Background/purpose: Foreign body (FB) ingestion in children is very common. Children can ingest a wide variety of FBs. Most of the ingested FBs pass spontaneously through the gastrointestinal tract. Other FBs, especially uncommonly ingested objects, can present with complications and need intervention to be extracted. The aim of this study was to highlight the importance of timely intervention to extract these FBs.Patients and methods: Between November 2012 and October 2017, patients who presented to our department with variously ingested FBs were retrospectively reviewed to detect those who needed intervention (surgical or endoscopic) to extract these FBs.Results: During the specified time period, 480 patients with FB ingestion presented to our department. Out of these children, 12 patients ingested uncommon FBs or presented with symptoms of complications of impaction and needed intervention to extract these FBs. Three patients ingested multiple magnets. Three patients ingested pins which were impacted in and penetrated the duodenum. One patient ingested a screw which was impacted in the appendix. One patient ingested a sticky rubber toy which was impacted in the pylorus. One patient ingested hair (bezoar), which was also impacted in the pylorus. One patient ingested a disk battery which was impacted in and penetrated the esophagus, and all were surgically extracted. One patient had a slipped stent of repaired choanal atresia which was impacted in the gastroesophageal junction and one patient with repaired tracheoesophageal fistula ingested a stone which was impacted at the site of esophageal anastomosis, and both were endoscopically retrieved.Conclusion: Children who ingested uncommon FBs or presented late with symptoms of complications of impaction needed intervention (surgically or endoscopically) to extract these FBs.Keywords: foreign bodies, foreign body extraction, ingestion, magnets ingestion, pin ingestio

Allam, Ayman M.

El-Asmar, Khaled M.

Elsherbeny, Mohammed S.

English

AJOL - African Journals Online

Downloadedfromhttps://journals.lww.com/apsbyBhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3l7ttZ9b/VuKxIwH3Dy/2pqEl0VxTbhh37J87j9nSKYU=on08/07/2018Downloadedfromhttps://journals.lww.com/apsbyBhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3l7ttZ9b/VuKxIwH3Dy/2pqEl0VxTbhh37J87j9nSKYU=on08/07/2018Foreign body ingestion in children: unusualpresentations and timely interventionMohammed S. Elsherbeny, Ayman M. Allam and Khaled M. El-AsmarBackground/purpose Foreign body (FB) ingestion inchildren is very common. Children can ingest a wide varietyof FBs. Most of the ingested FBs pass spontaneouslythrough the gastrointestinal tract. Other FBs, especiallyuncommonly ingested objects, can present withcomplications and need intervention to be extracted.The aim of this study was to highlight the importanceof timely intervention to extract these FBs.Patients and methods Between November 2012 andOctober 2017, patients who presented to our departmentwith variously ingested FBs were retrospectively reviewedto detect those who needed intervention (surgical orendoscopic) to extract these FBs.Results During the specified time period, 480 patients with FBingestion presented to our department. Out of these children, 12patients ingested uncommon FBs or presented with symptomsof complications of impaction and needed intervention to extractthese FBs. Three patients ingested multiple magnets. Threepatients ingested pins which were impacted in and penetratedthe duodenum. One patient ingested a screw which wasimpacted in the appendix. One patient ingested a sticky rubbertoy which was impacted in the pylorus. One patient ingestedhair (bezoar), which was also impacted in the pylorus. Onepatient ingested a disk battery which was impacted in andpenetrated the esophagus, and all were surgically extracted.One patient had a slipped stent of repaired choanal atresiawhich was impacted in the gastroesophageal junction and onepatient with repaired tracheoesophageal fistula ingested astone which was impacted at the site of esophagealanastomosis, and both were endoscopically retrieved.Conclusion Children who ingested uncommon FBsor presented late with symptoms of complicationsof impaction needed intervention (surgically orendoscopically) to extract these FBs. Ann Pediatr Surg14:157–160 © 2018 Annals of Pediatric Surgery.Annals of Pediatric Surgery 2018, 14:157–160Keywords: foreign bodies, foreign body extraction, ingestion,magnets ingestion, pin ingestionDepartment of Pediatric Surgery, Faculty of Medicine, Ain Shams University,Cairo, EgyptCorrespondence to Mohammed S. Elsherbeny, MD, Department of PediatricSurgery, Faculty of Medicine, Ain Shams University, Lotfy Elsayed Street,Abbasyyah, Cairo 11566, EgyptTel: + 20 100 365 0916; fax: + 20 24 830 833;e-mail: mohamedsaid@med.asu.edu.egReceived 4 December 2017 accepted 26 February 2018IntroductionForeign bodies (FBs) ingestion is common in children.The American Association of Poison Control Centersreported 70 000 pediatric FB ingestion in 2014 [1].Children ingest FBs due to curiosity affected by theirnatural cognitive development and the peak of ageincidence is between 6 months and 3 years [2,3].The commonly ingested FBs are coins, toy parts,jewelry, needles, batteries, and fish bones. Most of theseingested FBs pass spontaneously through the gastro-intestinal tract without consequences [4].The clinical manifestations of FBs’ ingestion in childrencan vary widely according to the site of impaction, the typeof the ingested FB, and the age of the child [5]. The mostcommonly presenting symptoms are drooling, dysphagia,odynophagia, vomiting, or symptoms of complications [6].Some of these FBs, especially those which are uncom-monly ingested, impact in a part of the gastrointestinaltract and need intervention to be extracted [7].In this study, we aimed to highlight the importance oftimely intervention to extract uncommonly ingested FBsand impacted FBs in patients presenting with symptomsof complications.Patients and methodsBetween November 2012 and October 2017, afterapproval of the Internal Review Board, patients presentedto Pediatric Surgery Department, Ain Shams Universitywith variously ingested FBs were retrospectively reviewedto detect those who ingested uncommon FBs or presentedwith symptoms of complications of impaction.The study was approved by our ethics committee andindividuals gave informed consent to participate in the study.ResultsDuring the specified period, 480 patients presented to ourdepartment with FB ingestion. Their age ranged between6 months and 8 years (mean: 4.2 years). Out of these 480children, 12 (2.5%) children ingested uncommon FBs orpresented with symptoms of complications of impaction.Surgical exploration was performed in 10 (83%) cases.The indication for surgery was to extract the magnets inthree (30%) patients, to extract the pins penetrating theduodenum in three (30%) patients, a diagnosis other thanFB ingestion in three (30%) patients (acute appendicitisand gastric outlet obstruction), and to extract the diskbattery penetrating the esophagus in one (10%) patient,whereas endoscopic retrieval was possible in two (17%)patients with the slipped stent and the stone.Three patients ingested multiple magnets. They were a3-year-old girl, and 4-year and 7-year old boys and theysought medical advice 1 month, 12 h, and 1 day afteringestion, respectively. The magnets were seen in theabdominal radiography. The magnets were attracted toOriginal article 1571687-4137 © 2018 Annals of Pediatric Surgery DOI: 10.1097/01.XPS.0000531234.16566.2aCopyright r 2018 Annals of Pediatric Surgery. Unauthorized reproduction of this article is prohibited.each other compressing bowel loops in between and thechildren presented with a picture of intestinal obstruc-tion in the two boys and with chronic diarrhea in thefemale child. The three patients were explored afterresuscitation; the compression resulted in intestinalfistulae in one patient. The magnets were extractedand the fistulae were closed in this patient, whereas themagnets were milked to the anus in one patient and wereextracted through enterotomy in the third patient (due toits large size and attachment to other metallic objects).Leakage occurred in the patient with closed fistula4 days after the operation, so ileostomy was done whichwas closed 6 weeks later. The other two patients did welland were discharged on postoperative day 6 and 3,respectively (Fig. 1).Three patients ingested pins. They were 5-year, 7-year,and 8-year old girls and they sought medical advice2 weeks, 5 days, and 1 week after ingestion, respectively.In the radiograph the pins were seen in the right upperquadrant and the children presented with abdominalpain. A trial of endoscopic retrieval of the pins was donebut failed. So, surgical exploration was done and the pinswere found penetrating the second part of the duode-num. They were extracted and the duodenum wasclosed. The children did well and was discharged onpostoperative day 5, 6, and 8, respectively.One patient ingested a screw. He was a 5-year-old maleand presented with a picture of acute appendicitis of3 days duration. On exploration, the screw was foundFig. 1A 7-year-old boy presented after few hours of multiple magnets ingestion. (a) Plain abdominal radiograph showing two magnets in the lower abdomen;(b) enterotomy was done to extract the magnets; (c) the extracted magnets with attached metallic objects.158 Annals of Pediatric Surgery 2018, Vol 14 No 3Copyright r 2018 Annals of Pediatric Surgery. Unauthorized reproduction of this article is prohibited.impacted in the base of the appendix obstructing it withsuppurative inflammation and impending rupture of itstip. It was extracted and appendectomy was done. Thechild did well and was discharged on the third daypostoperatively.One patient ingested a sticky rubber toy. He was a3-year-old boy. The patient was referred to our depart-ment because of persistent nonbilious vomiting of2 weeks duration. Radiographs showed dilated stomachwith scanty aeration representing a picture of gastricoutlet obstruction. On exploration, the toy was foundimpacted in the pylorus closing it. The toy was extractedthrough gastrotomy. The child did well and wasdischarged on the fifth day postoperatively (Fig. 2).An 8-year-old girl, known to have a psychiatric disorder,presented with a picture of gastric outlet obstruction.Nothing specific could be seen in the radiograph excepta hugely dilated stomach. On exploration, a tuft of hair(bezoar) was found impacted in and obstructing thepylorus. The hair was extracted and the stomach wasclosed. The child did well and she was discharged onpostoperative day 4.A 3-year-old boy presented with respiratory tract infec-tion. Chest radiography showed a radiopaque diskshadow about 1 cm in diameter. The parents could notremember a history of battery ingestion. Esophagealendoscopy was negative except for mild esophagitis inthe middle of the esophagus. On exploration, viathoracotomy, the battery was found penetrating the wallof the esophagus and adherent to the surroundingstructures. The battery was extracted and the esophaguswas closed. The patient did well and was discharged onpostoperative day 9.A 2-week-old boy in the neonatal intensive care unit hada slipped nasal stent after repaired choanal atresia. In theradiograph, the stent was seen in the lower esophagus.On endoscopy, the stent was seen in the gastroesopha-geal junction and was retrieved using a rigid esophago-scope (Fig. 3).A 4-year-old mentally retarded male patient withrepaired esophageal atresia and tracheoesophageal fistulaingested a stone while playing. He came few hours afteringesting it with absolute dysphagia. In the radiograph,the stone was seen between the upper and the middlethird of the esophagus. On endoscopy, it was impacted atthe site of the previous esophageal anastomosis. Thestone was retrieved endoscopically by passing a follycatheter behind the stone, then the balloon was inflatedand withdrawn slowly to retrieve the stone through hismouth and the patient was discharged 6 hours later.DiscussionFB ingestion in children is very common. The vastmajority of these FBs pass spontaneously through thegastrointestinal tract with no symptoms. Other FBs do notfollow this rule. They become impacted in a part of thegastrointestinal tract and begin to cause clinical manifesta-tions. The child may come with symptoms and signs dueto the complications of FB impaction without clear historyof FB ingestion [8,9]. The impaction of the FB can be lifethreatening, if prompt management was not done [10].Ingestion of multiple magnets is associated with in-testinal necrosis and fistula formation. Although it is not acommonly ingested FB, its use is increasing and theincidence of their swallowing is on the rise [11,12].On the other hand, single magnet can pass spontaneouslyFig. 2Plain abdominal radiograph of a 3-year-old boy with impacted stickyrubber toy in the pylorus causing gastric dilatation.Fig. 3Plain abdominal radiograph of a neonate with slipped nasal stent ofrepaired choanal atresia showing the stent in the stomach.Foreign body ingestion in children Elsherbeny et al. 159Copyright r 2018 Annals of Pediatric Surgery. Unauthorized reproduction of this article is prohibited.without consequences, if not combined with ingestion ofa metallic object [2].Button batteries ingestion needs special precautions as ifthey are lodged in the esophagus, liquefactive necrosisand fatal complications can happen. So, they should beemergently extracted [13]. Impacted batteries in theesophagus can present with respiratory symptoms likestridor and chronic chest infection due to trachealcompression [14]. On the other hand, if the battery ismoving through the gastrointestinal tract without beingimpacted, expectant management can be applied [15].Other FBs such as toy parts and even sharp objects canpass spontaneously through the gastrointestinal tractwithout causing clinical manifestations or needing inter-vention to extract them. However, a predisposing factorlike previous gastrointestinal tract surgery or congenitalgut malformation causing its narrowing can lead to itsimpaction and hence the appearance of complications andthe need for intervention [16–18]. Some authors foundthat the presence of gut malrotation in a child whoingested atypical FBs resulted in serious consequenceswhich required urgent surgical intervention [8].In our series, the uncommonly ingested FBs (magnets,sticky rubber toy, and stone) needed extraction as theyimpacted in a part of the gastrointestinal tract. The otherFBs (pins, screw, and battery), although common, theycould not pass spontaneously. They impacted andcaused complications. So, extraction of these FBs wasnecessary. The incidence for surgical intervention toextract the ingested FBs was 2% (10/480), which isslightly higher than that reported in the literature (1%)[3,14]. The indication for surgical intervention, as statedin most of the articles, was due to the occurrence ofcomplications or due to failure of endoscopic retrieval.ConclusionChildren who ingested uncommon FBs or presented latewith symptoms of complications of impaction neededintervention (surgically or endoscopically) to extractthese FBs.Conflicts of interestThere are no conflicts of interest.References1 Mowry JB, Spyker DA, Brooks DE, McMillan N, Schauben JL. 2014 annualreport of the American Association of Poison Control Centers’ NationalPoison Data System (NPDS): 32nd Annual Report. Clin Toxicol (Phila)2015; 53:962–1147.2 Alzahem AM, Soundappan SS, Jefferies H, Cass DT. Ingested magnets andgastrointestinal complications. J Paediatr Child Health 2007; 43:497–498.3 Lee JH, Lee JS, Kim MJ, Choe YH. Initial location determines spontaneouspassage of foreign bodies from the gastrointestinal tract in children. PaediatrEmerg Care 2011; 27:284–289.4 Naji H, Isacson D, Sevensson JF, Wester T. Bowel injuries caused byingestion of multiple magnets in children: a growing hazard. Pediatr Surg Int2012; 28:367–374.5 Arana A, Hauser B, Hachimi-Idrissi S, Vandenplas Y. Management ofingested foreign bodies in childhood and review of the literature. Eur JPediatr 2001; 160:468–472.6 Liming BJ, Fischer A, Pitcher G. Bronchial compression andtracheoesophageal fistula secondary to prolonged esophageal foreign body.Ann Otol Rhinol Laryngol 2016; 125:1030–1033.7 Palta R, Sahota A, Bemarki A, Salama P, Simpson N, Laine L. Foreign-bodyingestion: characteristics and outcomes in a lower socioeconomicpopulation with predominantly intentional ingestion. Gastrointest Endosc2009; 69 (Pt 1):426–433.8 De la Fuente SG, Rice HE. Ingestion of unusual foreign bodies andmalrotation: a ‘perfect storm’. Pediatr Surg Int 2006; 22:869–872.9 Lai AT, Chow TL, Lee DT, Kwok SP. Risk factors predicting the developmentof complications after foreign body ingestion. Br J Surg 2003;90:1531–1535.10 Sardana P, Bais AS, Singh VP, Arora M. Unusual foreign bodies of theaerodigestive tract. Indian J Otolaryngol Head Neck Surg 2002;54:123–126.11 Macedo M, Velhote M, Maschietto R, Waksman R. Intestinal fistula aftermagnets ingestion. Einstein (Sao Paulo) 2013; 11:234–236.12 Hussain S, Bousvaros A, Gilger M, Mamula P, Gupta S, Kramer R, Noel R.Management of ingested magnets in children. J Pediatr Gastroenterol Nutr2012; 55:239–242.13 Smith MT, Wong RK. Esophageal foreign bodies: types and techniques forremoval. Curr Treat Options Gastroenterol 2006; 9:75–84.14 Aihole JS, Kumar P. Uncommon presentation of an unusual foreign body.Indian J Crit Care Med 2017; 21:460–462.15 Cowan SA, Jacobsen P. Ingestion of button batteries. Epidemiology, clinicalsigns and therapeutic recommendations. Ugeskr Laeger 2002;164:1204–1207.16 Gretarsdottir HM, Jonasson JG, Björnsson ES. Etiology and managementof esophageal food impaction: a population based study. Scand JGastroenterol 2015; 50:513–518.17 Alrazzak BA, Al-Subu A, Elitsur Y. Etiology and management of esophagealimpaction in children: a review of 11 years. Avicenna J Med 2013; 3:33–36.18 Williams P, Jameson S, Bishop P, Sawaya D, Nowicki M. Esophageal foreignbodies and eosinophilic esophagitis – the need for esophageal mucosalbiopsy: a 12-year survey across pediatric subspecialties. Surg Endosc 2013;27:2216–2220.160 Annals of Pediatric Surgery 2018, Vol 14 No 3Copyright r 2018 Annals of Pediatric Surgery. Unauthorized reproduction of this article is prohibited.

Foreign body ingestion in children: unusual presentations and timely intervention

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Foreign body ingestion in children: unusual presentations and timely intervention

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