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Foreign Bodies

Foreign Bodies. Tintinalli Chapter 76, 82. Population. Children 80% Toys, coins Edentulous adults Bones, packaging Prisoners Utensils, razor blades Psychiatric patients Utensils, razor blades. Pathophysiology . Most (80%) pass without intervention Few (1%) require surgery

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Foreign Bodies

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  1. Foreign Bodies Tintinalli Chapter 76, 82

  2. Population • Children 80% • Toys, coins • Edentulous adults • Bones, packaging • Prisoners • Utensils, razor blades • Psychiatric patients • Utensils, razor blades

  3. Pathophysiology • Most (80%) pass without intervention • Few (1%) require surgery • Objects traversing pylorus usually pass through to stool

  4. Pediatrics Most obstructions are in the proximal esophagus Areas of constriction Cricopharyngeal narrowing (C6) Thoracic narrowing (T1) most common Aortic arch (T4) Tracheal bifurcation (T6) Hiatal narrowing (T10-11) Adult Most obstructions in distal esophagus Arise from preexisting disease 97% of adults with meat impaction have underlying disease process. Pathophysiology

  5. Pediatrics Refusal to eat Coughing Vomiting Stridor Increased salivation Drooling Anxiety Palatal abrasion Reddened throat Adults Anxiety Discomfort Retrosternal pain Choking Vomiting Drooling Clinical Presentation

  6. Objects past the pylorus Expectant care X-ray Possibly serial Esophagram Endoscopy Metal detectors Esophageal FBs warranting endoscopy Sharp or elongated Multiple Button batteries Evidence of perforation Coin at level of cricopharyngeus muscle Airway compromise Presence >24 hours General Care

  7. May wait expectantly up to 12 hours if the patient can handle secretions Do not use meat tenderizer IV glucagon Relaxes esophageal smooth muscle Test dose then 1mg and 2mg 20 minutes later if needed Not effective in recent study compared to placebo Nifedipine Reduces LES pressure without changing esophageal body contraction strength 10mg sublingually Food Impaction

  8. Children 35% asymptomatic Esophagus Frontal plane Trachea Sagittal plane Coin Ingestion

  9. Treatment If coin past LES – expectant observation Endoscopy Foley catheter technique while intubated Coin Ingestion

  10. Button batteries Burns within 4 hours Perforations in as little as 6 hours Lithium cell worst Mercuric oxide cells Check blood and urine mercury levels if cell splits Button Battery Ingestion

  11. Treatment Past LES: no removal necessary unless it remains in the stomach after 48 hours Must be removed from the esophagus Document on X-Ray Endoscopy Button Battery Ingestion

  12. Objects to remove Longer than 5cm and wider than 2cm rarely will pass the stomach Pointed objects 15-35% will cause perforation Ingestion of Sharp Objects

  13. Management Document on X-ray Symptomatic or sewing needle Surgical consultation Asymptomatic Expectant management Serial x-rays May need contrast film Any sign perforation – surgical consultation Ingestion of Sharp Objects

  14. One condom can hold 5 grams of cocaine Surgical removal recommended May observe for spontaneous passage. Cocaine Ingestion

  15. History What was it? How long ago was it inserted? May not volunteer information – “belly hurts” Treatment X-ray Position Number Shape Free air? Rectal Foreign Bodies

  16. Treatment Occassionally may be removed in the ED Follow up x-rays and exam to rule out perforation 12 hour observation Otherwise surgical consult Removal technique IV sedation Lithotomy position Local anesthesia a 6 and 12 o’clock Then internal sphincter anesthesia circumferentially Can use foley catheter to break vacuum Rectal Foreign Bodies

  17. Treatment Risk of perforation or significant manipulation? Antibiotics – aerobic and anerobic coverage. Rectal Foreign Bodies

  18. Guess the Foreign Body Ready?

  19. Paper clip x 2 That was easy! It gets tougher!

  20. Good – it’s a spoon

  21. Two needles, Necklace Charm Notice anything else?

  22. Esophagus packed with a week’s worth of food

  23. Iron tablet overdose

  24. A case of iron deficiency?

  25. 78 pieces of cutlery

  26. This is why you do not use narrow necked bottles to collect urine samples.

  27. Electric rolling pin

  28. Yet another reason, not to play naked billiards in the rain

  29. Concrete enema

  30. Dr Beight

  31. This is why you should always have a non-slip mat in the shower Dr. Beight

  32. Gives new meaning to “explosive diarrhea”

  33. Last one to leave, please close the door

  34. Questions?

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