How to manage a pediatric patient with an esophageal foreign body obstruction?

Management of Pediatric Esophageal Foreign Body Obstruction

Urgent flexible endoscopy (within 2-6 hours) is the recommended first-line treatment for this 9-year-old female with an esophageal chicken impaction causing pain. 1

Initial Assessment and Management

• Immediate interventions:

  • IV fluids and IV Toradol for pain management are appropriate initial steps
  • Chest X-ray is indicated to confirm location and assess for complications
  • Consulting pediatric GI is the correct approach for this case

• Timing of intervention:

  • For food bolus impaction without complete obstruction: urgent flexible endoscopy within 24 hours 1
  • If there are signs of complete obstruction (inability to swallow saliva): more emergent intervention within 2-6 hours 1

Endoscopic Management

First-line approach:

• Flexible endoscopy is the preferred initial approach for esophageal foreign body removal 1
• For food impaction, the "push technique" (gently pushing the bolus into the stomach) has up to 90% success rate 1
• If push technique fails, retrieval using appropriate tools should be performed 1

Alternative techniques if standard approach fails:

• Balloon catheter passage past the foreign body with inflation and withdrawal (push-and-pull effect) 1
• Retrieval techniques using baskets, snares, or grasping forceps for resistant objects 1
• Rigid endoscopy as a second-line approach, particularly useful for objects in the upper esophagus 1

Important Considerations

Diagnostic evaluation:

• Assess for underlying esophageal disorders (found in up to 25% of patients) 1
• Common associated conditions include:
  • Esophageal stricture
  • Hiatus hernia
  • Esophageal web or Schatzki ring
  • Eosinophilic esophagitis (found in up to 9% of patients)
  • Achalasia
  • Tumors

Potential complications:

• Perforation (risk increases with duration of impaction)
• Mediastinitis
• Aspiration
• Pressure necrosis of the esophageal wall

Contraindications:

• Avoid oral contrast studies (barium/gastrografin) as they:
  • Increase aspiration risk in patients unable to swallow saliva
  • May coat the foreign body and impair endoscopic visualization
  • Should not delay definitive management 1

Post-procedure Management

• Monitor for signs of perforation or other complications
• Evaluate for underlying esophageal pathology with appropriate diagnostic testing
• Consider histological evaluation during endoscopy to identify conditions like eosinophilic esophagitis 1

Surgical Considerations

• Surgery is rarely needed (1-3% of cases) but may be required for:
  • Irretrievable foreign body
  • Perforation
  • Foreign body close to vital structures (e.g., aortic arch)
  • Other complications 1

This 9-year-old with esophageal chicken impaction requires urgent endoscopic intervention, with appropriate pre-procedure management including IV fluids, pain control, and imaging to guide the approach and identify potential complications.