Introduction

Pediatrics gastrointestinal foreign bodies(FB) is a common pediatric surgical emergency that faces the pediatric surgeons. Gastrointestinal FB is common and potentially serious cause of morbidity and mortality in children. The majority of ingested foreign objects will pass spontaneously. However, 10% to 20% may become lodged in the esophagus or other locations in the gastrointestinal tract and may require nonoperative intervention, and 1% or less will require surgery. (1,2,3) Extrapolation of the western data may not be relevant to our circumstances. The present study analyses the results our own 5 years' experience with diagnosis, presentation and management of accidental ingested upper digestive tract foreign bodies in children.

Material and methods

This study consisted of 60 consecutive patients presenting with history of accidental ingested upper gastro intestinal FB and admitted to the Pediatric surgery department of SDM medical college and hospital Sattur, Dharwad, Karnataka between July 2009 and July 2014. Our hospital is the one of the tertiary referral central in north Karnataka.

The detailed history was recorded and a clinical examination performed. All patients were studied for gender, age, complaints, duration, time elapsed before coming to hospital, site of impaction, type and complication encountered are recorded. Radiological investigation was taken according to the case. Direct laryngoscopy and Magill forceps or Flexible esophagoscopehas been used for retrieval of foreign bodies. All patients were fasting for not less than 4 hours. All procedures were performed as inpatients procedure under general anesthesia which was delivered via mask for Magill forceps procedure, while those undergoing oesophagoscopy had anaeshesia delivered via endotracheal tube. There were no anaeshesia related complications. After the procedure completion, type and site of the foreign body and state of mucosa at the site of impaction were recorded. All patients except 4 were discharged within 24 hours after the procedure. The study was approved by the institutional review board and had informed consent of all the parents.

Results

There were a total of sixty children. Out of 60 cases forty two (70%) were males and eighteen (30%) were females. Fifty one (85%) patients were aged six months to six years. Nine (15%) were more than 6 years old. (Table-1)

At presentation, the foreign bodies had been in the upper gastro intestinal fewer than 24 hr in 36 patients (60%), between 1 day and 1 week in 12 patients (20%), and from 1 week to 4 months in 6 patients (10%). In 6(10%) the duration was unknown. Fifty one (85%) patients had definitive history of FB ingestion. Predisposing esophageal disease seen in 20% of patients. Most commonly postoperative esophageal atresia seen in 6 (10%) patients and the history of caustic stricture and postoperative fundoplication present in one patient each

The commonest presenting complaints were difficulty of swallowing occurring in forty two (70%) followed by vomiting in 30 (50.6%) patient, drooling of saliva in 12(20%) and repeated respiratory tract infections in 3(5%). Whereas twelve (20%) patients were asymptomatic. The most common FB ingested was coin recorded in 48(80%) patients, followed by metallic and food materials 12(20%). Metallic and food materials included seeds in five (8%) patients, battery in three (5%). safety pin in three (5%) and shaving blade in one patient.

Radiopaque objects were detected in fifty five (92%) patients, while the radiology investigation was negative in five (8%). Depending on the plain x rays majority of the foreign bodies were impacted in the upper 1/3 of the esophagus (just below the cricophyarngeal muscle) 70% (42 patient), and the second most common site was the lower 1/3 of esophagus 20%. While the least number 5% (5 patients) each FB were recorded in the Middle 1/3 of esophagus and stomach.

Total sixty patient have been subjected to intervention for the removal of their impacted foreign bodies. Twenty four (40%) F B were removed by direct laryngoscope and Magill forceps and thirty six (60%) patient were removed by flexible esophagoscopy. All of the cases had smooth uneventful intervention apart from two of the patients. One of them developed bleeding due to mucosal injury during extraction of a razor, in which the patient kept on nothing by mouth, i.v fluid, systemic antibiotic and monitoring clinically and radiologicaly. There was one patient of lower esophageal FB (tamarid seed) which was difficult to grasp, which was removed with multiple attempts. Foreign bodies were successfully removed without major complication in all cases. Significant mucosal erosions were seen in four (6%) patients after extraction all were improved with conservative treatment.

Discussion

The majority of foreign body ingestions occur in the pediatric population, with a peak incidence between the ages of 6 months and 6 years. (1,2) In our study also FB ingestion is common in children between 6 months to 6 years. The presence of symptoms is significantly associated with gastrointestinal FB, but the absence of symptoms does not reliably exclude the possibility of an esophageal foreign body where a patient may have a foreign body lodged in the esophagus and be completely asymptomatic, for these reason radiological studies can be beneficial in the management of suspected foreign body ingestions. (1) In our study twelve (20%) were asymptomatic and fifteen percentage of patients do not have history of FB ingestion. This result is recorded in other studies and consistent with our present study. (4,5)

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Figure 1:

A: X ray chest showing coin struck at upper esophagus. B: X ray chest showing coin struck at lower esophagus. C: X ray chest and abdomen showing coin in the stomach

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Figure 2:

A: X ray of the neck and chest showing metallic foreign body (pendent) (arrow) in the upper esophagus B: Endoscopically removed metal pendent

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Figure 3:

A: Barium swallow showing narrowing at junction of upper two-third and lower one-third of esophagus. B: Endoscopic view of impacted tamarind seed C: Endoscopically extracted tamarind seed pieces

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Figure 4:

A: X ray of the abdomen showing shaving blade (arrow) in the stomach. B: Endoscopically removed shaving blade

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Common signs and symptom in patients with a foreign body include dysphagia, drooling, vomiting, gagging and anorexia. Significant respiratory symptoms such as coughing, chest pain, stridor, hemoptysis and chronic upper respiratory tract infection are more common weeks or months after ingestion (6,7). In our study most of our patients presented with Dysphagia (70%), Vomiting(50%), Drooling(20%). This result is recorded in other studies and consistent with our present study (7,8).

Types of the foreign bodies ingested by the patient were versatile but the most common type was metallic objects 70% including coins, pins etc. However, all types of foreign bodies could be found in any age group, but the frequency of the type is very much age related. Coins were the most common reported foreign body.(7,8) Our series also confirmed that the most commonly retained esophageal foreign body in these infants and children.

Predisposing esophageal disease like esophageal strictures, particularly those related to esophageal atresia after surgery, were a common predisposing factor to recurrent esophageal foreign body retention in infants and children This result is recorded in other studies and consistent with our present study (2,3). Site of foreign body impaction in the esophagus was consistent with the results of other similar studies (2,3) where the most common site was at the lower border of cricophyarngeal muscle (70%), and this is expected anatomically because the upper esophageal sphincter is the first narrowing which faces the ingested foreign body (2,3). Next common site is the middle esophagus. The site of impaction also could be influenced by preexisting esophageal pathology.

In symptomatic patients, diagnosis and treatment are usually straightforward. Because foreign bodies impacted in the upper or mid esophagus have little prospect of passing spontaneously, instrumentation should be pursued immediately (9). Therefore, all patients with suspected foreign body ingestions should undergo immediate chest radiography or esophagoscopy exclude retention, even if the child is asymptomatic. Biplane radiographs identify most true foreign objects. Radiographs can confirm the location, size, shape, and number of ingested foreign bodies and help exclude aspirated objects. However food particles, wood, plastic, glass, and thin metal objects are not readily seen. The benefits of obtaining x-ray on a patient with known or suspected foreign body ingestion are well described. An important role of x-ray especially in radiopaque objects is that it can help to determine if there is more than one foreign body ingested. An important point to remember is that the patient still can have esophageal foreign body despite a normal x-ray and asymptomatic patient (4,5,9). In our study 80% of the patient had the positive x-ray findings.

The method of intervention used in our study was either Magill forceps procedure or flexible oesophagoscopy, similar as other studies.(9,10,11) Several different treatment options exist for impacted upper gastrointestinal FBs. These include observation, esophageal bougienage, Foley catheter extraction, and penny pincher technique, flexible and rigid esophagoscopy. (12,13,14,15) But we did not use any of them because with the long accumulating experience in our institute in adults patients with the upper gastrointestinal FBs they found that flexible esophagoscopy safer, more reliable and quick technique for removal of all types of foreign bodies with very high success rate.

Direct laryngoscopy and Magill forceps is an option to remove objects lodged at or above the cricopharyngeus. Otherwise flexible endoscopy may be performed when laryngoscopy is unsuccessful or for treatment of objects lodged below this area. The current technique is predicated on the fact that coins lodged in the upper esophagus generally are firmly, not rigidly, impacted, and they always are situated in the coronal plane. Only if coin seen clearly. If the coin is not seen, the anesthetic administration is converted from mask to endotracheal, and the coin is extracted using a flexible endoscope. Removal with flexible endoscopes has a high success rate Endoscopic retrieval of sharp objects may be accomplished with retrieval forceps,a retrieval net, or a polypectomy snare. Foreign body forceps, snare, or retrieval net. The risk of mucosal injury during retrieval can be minimized by orienting the object with its point trailing during extraction, by using an overtube, or by fitting the endoscope with a protector hood. We used over tube for sharp blade which preset in stomach. None of our patients required surgery for the extraction of his foreign body compared to other studies where 1.66%and 2% required surgery.(15,16) May be this is because the more cases are collected the more difficult and rare cases will appear. Only four of our patient developed mucosal injury following extraction of sharp objects, all were improved with conservative treatment