Overview
Esophageal Foreign Body
Quick Reference
Critical Alerts
- Button batteries in esophagus = Emergent removal: Tissue necrosis within 2 hours
- Sharp objects = Urgent endoscopy: High perforation risk
- Complete obstruction (unable to swallow saliva) = Urgent: Within 6 hours
- Airway compromise takes priority: May need intubation
- Most foreign bodies pass spontaneously once in stomach: Watchful waiting
- Food impaction at GEJ: Consider underlying pathology (eosinophilic esophagitis, stricture)
Timing for Endoscopy
| Scenario | Timing |
|---|---|
| Button battery in esophagus | Emergent (<2 hours) |
| Sharp object in esophagus | Emergent |
| Complete esophageal obstruction | Urgent (<6 hours) |
| Partial obstruction, low-risk object | <24 hours |
| Coin in stomach (>0mm), magnets | Elective or observation |
Emergency Treatments
| Intervention | Indication |
|---|---|
| NPO | All esophageal FBs |
| IV fluids | Maintain hydration |
| GI/Surgical consult | Endoscopic or surgical removal |
| Glucagon trial | Food bolus without complete obstruction |
| Emergent endoscopy | Button battery, sharp object, complete obstruction |
Definition
Overview
Esophageal foreign body (FB) ingestion occurs when a swallowed object becomes lodged in the esophagus. Depending on the type of object and degree of obstruction, management ranges from observation to emergent endoscopic removal. Button batteries and sharp objects in the esophagus are surgical emergencies due to rapid tissue damage.
Classification
By Object Type:
| Type | Examples | Risk |
|---|---|---|
| Food bolus | Meat, bread | Usually benign; underlying pathology likely |
| Blunt objects | Coins, toys | Usually pass if reach stomach |
| Sharp objects | Bones, toothpicks, dental prostheses | High perforation risk |
| Button batteries | Disk/lithium batteries | Emergent—caustic injury |
| Magnets (multiple) | Rare | Bowel necrosis if opposed across walls |
By Location:
| Site | Frequency |
|---|---|
| Cricopharyngeus (C6) | 60-70% |
| Aortic arch (T4) | 15-20% |
| Lower esophageal sphincter (LES) | 10-15% |
Epidemiology
- ~100,000 cases/year in US (ED visits)
- Children: 75-80% of cases (coins, toys, batteries)
- Adults: Food impaction most common; often underlying pathology
- Elderly: Dentures, pills
Etiology
Risk Factors for Food Impaction:
| Factor | Notes |
|---|---|
| Eosinophilic esophagitis (EoE) | Common in young adults |
| Esophageal stricture | Peptic, post-surgical |
| Schatzki ring | Distal esophageal narrowing |
| Esophageal malignancy | Elderly |
| Esophageal dysmotility | Achalasia |
| Prior esophageal surgery | Altered anatomy |
| Eating while distracted | Rushed meals |
Pathophysiology
Mechanism
Foreign Body Impaction:
- Object size exceeds esophageal lumen diameter
- Lodges at anatomic narrowing
Button Battery Injury:
- Current generation: Low-voltage current between poles
- Electrolyte leakage: Alkaline hydroxide production
- Caustic burn: Tissue necrosis within 2 hours
- Perforation: Can occur within 6 hours
- Fistula formation: Tracheoesophageal or aortoesophageal (fatal)
Sharp Object Injury:
- Perforation of esophageal wall
- Mediastinitis if perforated
Sites of Impaction
- Cricopharyngeus muscle (most common)
- Aortic arch indentation
- GE junction (LES)
Clinical Presentation
Symptoms
| Symptom | Description |
|---|---|
| Dysphagia | Difficulty swallowing |
| Odynophagia | Pain with swallowing |
| Drooling | Unable to swallow saliva (complete obstruction) |
| Chest discomfort | Retrosternal |
| Globus sensation | Feeling of "something stuck" |
| Regurgitation | Food comes back up |
| Airway symptoms | Stridor, cough, choking (if proximal) |
History
Key Questions:
Physical Examination
| Finding | Significance |
|---|---|
| Drooling | Complete obstruction |
| Stridor, wheezing | Airway compromise |
| Odynophagia on swallowing | FB presence |
| Localized tenderness | Possible perforation |
| Cervical crepitus | Esophageal perforation (late) |
| Fever, tachycardia | Perforation, mediastinitis |
What was swallowed?
Common presentation.
Time of ingestion
Common presentation.
Able to swallow saliva, liquids, solids?
Common presentation.
Complete obstruction?
Common presentation.
Prior episodes (suggests underlying pathology)
Common presentation.
Dentures, prior esophageal surgery
Common presentation.
History of eosinophilic esophagitis
Common presentation.
Symptoms of airway compromise
Common presentation.
Red Flags
Emergent Conditions
| Finding | Concern | Action |
|---|---|---|
| Button battery in esophagus | Caustic injury | Emergent endoscopy (<2 hours) |
| Sharp object in esophagus | Perforation risk | Emergent endoscopy |
| Complete obstruction (can't swallow saliva) | Aspiration risk | Urgent endoscopy (<6 hours) |
| Airway compromise | Obstruction | Secure airway, emergent removal |
| Signs of perforation (fever, crepitus) | Mediastinitis | CT, surgical consult |
| Multiple magnets | Bowel necrosis | Emergent removal |
Differential Diagnosis
Other Causes of Dysphagia
| Diagnosis | Features |
|---|---|
| Esophageal stricture | Progressive dysphagia to solids |
| Esophageal malignancy | Weight loss, progressive symptoms |
| Eosinophilic esophagitis | Recurrent food impaction, young adult |
| Achalasia | Progressive dysphagia, regurgitation |
| Extrinsic compression | Mediastinal mass |
| Globus sensation | No true dysphagia, psychogenic |
Diagnostic Approach
Imaging
Plain Radiographs (AP and Lateral Chest/Neck):
| Finding | Significance |
|---|---|
| Radiopaque FB | Coins, batteries, bones |
| Air in mediastinum | Perforation |
| Pre-vertebral soft tissue swelling | Perforation |
CT Chest/Neck with Contrast:
- If perforation suspected
- If FB not visible on X-ray
- Delineates abscess, mediastinitis
Contrast Swallow:
- Use water-soluble contrast (Gastrografin) first
- Then dilute barium if Gastrografin negative
- Visualizes radiolucent FBs
Laboratory Studies
| Test | Purpose |
|---|---|
| CBC | Leukocytosis if infection/perforation |
| BMP | Dehydration if prolonged obstruction |
| Type and screen | If surgical intervention anticipated |
Treatment
Principles
- NPO: All esophageal FBs
- Assess urgency: Button battery, sharp, complete obstruction = emergent
- Endoscopy for removal: Most common method
- Address underlying pathology: EoE, stricture
Initial Management
| Intervention | Details |
|---|---|
| NPO | Prevent aspiration |
| IV fluids | Maintain hydration |
| Position | Upright or left lateral decubitus (if drooling) |
| Airway management | If stridor or airway compromise |
Endoscopy (Definitive Treatment)
Timing:
| Urgency | Scenario | Timeframe |
|---|---|---|
| Emergent | Button battery in esophagus, sharp object, complete obstruction with aspiration risk | <2 hours |
| Urgent | Complete food bolus obstruction | <6 hours |
| Non-urgent | Partial obstruction, blunt object | <24 hours |
Techniques:
- Direct visualization and retrieval
- Various grasping tools (nets, forceps, baskets)
- Protective devices for sharp objects (hood, overtube)
Medical Management for Food Bolus
Glucagon Trial (Controversial, limited evidence):
| Agent | Dose | Notes |
|---|---|---|
| Glucagon | 1-2 mg IV | Relaxes LES; may help passage |
| Nausea, vomiting common | ||
| Do NOT delay endoscopy for trials |
Effervescent Agents (Carbonated beverages):
- May help push food bolus distally
- Limited evidence; avoid if complete obstruction
Observation:
- Watchful waiting for partial obstruction if patient comfortable
- Most food boluses pass within 24 hours
Button Battery Management
Esophageal Location:
- EMERGENT endoscopic removal (<2 hours)
- Do NOT induce vomiting
- Do NOT wait for symptoms
Gastric Location (Asymptomatic):
- If <20mm diameter and symptomatic or impacted → Remove
- If ≥20mm → Remove (may not pass pylorus)
- Serial X-rays if observation
Sharp Object Management
- Endoscopic removal with protective equipment
- Do NOT attempt passage—high perforation rate
- Surgical consultation if not amenable to endoscopy
Post-Removal
- Assess for perforation (repeat imaging if concern)
- Evaluate for underlying pathology (EoE, stricture)
- Outpatient GI follow-up
Disposition
Discharge Criteria
- FB removed and no perforation
- Tolerating oral intake
- No airway or respiratory symptoms
- Follow-up arranged for underlying pathology
Admission Criteria
- Unsuccessful removal
- Perforation
- Unable to tolerate oral intake
- Need for surgical intervention
- Observation for passage (select cases)
Follow-Up
| Situation | Follow-Up |
|---|---|
| Food impaction in young adult | EoE workup (EGD with biopsies) |
| Recurrent food impaction | GI for stricture evaluation |
| Button battery removal | GI for mucosal assessment |
Patient Education
Condition Explanation
- "Something you swallowed is stuck in your esophagus."
- "We need to remove it with a procedure called endoscopy."
- "It's important to find out why this happened to prevent it from happening again."
Prevention
- Chew food thoroughly
- Avoid distractions while eating
- Cut food into small pieces
- Denture care in elderly
- Keep small objects and button batteries away from children
Warning Signs to Return
- Difficulty breathing
- Fever, chills
- Severe chest pain
- Vomiting blood
- Inability to swallow
Special Populations
Children
- Coins most common FB
- Button batteries: EMERGENT removal from esophagus
- Most coins pass if in stomach
- Lower threshold for imaging and intervention
Elderly
- Dentures, pills, food bolus common
- Higher risk of underlying malignancy
- May have atypical presentation
Psychiatric Patients
- Intentional ingestion (sharp objects, multiple objects)
- Higher risk of repeat ingestion
- Psychiatric evaluation needed
Prisoners
- May ingest objects intentionally
- Body packing (drug packets) is separate entity
- Multidisciplinary approach
Quality Metrics
Performance Indicators
| Metric | Target | Rationale |
|---|---|---|
| Button battery removal <2 hours | 100% | Prevent perforation |
| Endoscopy for complete obstruction <6 hours | >0% | Prevent aspiration |
| X-ray for suspected FB | 100% | Identify radiopaque objects |
| EoE workup after food impaction | >0% | Identify underlying cause |
Documentation Requirements
- Object type and time of ingestion
- Symptoms (complete vs partial obstruction)
- Imaging findings
- Intervention timing and technique
- Post-procedure assessment
- Follow-up plan
Key Clinical Pearls
Diagnostic Pearls
- Button battery = Emergent: Within 2 hours
- Sharp objects = Emergent: High perforation rate
- Complete obstruction (can't swallow saliva) = Urgent: Within 6 hours
- X-ray first: Identifies location and type
- Most food boluses pass if partial obstruction: But need EoE workup
- Recurrent food impaction → EoE: Common underlying cause
Treatment Pearls
- NPO all esophageal FBs: Prevent aspiration
- Endoscopy is definitive: Most effective removal method
- Glucagon is controversial: May try while arranging endoscopy
- Protective devices for sharp objects: Hood, overtube
- Don't delay for trials: Especially with high-risk objects
- Address underlying pathology: Prevents recurrence
Disposition Pearls
- Most can be discharged after removal: If tolerating PO
- Admit for perforation: Surgical management
- GI follow-up essential: Especially for recurrent food impaction
- EoE is common in young adults: Needs EGD with biopsies
References
- Birk M, et al. Removal of foreign bodies in the upper gastrointestinal tract in adults: ESGE Clinical Guideline. Endoscopy. 2016;48(5):489-496.
- ASGE Standards of Practice Committee. Management of ingested foreign bodies and food impactions. Gastrointest Endosc. 2011;73(6):1085-1091.
- Kramer RE, et al. Management of Ingested Foreign Bodies in Children. J Pediatr Gastroenterol Nutr. 2015;60(4):562-574.
- Ikenberry SO, et al. Management of ingested foreign bodies and food impactions. Gastrointest Endosc. 2011;73(6):1085-1091.
- Litovitz T, et al. Emerging battery-ingestion hazard: clinical implications. Pediatrics. 2010;125(6):1168-1177.
- Ko HH, et al. Review article: esophageal food bolus impaction—evidence-based treatment recommendations. Aliment Pharmacol Ther. 2019;49(3):253-262.
- Longstreth GF, et al. Esophageal food impaction: epidemiology and therapy. A retrospective, observational study. Gastrointest Endosc. 2001;53(2):193-198.
- UpToDate. Ingested foreign bodies and food bolus impaction in adults. 2024.