A 9-year-old girl is brought to the emergency department due to chest pain. The patient was eating dinner with her family an hour ago when she accidentally swallowed a fish bone. She initially had sharp pain but now has only dull pain in the lower part of her chest. The patient can still drink liquids and appears comfortable. Vital signs are normal. There is no neck swelling, tenderness, or crepitus. The lungs are clear to auscultation. The abdomen is soft, nontender, and nondistended. The remainder of the physical examination is unremarkable. Chest radiograph reveals no objects in the esophagus. CT scan shows a 2-cm, linear hyperdensity in the distal esophagus near the lower esophageal sphincter but no subcutaneous emphysema or free air within the mediastinum. Which of the following is the best next step in management of this patient?

Question

A 9-year-old girl is brought to the emergency department due to chest pain.  The patient was eating dinner with her family an hour ago when she accidentally swallowed a fish bone.  She initially had sharp pain but now has only dull pain in the lower part of her chest.  The patient can still drink liquids and appears comfortable.  Vital signs are normal.  There is no neck swelling, tenderness, or crepitus.  The lungs are clear to auscultation.  The abdomen is soft, nontender, and nondistended.  The remainder of the physical examination is unremarkable.  Chest radiograph reveals no objects in the esophagus.  CT scan shows a 2-cm, linear hyperdensity in the distal esophagus near the lower esophageal sphincter but no subcutaneous emphysema or free air within the mediastinum.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d8f0_33dd_bc81_01ade1600e22_MD0003_00 This patient with chest pain has a fish bone lodged in the esophagus. Because it is sharp, a fish bone is considered a foreign body with a high risk of esophageal perforation, therefore warranting endoscopic removal. Although patients may be asymptomatic after ingestion, an esophageal foreign body can cause throat pain if lodged in the proximal esophagus or lower chest pain if lodged in the distal esophagus, as seen in this patient. Sharp objects (eg, needles, pins, fish bones) can lead to perforation and symptoms such as severe or acutely worsening chest/abdominal pain, vomiting with or without blood, and hemodynamic instability. Severe gastrointestinal hemorrhage can lead to shock and can be fatal. Imaging (x-ray followed by CT scan if the object is not identified) is used to determine foreign body location and assess for free air (indicative of perforation). Although human bones are readily seen on plain radiographs, most fish bones tend to be radiolucent and can be visualized only on CT scan. Immediate endoscopic removal should be performed in the following circumstances: Sharp object (eg, needle, safety pin) in the esophagus, stomach, or proximal duodenum (as in this patient) Symptoms of esophageal obstruction (eg, drooling, inability to swallow secretions) Symptoms of respiratory compromise Button battery in the esophagus (due to the risk of electrical and chemical injury) Magnets in the esophagus or stomach (due to the potential for bowel entrapment as a result of magnetic attraction across intestinal segments) (Choice A) In the case of foreign body ingestion, induced emesis can cause esophageal damage and is not recommended. (Choices B and E) If a sharp foreign body is distal to the proximal duodenum in an asymptomatic patient, observation with repeat x-ray in 12-24 hours may be appropriate because these objects are usually excreted uneventfully. In contrast, this symptomatic patient has a sharp object in the esophagus on CT scan that should be removed immediately. (Choice C) Barium esophagography may be performed several months after ingestion of a corrosive agent (eg, cleaning product) to assess for stricture formation. Contrast is avoided in the acute management of foreign body ingestion because it can obscure visualization and hinder removal of the object. Educational objective: The ingestion of a sharp foreign body is associated with a high risk of perforation and can be fatal. Endoscopic removal should be performed immediately when imaging confirms a sharp object in the esophagus, stomach, or proximal duodenum. References: A systematic review of paediatric foreign body ingestion: presentation, complications, and management. (http://www.ncbi.nlm.nih.gov/pubmed/23261258) Oroesophageal fish bone foreign body. (http://www.ncbi.nlm.nih.gov/pubmed/27461891)

A 9-Year-Old Girl Is Brought to the Emergency Department Due