A 2-year-old boy is brought to the emergency department by his father due to ingestion of a foreign body an hour ago. The patient's father states, "He was playing with his mother's purse when I saw him put a dime into his mouth. I immediately went over to try to remove the coin but it was no longer in his mouth." The child has been acting normally since the ingestion and has had no coughing, drooling, or vomiting. He has not tried to eat or drink since the incident. The patient is otherwise healthy and takes no daily medications. He has no known allergies. Blood pressure is 80/50 mm Hg, pulse is 120/min, and respirations are 24/min. Pulse oximetry is 99% on room air. Physical examination demonstrates a well-appearing, comfortable child. No foreign bodies are visualized in the mouth, nares, or ears. Cardiopulmonary examination is normal. The abdomen is soft, nontender, and nondistended. X-ray of the chest and abdomen reveals a 2-cm radiopaque object in the stomach. Which of the following is the best next step in management of this patient?

Question

A 2-year-old boy is brought to the emergency department by his father due to ingestion of a foreign body an hour ago.  The patient's father states, "He was playing with his mother's purse when I saw him put a dime into his mouth.  I immediately went over to try to remove the coin but it was no longer in his mouth."  The child has been acting normally since the ingestion and has had no coughing, drooling, or vomiting.  He has not tried to eat or drink since the incident.  The patient is otherwise healthy and takes no daily medications.  He has no known allergies.  Blood pressure is 80/50 mm Hg, pulse is 120/min, and respirations are 24/min.  Pulse oximetry is 99% on room air.  Physical examination demonstrates a well-appearing, comfortable child.  No foreign bodies are visualized in the mouth, nares, or ears.  Cardiopulmonary examination is normal.  The abdomen is soft, nontender, and nondistended.  X-ray of the chest and abdomen reveals a 2-cm radiopaque object in the stomach.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf31_91de_8f63_b92176869f0c_MD0005_00 Foreign body ingestion most commonly occurs in children age 6 months to 3 years due to normal developmental mouthing behavior in infants and toddlers. Both posteroanterior (PA) and lateral x-rays are indicated as flat objects (eg, coin) that lie in the sagittal plane may be difficult to visualize on PA film alone. Many children are asymptomatic at presentation, and most objects that reach the stomach will pass spontaneously. Coins are the most common gastrointestinal foreign bodies. They are considered low risk due to the lack of sharp edges and nontoxic material. Patient with no symptoms can be observed with weekly follow-up x-rays to ensure transit and passage of the coin. If serial x-rays reveal no distal progression, then endoscopic removal of the object is indicated (Choice C). High-risk objects (eg, button batteries, magnets, sharp items) typically require endoscopic removal regardless of symptoms due to the risk of necrosis and perforation of the gastrointestinal tract. Patients who are symptomatic due to obstruction also require removal of the object. Esophageal foreign bodies tend to lodge in areas of physiologic narrowing (eg, lower esophageal sphincter) and can present with retrosternal pain, drooling, or refusal to eat. Symptomatic gastric foreign bodies present with vomiting or abdominal pain. (Choice A) CT scan may be indicated for foreign body ingestion if the event was unwitnessed in a symptomatic patient or an unknown object appears to be high-risk based on x-ray. X-ray is sufficient for diagnosis of an asymptomatic, witnessed ingestion of a low-risk foreign body. (Choice B) Barium contrast studies are not recommended in the evaluation of suspected foreign body ingestion. Although these studies may confirm object type and location, they can complicate subsequent management by obscuring the gastrointestinal tract if endoscopic removal is indicated. (Choice D) Emetics (eg, ipecac syrup) are never recommended in the treatment of foreign body ingestion. Efficacy rates are low, and induction of emesis may cause an object to become lodged more proximally (eg, in the esophagus). Educational objective: Most ingested foreign bodies that reach the stomach will pass spontaneously. Observation and weekly follow-up x-rays are recommended for ingestions that are low-risk (eg, coin) and asymptomatic. References: Foreign body ingestion, pediatric. (http://www.ncbi.nlm.nih.gov/pubmed/28613665)

A 2-Year-Old Boy Is Brought to the Emergency Department by His