What is Esophageal Foreign Body?
When people accidentally swallow a foreign object and it becomes stuck in the esophagus (the tube connecting your mouth to your stomach), they typically know what they’ve swallowed and their symptoms are usually mild. They’ll often be in a fairly stable condition. However, some people may not be able to tell doctors what they’ve swallowed or when they swallowed it. This can be for a variety of reasons, such as young age (infants, children), cognitive impairments, mental health concerns, or being in custody.
Also, the symptoms can vary widely, from person to person, as can the potential complications from swallowing a foreign object. This makes it quite challenging to diagnose and manage this kind of condition. So, it’s important for medical professionals to consider all of these factors when evaluating a patient.
What Causes Esophageal Foreign Body?
The esophagus, the tube that connects your throat to your stomach, is about 20 to 25 cm long in adults. It’s made up of an inner lining and a muscular layer, which consists of circular muscles on the inside and long muscles on the outside. The upper third of the esophagus has muscles that we can control; this is what helps us start swallowing. Meanwhile, the muscles in the lower third of the esophagus work automatically.
The esophagus is the most common place where foreign objects or stuck food can cause problems in your digestive system. 80 to 90% of the time, when something is swallowed that isn’t supposed to be, it reaches the stomach and will eventually pass through without needing any help.
While all sorts of objects can be accidentally swallowed, some of the most common ones include chunks of food (especially meat), fish or chicken bones, dentures, and coins. The specific types of objects people most often swallow can change depending on where you are and local cultural habits. For example, in southern China, fish bones are the most common item to get stuck in the esophagus.
Risk Factors and Frequency for Esophageal Foreign Body
Children account for about 80% of the cases seen in emergency departments due to foreign objects stuck in their esophagus. They usually swallow small things accidentally like coins, pins, batteries, toy parts, crayons, bones, large food particles, jewelry, etc. Coins are commonly found objects in this context. Naturally, children have normal anatomy, but certain conditions increase the risk of such swallowing accidents. These conditions include eosinophilic esophagitis, prior esophageal atresia repair, and prior Nissen fundoplication.
Adults too have similar instances of accidentally swallowing foreign bodies, with food particles (mostly meat) being the prime cause of such situations. Around 13 out of 100,000 people are estimated to get food stuck in their esophagus every year. Such incidents usually involve issues with the distal esophagus, accounting for 80% to 90% of such cases, which often have anatomical or motor abnormalities such as deformities, webs, tightening, tumors, eosinophilic esophagitis, achalasia, scleroderma, or esophageal spasms. Hence, it is advised that any adult with a history of food impaction should go for a follow-up esophagus examination, even if the impaction has resolved itself.
Signs and Symptoms of Esophageal Foreign Body
If a person swallows a foreign body, certain factors need to be evaluated. These include the type and number of items swallowed, where the object is located, the duration since swallowing, and any symptoms the person is exhibiting. These can help medical professionals decide if the object needs to be removed immediately, raised on the priority list, or if the person can be monitored and tracked for a while.
For most adults and older kids, they’ll be able to inform you of the swallowing incident and give a time. The most common complaints are feeling as though something is stuck or difficulty swallowing. These symptoms often show up within minutes to hours of the incident. If the object is lodged in the upper food pipe, the person can generally pinpoint where they feel it. However, if it’s stuck in the middle or lower food pipe, they may feel a general discomfort, pain, or chest pain. They may also drool excessively, feel “full,” regurgitate, gag, choke, hiccup, or retch. Painful swallowing can indicate severe issues like cuts or tears in the food pipe.
Upon examination, the person may appear uneasy and experience discomfort while swallowing. If they are unable to swallow their saliva, this is an indication of a severe blockage requiring immediate treatment.
In some cases, infants, young children, people with mental disabilities, or prison inmates may not be able to provide this information. In these cases, always be on the lookout for these symptoms. For babies and young children, they may gag, feed poorly, drool, or show irritability. If there’s a foreign body lodged in the food pipe, it could press against the windpipe, causing breathing-related symptoms like wheezing, cough, difficulty breathing or noisy breathing. But also remember to consider objects stuck in the airway itself.
During a physical examination, it’s important to check if the airway is open, monitor vital signs, assess the person’s ability to handle secretions, and watch for complication signs like vomiting blood, abnormal breathing sounds, tenderness in the neck, chest, or stomach, or air under the skin.
Testing for Esophageal Foreign Body
If your doctor suspects you may have swallowed a foreign object, they’ll often start by taking a standard x-ray. These images show the object and its location, which can help your doctor decide how to proceed next. The x-ray also might show any complications caused by the swallowed item.
The usual starting point is a chest x-ray, taken from both the back and the side. Additional x-rays of your neck or abdomen may also be necessary, depending on the symptoms you’re experiencing.
Certain objects, like coins, bottle caps, or batteries, may appear different on an x-ray based on where they are in your body. For instance, if lodged in the windpipe (trachea), these items tend to move into a position that appears round when seen from the side. If stuck in the food pipe (esophagus), they usually move into a position that appears round when seen from the back. It’s critical for doctors to examine such objects carefully on an x-ray, as some (like button batteries) require immediate removal if swallowed.
The ability of an x-ray to distinguish between a coin and a button battery is generally quite good; it’s correct in about 80% of cases.
However, x-rays may not show all types of swallowed objects. Materials like food, plastic, wood, and aluminum often don’t appear on a standard x-ray. Even certain hard materials like bone and glass might not always be visible. If your doctor is still concerned you may have swallowed something despite the x-ray not showing anything, they may recommend further testing. This could be an endoscopy, where a thin tube with a camera on the end is used to look inside your body, or a CT scan, which can provide more detailed images of the inside of your body and is particularly good at finding swallowed objects and identifying any complications they’ve caused.
Treatment Options for Esophageal Foreign Body
If a foreign object is swallowed, the way it’s treated depends on the type of object, where it’s located, how much it’s blocking, and how long it’s been there. The preferred treatment is to take it out using a procedure known as endoscopy, which is successful in over 90% of cases and has less than a 5% risk of complications.
The urgency of the treatment will vary based on the specifics of the situation:
Emergency situations include a blocked esophagus that makes it impossible to swallow saliva, a battery or a sharp object in the esophagus.
Urgent situations requiring treatment within 12 to 24 hours include objects in the esophagus that are not sharp, food stuck in the esophagus that does not completely obstruct it, sharp objects in the stomach or duodenum (the first part of the small intestine), objects longer than 6 cm in the duodenum or above, multiple magnets (or a single magnet plus another magnetic object within reach of the endoscope), and coins in the esophagus.
Non-urgent situations include objects larger than 2.5 cm in the stomach, batteries in the stomach which have been there for up to 48 hours without causing symptoms, and blunt objects that haven’t passed out of the stomach after 3 to 4 weeks.
There’s been some research into medications that could help smooth, blunt objects pass into the stomach by relaxing the lower esophageal sphincter (LES) – a ring of muscle that closes off the esophagus from the stomach. One of these medications is called glucagon, which is given by injection and followed by a drink of water or a carbonated beverage. This medication can cause nausea and vomiting, which might dislodge the object. However, the studies on glucagon generally have not consistently shown that it provides significant benefit.
An ingredient in meat tenderizers called papain is not recommended for a meat bolus when food is impacted in the esophagus due to the risk of complications and potential harm to the esophagus.
A battery lodged in the esophagus is viewed as a real emergency that requires immediate removal. There’s a serious danger that the battery could create a fatal hole (fistula) between the esophagus and the aorta, especially in children under 5, when the battery is larger than 20 mm, if it’s lodged at the level of the aortic arch in the chest, if it’s been there a long time, or if there’s vomiting of blood. In these cases, it may take a group of medical specialists to manage the situation, including pediatric gastroenterology, pediatric surgery, cardiothoracic surgery, anesthesia, and radiology, and the procedure may be carried out in the operating room or cardiac catheterization lab.
If a child who’s not showing symptoms has swallowed a coin that’s lodged in the esophagus, it’s usually safe to wait up to 24 hours to see if it will pass on its own. The likelihood of the coin passing by itself depends on its location: 10% of coins in the upper esophagus, 26% of coins in the middle esophagus, and 43% of coins in the lower esophagus can be expected to pass spontaneously within 16 hours of being swallowed.
What else can Esophageal Foreign Body be?
Feeling like something is stuck in your throat can be caused by scratches in your food pipe, also called the esophagus. This might happen after swallowing something hard or sharp. If the person isn’t seriously affected and is able to swallow food or liquids, doctors usually re-check them after 12 to 24 hours. If there’s no improvement, a CT scan or an endoscopy (where they use a small camera to look inside your esophagus) might be required.
Other reasons you might feel like there’s something in your throat even when there isn’t include:
- Infections such as Candida, Herpes simplex virus (HSV), or Cytomegalovirus (CMV)
- Esophagitis, which is inflammation of the esophagus that can be caused by acid reflux, swallowing a pill that gets stuck, or a type of white blood cell called eosinophils
- Spasms in the esophagus, causing it to tighten up
- Globus pharyngeus, also known as globus hystericus, which is a feeling of a lump or foreign object in the throat that doctors can’t find a cause for
If, once again, the person is not in serious condition and is able to swallow, doctors will start treatment for any identified underlying conditions and arrange a re-check.
What to expect with Esophageal Foreign Body
It’s estimated that 80% to 90% of foreign objects that are accidentally swallowed will naturally pass through the body within 3 to 7 days.
Children who have swallowed a disc battery, which can cause injury to the esophagus, will need to be monitored for a short and long period. This is to ensure that there are no complications such as damage or puncture to the esophagus or strictures (a narrowing of the esophagus).
For adults who have had an incident where food has become lodged, there are usually underlying issues 85 to 90% of the time. These adults will require an evaluation to identify and treatment for these underlying issues.
