What is the emergency department workup for a 13-year-old female who swallowed a bottle top?

Emergency Department Workup for a 13-Year-Old Female Who Swallowed a Bottle Top

The emergency department workup for a 13-year-old female who swallowed a bottle top should include biplanar radiography (AP and lateral views) to confirm the presence and location of the foreign body, followed by appropriate endoscopic intervention based on the patient's symptoms and the object's location. 1, 2

Initial Assessment

• Obtain a detailed history regarding the time of ingestion, type of bottle top (size, material, sharp edges), and any symptoms such as drooling, inability to swallow saliva, chest pain, or respiratory distress 1
• Assess for signs of complete obstruction including drooling, inability to handle secretions, and respiratory distress 2
• Evaluate vital signs with particular attention to respiratory status, as foreign bodies can potentially dislodge and cause airway compromise 3
• Children aged 3-14 years account for a significant portion of foreign body ingestions, with non-food items like bottle tops being common foreign bodies 3, 2

Diagnostic Approach

• Perform biplanar radiography (anteroposterior and lateral views) as the initial imaging study to:
  • Confirm the presence of the bottle top if it's radiopaque 2
  • Distinguish between esophageal and tracheal location 2
  • Identify the exact anatomical level of impaction 1
• Common locations for foreign body impaction include:
  • Upper esophageal sphincter (cricopharyngeus muscle) 1
  • Thoracic esophagus at the level of the aortic arch 1, 2
• If the bottle top is not radiopaque (e.g., plastic), consider additional imaging such as contrast studies or CT scan if clinically indicated 3

Management Algorithm

For Symptomatic Patients (Complete Obstruction)

• If the bottle top is causing complete obstruction (inability to swallow saliva, drooling, respiratory distress), perform emergent endoscopic removal within 2-6 hours 1, 2
• Rigid endoscopy is preferred for foreign bodies in the upper esophagus 2
• Flexible endoscopy is the first-line approach for most esophageal foreign bodies 1

For Asymptomatic Patients (Partial or No Obstruction)

• If the bottle top is in the esophagus but not causing complete obstruction, perform urgent endoscopy within 24 hours 1
• If the bottle top has passed into the stomach and the patient is asymptomatic, consider conservative management with serial examinations and follow-up radiographs 2, 4
• Most foreign bodies that reach the stomach will pass through the gastrointestinal tract without complications 2, 4

Potential Complications to Monitor

• Prolonged retention of foreign bodies in the esophagus can lead to:
  • Pressure necrosis 2
  • Perforation and mediastinitis 2
  • Aspiration risk if the object dislodges and enters the airway 1
• The smaller diameter of a child's airway means that even small changes in the cross-section can lead to dramatic changes in airway resistance and air flow 3

Follow-up Care

• After successful removal, observe for signs of esophageal injury 2
• For bottle tops that pass into the stomach, most will exit the body without complications, but follow-up may be necessary to ensure passage 2, 4
• Provide anticipatory guidance to parents about prevention of foreign body ingestion 3, 2

Special Considerations

• Assess for any concerning history that might suggest intentional ingestion, which could indicate psychological issues requiring further evaluation 5, 6
• Consider the possibility of corrosive substances if the bottle top contained chemicals, which would require additional evaluation for chemical injuries 3, 7