Intern Report Case Discussion 2.3

intern-report

Presented by Aimee Nefcy, MD

Case

An 18-month female is brought to the ED by her parents, who state that less than one hour ago they took some coins away from her. They think she may have swallowed one of the coins.  There is no history of gasping, choking, or coughing, and they deny any drooling or crying. No fever, nausea, vomiting, or diarrhea. The child is refusing to drink fluids, but otherwise seems like her normal self

ROS: negative except for as noted in HPI.

PMH: bronchiolitis at age 6mo and hearing impairment

Birth history: full-term, uncomplicated vaginal delivery, birth weight 3.7kg

Meds: none, Allergies: NKDA

FH: asthma in her father

SH: no smoke exposure, does not attend daycare, working smoke detectors

PE: vitals: T 36.8, HR 104, RR 28, Pulse ox 99% RA

General: WN/WD, smiling, playful, active in room

HEENT: PERRL, EOMI, no conjunctival pallor/injection, clear TMs visualized B/L after removal of hearing aids, no nasal discharge, MMM, throat no erythema/exudates, no CLAD, no tenderness to palpation of neck, which is supple. No FB is visualized on examination of the throat.

Respiratory: no tachypnea/retractions/nasal flaring, lungs CTA B/L, no wheezes/stridor/rhonchi/crackles.

Cardiac: RRR, S1 & S2 heard, no M/R/G, pulses 2+ and symmetric

GI: +BS, soft, NT/ND, no masses/organomegaly

GU: normal external genitalia, no lesions/erythema

Musculoskeletal: no cyanosis/clubbing/edema, limbs are atraumatic/nontender

Neurological: cranial nerves grossly intact, no sensory or motor deficits

Skin: warm and dry, no rashes

An x-ray is obtained and is shown below.

_____________________________________________________________________________________________

Questions

1) Based solely on the x-ray, the most likely location is?

a. cannot tell without a lateral view

b. esophagus

c. oropharynx

d. stomach

e. trachea

2) What is the most appropriate course of action?

a. attempt direct visualization by laryngoscopy after appropriate sedation

b. oral fluid challenge and discharge home if tolerated

c. repeat x-ray at 12-24hrs post ingestion to make sure it has passed into the stomach

d. stat surgery consult for emergent endoscopy

e. surgery consult for admission and endoscopy in the morning

3) Which of the following excludes an expectant course of action in foreign body ingestion?

a. an asymptomatic patient

b. an object 5cm long in the stomach

c. an object still in the esophagus after 20hrs

d. a patient suspected of body packing with positive x-ray findings

e. a linear cluster of small, round objects in the small intestinesIntern Report

Answers:

1) b. esophagus

2) d. stat surgery consult for emergent endoscopy

3) e. a linear cluster of small, round objects in the small intestines

Discussion:

Flat, round objects in the esophagus are more likely to be oriented in the coronal plane, and therefore appear circular on AP films and edge-on on lateral films. Those in the trachea are more likely to be oriented sagittally. A history of ingestion, a lack of respiratory symptoms, and symptoms of dysphagia are not sufficient to place the object in the esophagus.

The most appropriate course of action in this case is emergent endoscopy. Although the history points towards ingestion of a coin, the x-ray findings are more consistent with a button battery. Button batteries can be differentiated from coins based on the “halo sign” – a lucent border at the edge of the circle – and a “stacked coins” appearance on lateral views. This child also has a source for the battery; her hearing aids. The National Button Battery Ingestion Hotline and Registry study found that 45% of button batteries ingested were from hearing aids, and 33% of those were removed by a child from their own hearing aid; most patients were 1-2 years old. If the object had been a coin, the correct answer would have been to repeat the x-ray, since blunt objects like coins pass spontaneously into the stomach in one-third of patients within 24hrs, and once in the stomach will likely pass completely without intervention. Only coins that remain in the esophagus after 24hrs require further intervention.

An expectant course of action is excluded by:

  • Objects in the esophagus 24hrs after ingestion or with an unknown time of ingestion, as these are unlikely to advance
  • Objects longer than 6-10cm, even if they are in the stomach, as they are unlikely to pass the duodenum
  • Symptomatic patients, especially those with airway compromise and inability to swallow secretions, but also those with fever, abdominal pain, or vomiting
  • Sharp objects, even those in the esophagus, as they can cause perforation and subsequent mediastinitis and GI bleeding
  • Magnets, which appear as a linear cluster of small, round objects. Magnets attract across intestinal walls and can cause pressure necrosis and perforation, and therefore require surgical retrieval even if the patient is asymptomatic
  • Button batteries, which create current and release corrosive chemicals when casing is degraded by stomach acids, can cause liquefactive necrosis and perforation; retrieval should always be attempted by endoscopy prior to passage into the duodenum
  • Body packers who show signs of intestinal obstruction or toxicity due to rupture of packets; otherwise, asymptomatic patients can be managed expectantly or with WBI

Below is the lateral x-ray, obtained after the battery-like appearance of the “coin” was noted

References:
Della-Giustina D, Kilcline BA, Denny M. Back pain: cost-effective strategies for Distinuishing between benign and life-threatening causes. Emergency medicine Practice February 2000

Reihsaus E, Waldbaur H, Seeling W. Neurosurg Rev. 2000 Dec;23(4):175-204

Leslie SW. Nephrolithiasis: Acute Renal Colic. Emedicine

Sexton DJ. Epidural abscess. upToDate
Lin M. Musculoskeletal Back Pain. Rosen’s Emergency Medicine. Philadelphia: Mosby; 2010: 591-603

This case discussion presented by Dr Aimee Nefcy

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