Esophageal foreign bodies
Esophageal foreign bodies are not common but are seen frequently enough that practitioners must be adept at diagnosing them,
otherwise the consequences can be catastrophic (e.g. pyothorax). The key to suspecting esophageal foreign bodies is to recognize that the acute vomiting reported by a client
is actually acute regurgitation. In such cases, immediately obtain thoracic radiographs. Most esophageal foreign bodies do
not show up as obvious esophageal lesions on plain radiographs. Instead, they often appear as ill-defined, soft tissue opacities
that look as if they could be in the pulmonary parenchyma.
Whenever a suspected pulmonary mass is detected radiographically, consider whether it could be an esophageal mass. If there
is any possibility the mass is esophageal, your next step should be to perform contrast radiography or endoscopy (which is
usually preferred). In general, endoscopic manipulation is the best way to resolve most cases of esophageal foreign objects.4 Surgical removal is necessary when the object cannot be removed endoscopically. If endoscopy is anticipated, avoid contrast
esophagograms, because barium tends to obscure the visual field and makes endoscopic removal more difficult. Contrast films
are rarely needed to detect esophageal perforation. Discovering a pneumothorax or pleural fluid on plain radiographs should
make you strongly suspect an esophageal perforation. Obtain pleural fluid for cytologic examination to diagnose sepsis.
Rigid endoscopy is often more effective than flexible endoscopy for removing esophageal foreign bodies. Rigid endoscopes allow
the use of rigid forceps, which permit a much stronger grip on the object and more delicate and precise manipulation of the
object to free it from any ulcers or craters it has created. Carefully placing the edge of the rigid endoscope against a lodged
bone may allow the rigid forceps to break off pieces of the bone or even to break it in two, without further injuring the
esophagus. This maneuver is especially helpful when the bone has eroded deep ulcers into the esophagus and cannot be removed
otherwise. A foreign body can be partially drawn into the rigid endoscope, facilitating its removal from the esophagus. This
is especially valuable if you are attempting to remove sharp-edged objects or trying to pull objects through the cricopharyngeal
area. Likewise, most fishhooks, even treble hooks, can be removed endoscopically.5 Again, rigid endoscopic equipment is preferred and can usually be used successfully, even if the hook and barb have penetrated
the esophageal mucosa. The limiting factors in removing such hooks are the size of the barb (i.e. large barbs will not tear out of the mucosa) and whether the hook and barb have penetrated the esophagus and could lacerate
the great vessels of the heart if they are pulled back into the esophagus. In these cases, surgical removal is warranted.
After removing a foreign object, immediately reexamine the esophagus endoscopically to assess the degree of esophagitis. Also
obtain a thoracic radiograph to check for evidence of pneumothorax, which would indicate perforation has occurred. While perforation
generally requires referral for surgery, a small perforation might heal spontaneously if pleural contamination is avoided.
If a minor perforation has occurred, placing a gastrostomy tube endoscopically may allow the perforation to heal. (The gastrostomy
tube prevents food, water, and medications from traversing the esophagus.) Depending on the amount of esophageal damage, it
may be advisable to treat the patient for esophagitis (i.e. placing a gastrostomy tube and providing aggressive antacid therapy and gastric prokinetic therapy).