Pediatric Gastrointestinal Foreign Body

  • Etiology:
    — Children love to put anything in their mouth and swallow it and the ingestion is usually unwitnessed
    — Is a dynamic process of migration and penetration and reactive inflammation
    — May be present for a long time
  • Imaging:
    — Obtain AP mouth and nasopharynx to anus radiograph and use lateral radiograph of foreign body to localize and characterize it
    — Note: Acute nasal foreign bodies can present with pain while chronic nasal foreign bodies can present with malodor or destruction of the nasal septum
    — Foreign bodies get stuck at cricopharyngeal sling at C6 and thoracic inlet and aortic arch and lower esophageal sphincter and pylorus of stomach and ileocecal valve
    — Note: On AP radiograph a sagitally oriented coin is more likely to be in the esophagus than in the trachea
  • Note: Ingested foreign bodies look different on radiograph then at direct visualization because not all parts are radiopaque therefore it can help to radiograph a similar foreign body to see its density and if you radiograph a foreign body do so with it in water to best predict its appearance inside the body
  • Note: Grill brush bristles can break off and be ingested with patients complanining of sudden pain while eating
    — Imaging UpperGI: Can demonstrate impacted Legos in esophagus if patient has continued dysphagia after swallowing Lego
    — DDX:
    — Complications:
    — Long standing esophageal foreign bodies can cause esophageal edema leading to soft tissue thickening between esophagus and trachea leading to tracheal narrowing
    — Esophageal erosion and fistula can cause retropharyngeal soft tissue swelling
  • Treatment:
    — Most ingested foreign bodies (including sharp ones) pass through the gastrointestinal tract
    — Ingested foreign bodies that are medical emergencies which require immediate removal are button batteries and rare earth magnets
    — Some sharp or pointed foreign bodies may be removed if in stomach
  • Imaging of coin:
    — Round thin radiopaque object without beveled edge or halo of lucency around object
    — No double rim on AP view or step off on lateral view
  • DDX of coin: Two stacked coins can mimic button battery
  • Complications of coin:
  • Treatment of coin: Endoscopic removal if in esophagus, otherwise allowed to pass
  • Imaging of button battery:
    — Has beveled edge
    — Halo of lucency around object
    — Double rim on AP view and step off on lateral view
    — Note: Two adjacent coins can mimic a button battery
  • DDX of button battery: Two stacked coins can mimic button battery
  • Complications of button battery:
    — Button battery can cause severe esophageal injury within 2 hours of ingestion due to pressure necrosis and chemical damage and electrical damage and must be removed immediately
    — Button battery distal to esophagus is less susceptible to causing injury but it could have caused esophageal injury before it left esophagus
    — Esophageal injuries from button battery include tracheoesophageal fistula and perforation and stricture and aortoenteric fistula
    — Can also cause injury to gastric mucosa
  • Treatment of button battery: Remove emergently if in esophagus or stomach
  • Imaging of rare earth magnets: Suspect when multiple magnets attract each other or 1 magnet and 1 metallic foreign body attract each other
  • DDX of rare earth magnets: Remove emergently if in esophagus or stomach
  • Complications of rare earth magnets: Rare earth magnets must be removed immediately as two rare earth magnets in adjacent bowel loops can attract each other causing pressure necrosis and ulceration and ischemia and perforation and obstruction
  • Treatment of rare earth magnets: Remove emergently if in esophagus or stomach
  • Clinical:
    — In patients with multiple foreign body ingestions think of underlying psychiatric illness
    — Coins are most common ingested radiopaque foreign body and pennies are most commoly ingested coin
    — Water bottle caps are becoming more common

Radiology Cases of Gastrointestinal Foreign Body

Radiology Cases of Coin as Gastrointestinal Foreign Body

CXR of a coin in the stomach
CXR shows a round radiopaque foreign body in the antrum of the stomach.

Radiology Cases of Three Coins as Gastrointestinal Foreign Body Mimicking a Button Battery

AXR of 3 coins in the stomach that are stuck together and mimicking a button battery
AXR AP shows a radiopaque foreign body in the fundus of the stomach which has a combination of beveled edges and step offs.

Radiology Cases of Button Battery as Gastrointestinal Foreign Body

Radiograph of a button battery in the stomach
AXR AP (left) shows a round radiopaque object in the region of the pylorus of the stomach that has a lucent halo around it. Zoomed up image of the object (right) better shows the lucent halo.
AXR of a button battery gastrointestinal foreign body
AXR AP (above) shows a round radiopaque foreign body in the stomach which is oriented laterally and has a beveled edge / step off. AXR lateral (below) shows the radiopaque foreign body to have a halo / double rim appearance.
AXR of button battery in the stomach
Initial AXR (left) shows a round radiopaque object with a halo and double rim in the antrum of the stomach that on a later AXR (right) shows a beveled edge.
AXR of a button battery as a gastrointestinal foreign body
AXR AP shows a round radiopaque foreign body in the small bowel which is oriented laterally and which has a beveled edge / step off.
AXR of button battery in the stomach
AXR shows a round radiopaque foreign body with a halo and double rim projecting over the antrum of the stomach.

Radiology Cases of Button Battery as Gastrointestinal Foreign Body With an Incidental Morgagni Hernia

CXR of button battery ingestion in a patient with a Morgagni hernia
CXR AP (above left) shows a round radiopaque object with a halo of lucency around it in the neck and there is a dense opacity in the medial aspect of the right lower lobe. CXR lateral (above right) shows the round object to be in the esophagus posterior to the airway and there is a loop of bowel coursing up from the abdomen to the chest anterior to the heart. Axial (below left) and sagittal (below right) CT without contrast of the chest shows the loop of bowel anterior and medial in location in the right chest to have haustra and therefore to be colon.

Radiology Cases of Rare Earth Magnets (Neodymium Magnets) as Gastrointestinal Foreign Body

AXR of neodymium magnets
AXR shows two small round radiopaque foreign bodies that are attracted to each other.
AXR of gastrointestinal foreign body in the form of ingested rare earth magnets
AXR AP shows 13 small round radiopaque objects that are joined together in a chain.
AXR of rare earth construction magnets in the stomach
AXR AP (left) and AXR lateral (right) show 4 radiopaque linear objects that are joined together in the mid abdomen.

Radiology Cases of Rare Earth Magnets (Neodymium Magnets) as Gastrointestinal Foreign Body Causing Small Bowel Obstruction

AXR of rare earth magnets causing small bowel obstruction
AXR shows multiple round and cylindrical radiopaque objects in the lower abdomen that are all in close approximation to each other. There are multiple dilated loops of small bowel present.

Radiology Cases of AA Battery as Gastrointestinal Foreign Body

AXR of ingested AA batteries in the stomach
AXR AP shows two radiopaque cylindrical objects in the abdomen in the region of the stomach.
AXR of a AA battery
AXR AP shows a radiopaque cylindrical object projecting over the stomach.

Radiology Cases of Lead Pencil and AA Batteries as Gastrointestinal Foreign Body

AXR of battery and lead pencil in the stomach
AXR AP shows two radiopaque cylindrical objects in the abdomen. There is a faintly radiopaque thin straight object coursing from the T12-L1 intervertebral disk space to the left and ending just above the superior most cylindrical object.

Radiology Cases of Chain Necklace as Gastrointestinal Foreign Body

AXR of chain necklace gastrointestinal foreign body
AXR AP (above) shows a radiopaque foreign body in the cecum. Endoscopic image (below left) shows the foreign body within the cecum. Gross pathological image (below right) shows the foreign body to be a chain necklace.

Radiology Cases of Gastrointestinal Foreign Body Impacted in the Esophagus Post Repair of Esophageal Atresia

Upper GI of gastrointestinal foreign body impacted in the esophagus of a patient post repair of esophageal atresia
AP (above left) and lateral (above right) images from an esophagram show a large, irregular filling defect in the proximal esophagus that is both above and below the waist in the esophagus that is the site of the esophageal anastomosis. The patient underwent endoscopy and the surgical image (below) shows a ball of paper that was removed from the patient’s esophagus.

Radiology Cases of Simultaneous Gastrointestinal Foreign Body in the Esophagus and Airway Foreign Body in the Trachea in the Form of an Earing

CXR of a foreign body in the airway and the esophagus in the form of an earing
CXR AP (left) shows a linear radiopaque object projecting over the trachea. CXR lateral (right) shows the anterior portion of the radiopaque object to project over the trachea and its posterior portion to project over the esophagus.

Radiology Cases of Chronic Gastrointestinal Foreign Body Causing Retropharyngeal Abscess

Pathological image of an esophageal foreign body
Lateral radiograph of the airway (left) shows a radiopaque foreign body in the cervical esophagus which is associated with a large amount of retropharyngeal soft tissue swelling. Gross pathological image (right) shows a metal flag-shaped pin that was endoscopically retrieved from the patient’s esophagus.
Radiograph and CT and UGI of chronic esophageal foreign body and retropharyngeal abscess
Lateral radiograph of the airway (above left) shows a radioopaque coin on edge in the esophagus at the level of C5. There is retropharygeal soft tissue swelling around the foreign body and air anterior to the coin in the retropharyngeal soft tissue. Axial CT with contrast of the neck after foreign body removal (below left) better shows the retropharyngeal fluid and air collection anterior to the vertebral body and causing some mass effect on the trachea. Lateral image from an upper GI exam (right) shows that the esophagus communicates with the retropharyngeal fluid and air collection.
CXR and Upper GI of esophageal foreign body
Lateral spot images from an upper GI show fixed narrowing of the trachea (left + middle) with an esophageal perforation / fistula arising from the anterior wall of the esophagus (right). Endoscopy done earlier in the day removed a set of plastic wheels from a toy car which was felt to have been present for a long time as the esophagus was ulcerated and edematous in the area of perforation.

Gross Pathology Cases of Gastrointestinal Foreign Body

Pathological image of an esophageal foreign body
Lateral radiograph of the airway (left) shows a radiopaque foreign body in the cervical esophagus which is associated with a large amount of retropharyngeal soft tissue swelling. Gross pathological image (right) shows a metal flag-shaped pin that was endoscopically retrieved from the patient’s esophagus.