How should a pediatric patient who ingested a nail be evaluated and managed?

Management of Nail Ingestion in Pediatric Patients

A pediatric patient who has ingested a nail requires immediate plain radiography to confirm location, followed by urgent endoscopic removal if the nail is in the esophagus or stomach, or close clinical observation with serial imaging if it has passed into the small bowel. 1, 2

Initial Evaluation and Risk Stratification

Clinical Assessment

• Most children who ingest nails are asymptomatic at presentation, making history and radiographic confirmation essential 2, 3
• Assess for acute symptoms including dysphagia, inability to swallow saliva, odynophagia, neck tenderness, retrosternal pain, drooling, choking, stridor, or dyspnea 1
• Physical examination should focus on detecting fever, cervical subcutaneous emphysema, or erythema/tenderness suggesting perforation 1

Imaging Protocol

• Obtain biplanar (anteroposterior and lateral) plain radiographs of the neck, chest, and abdomen immediately to determine the presence, exact location, size, and orientation of the nail 1
• Lateral projection is critical to differentiate between esophageal and tracheobronchial location 1
• CT scan should be performed if there is any suspicion of perforation or complications (mediastinitis, abscess formation, or inability to clearly visualize the foreign body) 1

Laboratory Testing

• Obtain complete blood count (CBC), C-reactive protein (CRP), and lactate if complications are suspected 1

Management Algorithm Based on Location

Esophageal Location (Urgent - Within 24 Hours)

• All esophageal foreign bodies require removal within 24 hours due to high risk of perforation and fistula formation 1, 4
• Therapeutic flexible endoscopy is the first-line treatment for esophageal nails 1
• Use protective equipment such as overtubes or rubber hoods when removing sharp objects to prevent mucosal injury during extraction 4
• Test grasping accessories (Dormia basket, rat-tooth forceps, or polypectomy snare) on a duplicate nail as a "dry run" before the procedure 2, 4

Gastric or Duodenal Location (Urgent Endoscopy Indicated)

• Sharp, pointed objects like nails in the stomach or duodenum should be removed endoscopically regardless of symptoms 1, 4
• Endoscopic removal is indicated for objects longer than 4 cm or wider than 2 cm in young infants and children 4
• Successful retrieval has been documented using Dormia baskets, polypectomy snares, or rat-tooth forceps 2
• The procedure should be performed under appropriate sedation or general anesthesia with endotracheal intubation for airway protection 4

Beyond the Duodenum (Individualized Approach)

• Sharp or pointed foreign bodies that have passed beyond the second part of the duodenum present a management dilemma 2, 5
• If the nail has reached the duodenojejunal junction or beyond, close clinical observation with serial radiographs every 12-24 hours is reasonable in asymptomatic patients 2, 3
• Urgent laparotomy is indicated if the patient develops abdominal pain, vomiting, rectal bleeding, fever, or signs of peritonitis 2, 5
• Spontaneous passage can occur even with long nails (up to 30mm documented), typically within 24-72 hours 3, 6

Observation Protocol for Distal Foreign Bodies

Monitoring Requirements

• Serial abdominal radiographs every 12-24 hours to track progression through the GI tract 3, 5
• Assess for development of symptoms: abdominal pain, vomiting, rectal bleeding, fever 2, 3
• If the nail remains in the same location for more than 24-48 hours or the patient develops any symptoms, surgical intervention is warranted 2, 5

Expected Timeline

• Most foreign bodies that pass the duodenum will transit through the entire GI tract within 4-7 days 3
• Blunt objects can be observed in the stomach for up to 2 weeks or in the duodenum for 1 week, but sharp objects like nails require more aggressive management 4

Critical Pitfalls to Avoid

• Never assume spontaneous passage is safe for esophageal or gastric nails—80-90% of blunt foreign bodies pass spontaneously, but sharp objects carry 1% perforation risk 1, 3
• Do not delay endoscopy beyond 24 hours for esophageal foreign bodies, as perforation risk increases significantly 1, 4
• Avoid barium or gastrografin contrast studies, as they can coat the foreign body, impair endoscopic visualization, and increase aspiration risk in patients unable to swallow 1
• Do not perform endoscopy for nails that have passed into the jejunum or beyond—this increases perforation risk and surgical retrieval becomes necessary if complications develop 2
• Never discharge a patient with a sharp foreign body still in the GI tract without clear follow-up instructions and arrangements for serial imaging 5

Surgical Intervention Criteria

Immediate surgical consultation and likely laparotomy are indicated for: 2, 5

• Development of peritoneal signs (guarding, rebound tenderness, rigidity)
• Persistent or worsening abdominal pain
• Fever or elevated inflammatory markers suggesting perforation
• Failure of the nail to progress on serial radiographs beyond 48 hours
• Radiographic evidence of free air or extraluminal location of the foreign body