will migrate through the intestine and into the
stool without incident. The remaining 20% will have to be extracted
surgically.
CLINICAL PICTURE
Symptoms caused by foreign bodies lodged in the esophagus depend
on the object’s size, shape, consistency, and location. Many children
will have had only transient symptoms or may be asymptomatic. About
50% of patients have symptoms at the time of ingestion, such as retroster-
nal pain, choking, gagging, or cyanosis. They may drool; dysphagia may
occur in up to 70% and vomiting in 24%. Patients also report odyno-
phagia, chest pain, and intrascapular pain. Children or adults with
long-standing esophageal foreign bodies reveal signs such as weight
34
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loss, aspiration pneumonia, and fever. If esophageal perforation is the
eventual presentation, there will be crepitus, pneumomediastinum, or
gastrointestinal bleeding.
Infants are unable to express their discomfort or locate the sensation
of pain; they may have vague symptoms, making diagnosis difficult.
Retching, difficulty swallowing, and localized cervical tenderness may
be the only ways in which the obstruction can be confirmed.
DIAGNOSIS
Radiopaque substances, such as metallic objects, chicken or fish bones,
or clumps of meat can readily be recognized on x-ray film. Therefore
an anteroposterior and lateral x-ray of the neck, chest, and abdomen
should be performed. Nonradiopaque objects, such as cartilaginous
and thin fish bones, may be seen on computed tomography (CT) or
during esophagoscopy if other modalities are not diagnostic.
TREATMENT AND MANAGEMENT
Treatment of foreign bodies depends on the type of object, its location,
and the patient’s age and size. Emergent removal of foreign bodies of
the esophagus may be necessary because of the risk of respiratory com-
plications and esophageal erosion or perforation.
Objects that are long and sharp, magnets, and those that contain
superabsorbent polymers as well as disk batteries should always be
removed because of their ability to cause a caustic injury and perforation.
If the object is causing obstruction of the trachea or airway compromise,
removal is imperative. Esophageal obstruction requires urgent removal;
symptoms of fever, abdominal pain, or vomiting may be indicative. If
the time since ingestion is unknown or more than 24 hours, earlier
removal has a better prognosis. Ingestion of a single magnet may be
treated observantly; however, multiple magnets can attract in the bowel
and cause necrosis and perforation and should be promptly removed.
Patients who are capable of tolerating their own secretions can delay
treatment for a day. Objects such as food, coins, or blunt objects may
have time to pass through the bowel spontaneously. Passage occurs
naturally in 50% of all foreign body ingestions. Small, smooth objects
and all objects that have passed the duodenal sweep should be managed
conservatively by radiographic surveillance and stool inspection.
Spontaneous passage of coins in children occurs in 25% to 30% of
cases without complications; therefore these patients should be observed
for 24 hours, especially with distally located coins. Spontaneous passage
of coins is more likely in older, male patients, especially when the coins
become lodged in the distal third of the esophagus. If coins do not pass,
esophageal bougienage or endoscopic removal may be required. For
most objects, esophageal bougienage entails the lowest complication
rate and the lowest cost.
 CHAPTER 6  Foreign Bodies in the Esophagus 35

Denture Coin
(esophagoscopic view)

Denture

Chicken bone

Fish bone

Fig. 6.1  Foreign Bodies in the Esophagus.

When foreign bodies are trapped in the upper esophagus or hypo-
pharynx, rigid endoscopy or Magill forceps are most successful at
extracting objects. Esophagoscopy is used for most foreign body extrac-
tions in the middle to lower esophagus because it is both diagnostic
and therapeutic. Endoscopy can be adapted to extract multiple different
types of objects in the esophagus as well as the stomach and duodenum.
It can also assess for damage to the intestinal lining. It is successful in
95% to 98% of patients and results in minimal morbidity. Innovative
methods such as a loop basket, suction retrieval, suture technique,
double-snare technique, and combined forceps/snare technique for long,
large, and sharp foreign bodies, along with newer equipment such as
retrieval nets and specialized forceps, may be necessary if removal is
difficult.
Management of blunt objects have a less than 1% complication rate.
Sharp foreign bodies have a complication rate between 15% to 35%
but straight pins cause less problems unless multiple are ingested. Ingested
batteries that lodge in the esophagus require urgent endoscopic removal
even in the asymptomatic patient because of the high risk of burns and
possible death. Batteries that are 2 cm or larger in size are especially
likely to become lodged. Patients must be anesthetized. Approximately
90% can tolerate conscious sedation; the rest require general anesthesia.
The pressure from a large mass in the esophagus against the trachea
may cause asphyxia, necessitating tracheotomy before the object can
be removed, especially in children.
Food often accumulates above an entrapped object and must be
removed by forceps. Food boluses can be removed using grasper devices,
polypectomy snares, or retrieval nets; friction-fit adaptors can be used
to break up the food or retrieve it in total or piecemeal. Small pieces
of food may be pushed into the stomach. Maximal dilatation of the
esophageal wall will allow visualization of the foreign body. Sharp or
pointed objects (e.g., nails, pins, bristles) may become embedded in
the esophageal wall with only their tips visible; they must be retrieved
using endoscopic forceps.
On occasion, magnets are used to localize a metallic foreign body
and position it so that it can be removed. Magill forceps enable quick,
uncomplicated removal of coins in children, especially coins lodged at
or immediately below the level of the cricopharyngeal muscle. Proximal
dilatation using an oral side balloon is safe and effective for removing
sharp foreign bodies from the esophagus, thus avoiding surgery and
possible perforation; it is successful in 95% of patients.
Surgical treatment is unavoidable for the 1% of patients from whom
an object cannot be retrieved by endoscopy and therefore the risk of
perforation arises. These objects are usually lodged in the cervical
esophagus. Surgical treatment of perforation includes cervical medi-
astinotomy or thoracotomy and drainage. Success of surgery depends
on the size of the injury, its location, the time elapsed between rupture
and diagnosis, the patient’s underlying medical condition, and whether
sepsis has developed. Ultimately poor conditions in esophageal perfora-
tion may result in mortality.
Conservative treatment is successful in patients with perforation
but no abscess or significant contamination. These patients are treated
immediately with broad-spectrum antibiotics and are not permitted
food or liquids, receiving either enteral feeding or total parenteral nutri-
tion until healing is documented by meglumine diatrizoate (Gastrografin)
swallow. If the patient develops a cervical abscess or mediastinitis, he
or she should undergo exploratory surgery with surgical drainage.

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36 SECTION I Esophagus

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