From the Guidelines
For an 11-year-old boy with fish bone ingestion requiring admission, immediate medical attention is essential to prevent serious complications such as perforation, retropharyngeal abscess, or mediastinitis, as highlighted in the WSES guidelines on esophageal emergencies 1. The child should be kept nil by mouth (NPO) while awaiting evaluation to minimize the risk of further injury or aspiration. Initial assessment includes a thorough history to determine timing, symptoms (pain, dysphagia, drooling), and examination of the oropharynx.
- Lateral neck X-rays may identify radiopaque bones, though CT scan offers better visualization if the bone isn't visible but symptoms persist, as the clinical presentation can include acute onset of dysphagia, odynophagia, neck tenderness, retrosternal pain, sore throat, foreign body sensation, retching, vomiting, and drooling 1.
- Flexible endoscopy is the definitive diagnostic and therapeutic approach, allowing direct visualization and removal of the fish bone, as it is a sharp-edged foreign body that can penetrate the esophageal mucosa, potentially causing serious complications. While waiting for the procedure, the child should receive IV hydration with normal saline at maintenance rate based on weight.
- Pain management with acetaminophen 15mg/kg/dose every 6 hours (maximum 650mg/dose) is appropriate, as it can help alleviate symptoms such as pain and discomfort.
- Antibiotics (ampicillin-sulbactam 50mg/kg/dose every 6 hours) may be indicated if there's evidence of perforation or infection, as the presence of fever, cervical subcutaneous emphysema or erythema and tenderness can suggest complications 1. Post-removal, the child should be observed for complications like perforation, retropharyngeal abscess, or mediastinitis.
- Clear liquids can be started after successful removal and advanced as tolerated, to ensure the child can swallow and digest food properly without any further complications. Fish bones are particularly dangerous foreign bodies due to their sharp edges that can penetrate the esophageal mucosa, potentially causing serious complications including perforation, which explains the need for admission and careful management, as emphasized in the WSES guidelines on esophageal emergencies 1.
From the Research
Admission Details for an 11-Year-Old Boy with Fish Bone Ingestion
The boy's admission for fish bone ingestion requires careful consideration of potential complications.
- The risk of complications from ingested foreign bodies, such as fish bones, is increased due to their sharp nature 2.
- Eighty percent of ingested foreign bodies that reach the stomach will pass uneventfully through the gastrointestinal tract, but the remainder may cause obstruction, perforation, or hemorrhage 2.
- Pre-existing intestinal disease or prior abdominal surgery may predispose the boy to complications 2.
Diagnostic Considerations
- Symptoms of gastroesophageal reflux disease (GERD) in children can be confusing and may mask the presence of a foreign body 3.
- The boy's age and potential developmental disorders should raise suspicion for accidental foreign body ingestion, even in the absence of acute signs or symptoms of choking 3.
- A thorough diagnostic evaluation is necessary to rule out other potential causes of symptoms, such as appendicitis or acute diverticulitis 4.
Management and Treatment
- Early endoscopic retrieval of ingested foreign objects is recommended for patients at increased risk for complications, such as those with sharp objects or animal bones 2.
- The use of overtubes has made endoscopic removal of sharp objects safer 2.
- Surgical treatment may be necessary in cases of intestinal perforation due to foreign body ingestion, and treatment typically consists of surgery and antibiotics 4.