Let’s be honest: our job is awesome … on so many levels! One of the most awesome aspects, though, is the ability to feel like a Superhero when you are able to make a patient actually feel better! Sometimes that is by simple acts (like treating a Nursemaid’s elbow or removing a Nasal Foreign Body) and other times it is through more exotic means (like administering Adenosine or Ketamine). One condition that we often don’t consider, but perhaps we should more, is a stuck Esophageal Foreign Body (FB). Let us review how we can become Superheroes in this realm as well – Bougienage for Esophageal Foreign Bodies in Children:

Esophageal Foreign Bodies

• Kids may accidentally or purposefully (see Pica) eat non-food items .
  • The substance ingested is important (examples):
    • Lead
    • Button Batteries
    • Laundry Detergent Pods
  • Fortunately, most often the ingested object is benign and moves through the GI tract without complication.
    • Coins account for a majority of the retained esophageal FBs.
• FBs can become impacted / stuck in children’s esophagus.
  • There are three main constriction sites in the esophagus:
    • Thoracic Inlet
    • Aortic Arch
    • Gastro-Esophageal Junction
  • Young children are more susceptible:
    • A quarter is a quarter-size.
    • A small child has relatively smaller anatomy and, thus, a coin is more likely to become entrapped.
  • Symptoms of retained esophageal FB:
    • Drooling
    • Dysphagia
    • Discomfort

• Esophageal FBs can cause significant problems.
  • “Harazardous” FBs
    • Magnets
    • Button Batteries
    • Sharp Objects
    • Lead Containing Objects
  • Left in the esophagus Coins and “benign” FBs can also cause: [Heinzerling, 2015]
    • Esophageal stricture
    • Mucosal Injury and Transmural perforation
    • Mediastinitis
    • Aortoenteric fistula
    • Tracheostomy’s-esohageal fistula

• Management options: [Heinzerling, 2015; Athanassiadi, 2002; Soprano, 2000]
  • Remove the Esophageal FB
    • Foley technique
      • Using fluoroscopy, pass foley past the FB and inflate balloon once distal to it.
      • Remove Fb by extracting foley.
      • Potential loss of control of the FB and subsequent aspiration.
      • Doesn’t allow visualization of the esophagus.
    • Rigid Esophagoscopy
      • Allows inspection of the esophageal mucosa.
      • Requires general anesthesia.
      • Most commonly used method for removal.

• Push the Esophageal FB into the Stomach
  • Patient drinks water and / or eats bread.
    • May be effective for cooperative, older children with larger anatomy and more distal FBs.
    • May lead to vomiting.
  • Bougienage with Hurst Dilator (see below)

Bougienage for Esophageal Foreign Bodies

• Bougienage has been shown to be safe, effective, and cost efficient [Heinzerling, 2015; Allie, 2014; Arms, 2008; Dahshan, 2007; Soprano, 2000]

• Bougienage uses a Hurst Dilator to PUSH the FB into the stomach. [Heinzerling, 2015; Allie, 2014]
  • Hurst Dilator (Medovations, Milwaukee, WI) = a silicone, flexible dilator with a weighted, rounded tip that does not use a guidewire.
  • Most hospitals have these devices in the endoscopy suite… but…
  • An Alternative to the Hurst Dilator has been described using a foley and an ETT.

• Shown to have several advantages: [Heinzerling, 2015; Allie, 2014]
  • Safe – to date no Major complications have been described.
  • Effective – documented success rates of 88 – 100%.
  • Avoids General Anesthesia – topical numbing medications, anxiolytics, and gentle restraint is what is typically required.
  • Does not require transfer to OR – can be done at bedside.
  • Can be done by Emergency Providers!
  • Costs less – fewer number of consultants, less time in the ED, and less hospital resources lead to significant savings.

• Bougienage should NOT be done when: [Heinzerling, 2015; Allie, 2014]
  • There is respiratory distress.
  • The FB is Hazardous (ex, Magnets, Button Batteries, Complex Shape, Sharp)
  • There is more than 1 Coin.
  • The Coin has been stuck for >24 hours (or the time is unknown).
  • There is a history of esophageal injuries (ex, Caustic Ingestion) or abnormalities / prior surgeries (be leery of those with history of Crohn’s disease)
  • There is a history of prior esophageal FBs.

• Bougienage: The Procedure [Dr. Orozco’s Vimeo; Heinzerling, 2015; Allie, 2014]
  1. Obtain Informed Consent
     • Ensure you have discussed pros, cons, and alternatives.
     • Ensure you have reviewed the X-rays and possible contraindications (above).
     • Acknowledge the likelihood of self-limited gagging, discomfort, and vomiting with the procedure.
  2. Select and Measure Dilator
     • 1-2 yr old – 28 F; 2-3 yr old – 32 F; 3-4 yr old – 36 F; 4-5 yr old – 38 F; 5+ yr old – 40 F
     • There is not a dilator specifically designed for children < 1 year.
     • Length = distance from child’s nose to xyphoid (epigastric) region) – mark the dilator.
  3. Prepare and Position the Patient
     • Child Life Specialists will be super helpful!
       Use topical anesthetic (although, some may tolerate this without it)
       
     • Consider mild anxiolytic (Intranasal Midazolam!)
       
     • Position the Child sitting upright with arms, legs, and head gently restrained.
  4. Bite Block
     • Use bite block from endoscopy kit or build one out of stacked tongue depressors.
     • This will be used to protect the dilator as it is passed down.
  5. Pass the Bougie
     • Apply a water-based lubricant to the Hurst Dilator.
     • Insert the Hurst Dilator quickly, but not forcefully through the mouth and into the stomach.
     • Stop at the pre-measured mark and then remove quickly.
     • Do NOT force the dilator. If there is resistance, remove it.
  6. Confirm Success!
     • Repeat the X-ray to confirm the FB has been dislodged into the stomach.
     • If it has not, may consider one more repeat attempt, or consult for rigid esophagoscopy.
  7. Discharge Instructions
     • Monitor for passage of the FB and signs of bowel obstruction (although most COINS pass uneventfully, some may require additional imaging).
     • Monitor for complications (which have, to date, not been described) of the procedure – abdominal pain, fever, dysphagia, chest pain.

Moral of the Morsel

• Feel Like a Superhero! Taking care of children is rewarding on many levels… and this is one of them!
• Make sure it is a coin! Button Batteries and other hazardous FBs have a higher likelihood of having caused structural injury and need to be removed under direct visualization.
• Push, don’t Pull! In the right patient, you can safely and effectively push the coin into the stomach allowing the child to go home earlier and charging the family less! This could even help avoid unnecessary transport of children!
• Learn Something New (even if this isn’t that new)! If you aren’t familiar with the procedure, look to find a way to learn a new skill!

References