Pediatric ulcerative colitis

What Is Ulcerative Colitis In Children?

Ulcerative colitis is an inflammatory bowel disease (IBD). In this condition, the inner lining of your child’s large intestine (colon or bowel) and rectum gets inflamed. This inflammation often starts in the rectum and lower (sigmoid) intestine. Then it may spread to the whole colon.

This causes diarrhea or frequent emptying of the colon. As cells on the surface of the lining of the colon die and fall off, open sores (ulcers) form. This causes pus, mucus, and bleeding.

What Causes Ulcerative Colitis In A Child?

Healthcare providers don't know what causes this condition. It may be triggered by a virus or bacteria. This interacts with your child’s immune system and causes an inflammatory reaction in the intestinal wall.

Children with ulcerative colitis often have problems with their immune system. It's not clear if these issues are a cause or a result of the disease.

There’s no known cure for this condition. But there are medical treatments and surgery if needed.

Which Children Are At Risk For Ulcerative Colitis?

People between the ages of 15 and 30 are at greatest risk of developing this condition. This issue can also start in children and older adults. It also seems to run in some families.

What Are The Symptoms Of Ulcerative Colitis In A Child?

Symptoms can happen a bit differently in each child. They can include:

• Stomach pain

• Bloody diarrhea

• Fatigue

• Weight loss

• Loss of appetite

• Rectal bleeding

• Loss of body fluids and nutrients

• Anemia caused by severe bleeding

Some children also have the following symptoms:

• Skin sores (lesions)

• Joint pain

• Inflammation of the eyes

• Liver problems

• Osteoporosis

• Rashes

• Kidney stones

Many of these symptoms may be caused by other health problems. Make sure your child sees their healthcare provider for a diagnosis.

How Is Ulcerative Colitis Diagnosed In A Child?

Your child's healthcare provider will ask about your child's health history. They will also give your child an exam.

Your child will have blood tests. These tests can tell if your child has anemia. They can also tell if your child has a high white blood cell count. This can be a sign of inflammation or infection. Your child’ may also have other tests.

Stool sample

This test checks for infection or inflammation in your child’s digestive tract. A small sample of stool is collected from your child and sent to a lab.

Upper endoscopy

In this test, a small, flexible tube (endoscope) is used to look at the inside of your child’s upper digestive tract. This tube has a light and a camera lens at the end of it. During the test, the healthcare provider may take tissue samples from your child's digestive tract. The provider will test these samples.

Colonoscopy

This test lets the provider look at the length of your child’s colon (the large intestine). This can spot abnormal growths, inflamed tissue, ulcers, and bleeding. In this test, the provider puts a special tool (colonoscope) in through the rectum up into the colon. This tool is a long, flexible, and lighted tube. During the test, the provider may take out tissue to look at it more closely. They may also treat some problems.

Biopsy

The provider may take tissue samples to be checked under a microscope. These samples may be taken from the lining of the colon during a colonoscopy. Or they may be taken from the end of the small intestine during an upper endoscopy.

Barium enema (lower GI series)

This test looks at the large intestine. Your child will get barium in their rectum as an enema. This is a metallic liquid that coats the inside of their organs. This helps them show up on an X-ray better. Your child’s healthcare provider will take X-rays of their belly. This can show narrowed areas (strictures), blockages (obstructions), and other issues.

How Is Ulcerative Colitis Treated In A Child?

Treatment will depend on your child’s symptoms, age, and general health. It will also depend on the specific cause and how severe the condition is.

Diet

No specific diet causes or cures this condition. If certain foods upset your child’s stomach, staying away from those foods may help ease your child’s symptoms. A healthy diet is always advised.

Medicine

Your child’s healthcare provider may prescribe medicines that reduce colon inflammation. These can include aminosalicylates, corticosteroids, and immunomodulators. Some medicines are given into the rectum as a suppository or enema. If your child’s condition is severe, they may also need steroids, antibiotics, or medicines that affect the body's immune system. These are called biologics and small molecules.

Hospital stay

If your child’s symptoms are severe, they may need to stay in the hospital for monitoring and treatment. This can help make sure your child is getting the nutrition and fluids they need. Treatment will be given to help stop diarrhea and the loss of blood, fluids, and minerals. Your child may need a special diet, feeding, and fluids or medicines through a vein. Some children may also need surgery.

Surgery

About 10% to 20% of children with this condition eventually need surgery. This is done because of heavy bleeding, tear (perforation) of the colon, cancer risk, or severe illness. In surgery, your child’s colon is removed. This may also be done if other treatments don’t work. Or if your child has side effects.

Your child may have 1 of the following surgeries:

• Proctocolectomy with ileostomy. This is the most common surgery. In a proctocolectomy, the whole colon and rectum are taken out. In an ileostomy, your child’s surgeon makes a small opening of the abdominal wall. The tip of the lower small intestine (ileum) is brought to the surface of your child’s skin. This allows waste to drain out into a bag.

• Ileoanal anastomosis. In this surgery, just the affected part of your child’s colon is taken out. The outer muscles of the rectum aren’t removed. Your child’s surgeon attaches the ileum to the inside of the rectum. This forms a pouch to hold the waste. This allows your child to pass stool through their anus in a normal way. But your child’s bowel movements may happen more often and be more watery than normal. This is sometimes done in 2 or 3 surgeries.

What Are Possible Complications Of Ulcerative Colitis In A Child?

In rare cases, this condition can cause death. If your child’s condition affects more than just their rectum and lower colon, your child has a higher risk for colon cancer. They're also at risk for a tear (perforation) of the bowel wall. This needs surgery. Your child may also have severe bleeding at times.

How Can I Help My Child Live With Ulcerative Colitis?

Children with this condition need long-term care. Your child may have times when symptoms go away (remission). This can sometimes last for months or years. But symptoms often come back. Medicines are often needed for the long term.

Your child should learn what foods trigger their symptoms and stay away from these foods. You and your child’s healthcare provider should make sure your child gets enough nutrients to grow and develop well. Support groups can help you and your child. Work with the provider to create a care plan for your child.

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Doç.Dr.E.Mahir Gülcan 20:55  No comment

Pediatric Crohn's disease

What is Crohn's disease in children?

Crohn's disease is when there is redness, swelling (inflammation), and sores along the digestive tract. It is part of a group of diseases known as inflammatory bowel disease or IBD.

Crohn’s disease is a long-term (chronic) condition. It may come and go at different times in your child’s life. In most cases it affects the small intestine, most often the lower part called the ileum. In some cases, both the small and large intestines are affected.

Sometimes the inflammation may affect the whole digestive tract. This includes the mouth, the food pipe (esophagus), the stomach, the first part of the small intestine (duodenum), the appendix, and the anus.

What causes Crohn's disease in a child?

Experts don’t know what causes Crohn's disease. It may be that a virus or bacteria affects the body's infection-fighting system (immune system). The immune system may have an abnormal inflammation reaction in the intestinal wall that doesn’t stop.

Many children with Crohn’s disease have an abnormal immune system. But experts don’t know if immune problems cause the disease. They also don’t know if Crohn’s disease may cause immune problems.

Which children are at risk for Crohn's disease?

Crohn's disease may happen at any age. It most often affects people ages 15 to 35. But Crohn's may also occur in young children. It affects both males and females equally.

Children or teens may be more at risk for Crohn’s disease if they:

• Have a family history of Crohn’s disease. In most cases this is a close relative such as a parent, sister, or brother.
• Are white
• Are American Jews of European descent
• Live in developed countries, in cities, and in northern climates
• Smoke

What are the symptoms of Crohn's disease in a child?

Each child’s symptoms may vary. Symptoms may include:

• Belly (abdominal) pain, often in the lower right area
• Loose stool (diarrhea), sometimes bloody
• Rectal bleeding
• Weight loss
• Fever
• Delayed growth
• Joint pain
• A cut or tear in the anus (anal fissure)
• Rashes

Some children may have no symptoms for a long time, even years. This is called being in remission. There is no way to know when remission may occur or when your child’s symptoms will return.

The symptoms of Crohn's disease may look like other health problems. Always see your child's healthcare provider for a diagnosis.

How is Crohn's disease diagnosed in a child?

Your child may be checked for signs of Crohn's disease if he or she has had long-term:

• Belly (abdominal) pain
• Loose stools (diarrhea)
• Fever
• Weight loss
• A loss of healthy red blood cells (anemia). This can make your child feel tired.

Your child’s healthcare provider will take a health history and do a physical exam. Other tests for Crohn's disease may include:

• Blood tests. These are done to see if your child has fewer healthy red blood cells because of blood loss. This is called anemia. These tests also check if your child has a higher number of white blood cells. That might mean there is an inflammation problem. Other blood tests can look for abnormal antibodies. The healthcare provider may use this result to help diagnose or classify the disease.
• Stool culture. This is done to see if an infection by a parasite or bacteria is causing the symptoms.
• Endoscopy. This test checks the inside of part of the digestive tract. It uses a small, flexible tube called an endoscope. The tube has a light and a camera lens at the end. Tissue samples or biopsies from inside the digestive tract may also be taken for testing.
• Colonoscopy. This test looks at the full length of the large intestine. It can help check for abnormal growths, inflamed tissue, sores or ulcers, and bleeding. It uses a long, flexible, lighted tube called a colonoscope. The tube is put into your child’s rectum up into the colon. This tube lets the provider see the lining of the colon and take out a tissue sample or biopsy to test it. Your child’s provider may also be able to treat some problems that may be found.
• Biopsy. A tissue sample is taken from the lining of the colon and checked in a lab.
• Upper GI series or barium swallow. This test looks at the organs of the top part of the digestive system. It checks the food pipe (esophagus), the stomach, and the first part of the small intestine (duodenum). Your child swallows a fluid called barium. This is a thick, chalky fluid. It is used to coat the inside of organs so that they will show up on an X-ray. Then X-rays are taken to check the digestive organs.
• Lower GI series or barium enema. This test checks the large intestine, including the colon and rectum. A thick, chalky fluid called barium is put into a tube. It is inserted into your child’s rectum as an enema. Barium coats the organs, so they can be seen on an X-ray. An X-ray of your child’s belly will show if there are any narrowed areas called strictures. It will also show any blockages or other problems.
• CT enterography or MR enterography. These imaging tests look at the small bowel and can show any inflammation or complications.
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How is Crohn's disease treated in a child?

Crohn’s disease is a long-term (chronic) disease. There is no cure for it. But there are some things that can help to control it. Treatment for the disorder has 4 goals:

• Correct nutritional problems
• Control the swelling and inflammation
• Ease symptoms such as belly pain, diarrhea, and rectal bleeding
• Keep complications from occurring. These include tunnels of inflammation to other organs (fistulas) and narrowing of the intestine (stricture) that causes blockages.

Your child’s healthcare provider will create a care plan based on:

• Your child's age, overall health, and medical history
• How serious your child’s case is
• How well your child handles certain medicines, treatments, or therapies
• If your child’s condition is expected to get worse
• Your opinion and what you would like to do

Your child’s treatment may include the following.

Medicine

Medicines often reduce the inflammation in the colon. This may help ease belly cramps and diarrhea. More serious cases may require steroids, antibiotics, or medicines that affect the body's immune system.

Diet

Making some changes in your child’s diet may help to ease symptoms. In some cases, symptoms are made worse by milk, hot spices, or fiber. Talk with your child’s provider. In some cases, your child may use a special meal plan called an elemental diet.

Vitamins

Vitamins may help prevent some problems or help maintain a remission. Because many children with Crohn's don't absorb nutrients normally, vitamin deficiencies are common. Your child may need lab tests to assess the nutrient levels. Talk with your child’s provider about any vitamin supplements. These treatments have risks and may cause harmful side effects.

Nutritional supplements

Your child’s provider may suggest nutritional supplements or special high-calorie liquid formulas. These may be helpful if your child has delayed growth.

IV or intravenous feeding

In rare cases IV feeding may be used for children who need extra nutrition for a short time.

Surgery

Surgery may help Crohn’s disease, but it can’t cure it. Surgery may help to reduce long-term symptoms that don’t get better with medicine. Surgery may also fix some problems. These include a blocked intestine, a hole or perforation, a sore or abscess, or bleeding. Types of surgery may include:

• Draining abscesses in or near fistulas. An abscess is a collection of pus or infection. Treatment includes antibiotics, but surgery may be needed.
• Bowel or intestinal resection. The diseased section of intestine is removed. The 2 healthy pieces of intestine are attached. This surgery shortens your child’s intestines.
• Ostomy. When part of the intestines is removed, a new way of removing stool from the body is created. The surgery to create the new opening is called an ostomy.

What are the complications of Crohn's disease in a child?

Children with Crohn’s disease may lose weight because they don’t get enough calories. This can happen because a child:

• May try to avoid eating, to prevent the pain that is linked to digestion
• May not want to eat if he or she can’t have any favorite foods 
• May not absorb nutrients well through the inflamed digestive tract
• Has greater nutritional needs than normal because of the disease

Nutritional supplements or special high-calorie liquid formulas may be suggested. This is often recommended if a child has delayed growth.

Crohn’s disease may also cause other health problems such as:

• A blocked intestine
• A type of tunnel, called a fistula, in nearby tissues. This can get infected.
• Rips or tears, called fissures, in the anus
• Problems with liver function
• Gallstones
• A lack of some nutrients, such as calories, proteins, and vitamins
• Too few red blood cells or too little hemoglobin in the blood (anemia)
• Bone weakness, either because bones are brittle (osteoporosis) or because bones are soft (osteomalacia)
• A nervous system disorder where legs feel painful, called restless leg syndrome
• Arthritis
• Skin problems
• Eye or mouth redness or swelling (inflammation)  

After bowel resection surgery, a condition called short bowel syndrome can occur. It often happens after a large part of the small intestine is removed. The body then may not be able to digest and absorb some vitamins, foods, and nutrients, including water. This poor absorption of food and nutrients is called malabsorption. It causes diarrhea. It can also lead to poor growth and development. Common symptoms of malabsorption include:

• Loose stool (diarrhea)
• Large amounts of fat in the stool (steatorrhea)
• Weight loss or poor growth
• Fluid loss or dehydration
• Lack of vitamins and minerals

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Doç.Dr.E.Mahir Gülcan 20:14  No comment

Cow's milk allergy and other food allergies

How do I know if my child has a food allergy?

A food allergy happens when the body reacts against harmless proteins found in foods. The reaction usually happens shortly after a food is eaten. Food allergy reactions can vary from mild to severe.

Because many symptoms and illnesses could be wrongly blamed on "food allergies," it is important for parents to know the usual symptoms. The following is information from the American Academy of Pediatrics (AAP) about food allergies and how to recognize and treat the symptoms. There is also important information about how to keep your child safe and healthy at home and in school if he has a food allergy.

Symptoms of a food allergy

When the body's immune system overreacts to certain foods, the following symptoms may occur:

• Skin problems
• Hives (red spots that look like mosquito bites)
• Itchy skin rashes (eczema, also called atopic dermatitis)
• Swelling
• Breathing problems
• Sneezing
• Wheezing
• Throat tightness
• Stomach symptoms
• Nausea
• Vomiting
• Diarrhea
• Circulation symptoms
• Pale skin
• Light-headedness
• Loss of consciousness

If several areas of the body are affected, the reaction may be severe or even life-threatening. This type of allergic reaction is called anaphylaxis and requires immediate medical attention.

Not a food allergy

Food can cause many illnesses that are sometimes confused with food allergies. The following are not food allergies:

• Food poisoning—Can cause diarrhea or vomiting, but is usually caused by bacteria in spoiled food or undercooked food.
• Drug effects—Certain ingredients, such as caffeine in soda or candy, can make your child shaky or restless.
• Skin irritation—Can often be caused by acids found in such foods as orange juice or tomato products.
• Diarrhea—Can occur in small children from too much sugar, such as from fruit juices.

Some food-related illnesses are called intolerance, or a food sensitivity, rather than an allergy because the immune system is not causing the problem. Lactose intolerance is an example of a food intolerance that is often confused with a food allergy. Lactose intolerance is when a person has trouble digesting milk sugar, called lactose, leading to stomachaches, bloating, and loose stools.

Sometimes reactions to the chemicals added to foods, such as dyes or preservatives, are mistaken for a food allergy. However, while some people may be sensitive to certain food additives, it is rare to be allergic to them. 

Foods that can cause food allergies

Any food could cause a food allergy, but most food allergies are caused by the following:

• Cow milk
• Eggs
• Peanuts
• Soy
• Wheat
• Nuts from trees (such as walnuts, pistachios, pecans, cashews)
• Fish (such as tuna, salmon, cod)
• Shellfish (such as shrimp, lobster)

Peanuts, nuts, and seafood are the most common causes of severe reactions. Allergies also occur to other foods such as meats, fruits, vegetables, grains, and seeds such as sesame.

The good news is that food allergies are often outgrown during early childhood. It is estimated that 80% to 90% of egg, milk, wheat, and soy allergies go away by age 5 years. Some allergies are more persistent. For example, 1 in 5 young children will outgrow a peanut allergy and fewer will outgrow allergies to nuts or seafood. Your pediatrician or allergist can perform tests to track your child's food allergies and watch to see if they are going away.

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Doç.Dr.E.Mahir Gülcan 01:16  1 comment

Gastritis and peptic ulcus

An ulcer is a sore, which means it's an open, painful wound. Peptic ulcers refer to ulcers in the stomach or the upper part of the small intestine, called the duodenum. An ulcer in the stomach is called a gastric ulcer and an ulcer in the duodenum is called a duodenal ulcer. Helicobacter pylori (H. pylori) is a bacterium that causes peptic ulcers. Gastritis is irritation or inflammation of the lining of the stomach. An untreated H. pylori infection can result in gastritis.

Causes

Both a gastric ulcer and a duodenal ulcer result when H. pylori bacteria or a drug weaken the protective mucous coating of the stomach and duodenum, allowing acid to get through to the sensitive lining beneath. H. pylori bacteria survive in the stomach acid because they secrete enzymes that neutralize the acid. This mechanism allows H. pylori bacteria to make their way to the "safe" area – the protective mucous lining. Once there, the spiral shape of the bacteria help them burrow through the lining. Both the acid and the bacteria can irritate the lining and cause an ulcer to form.

The exact transmission of H. pylori is unknown but it is suspected that transmission occurs via bodily fluids. If left untreated, an H. pylori infection can cause gastritis. Gastritis can occur suddenly (acute gastritis) or gradually (chronic gastritis). Gastritis also can be caused by long-term use of aspirin and anti-inflammatory drugs.

An untreated H. pylori infection also can cause peptic ulcer disease or stomach cancer later in life. In the past, having peptic ulcers meant living with a chronic condition for several years or even a lifetime. But today, a better understanding of the cause of peptic ulcers and how to treat them means that most people can be cured.

Symptoms

Abdominal discomfort is the most common symptom of peptic ulcers. This discomfort usually feels like a dull, gnawing ache. The pain usually occurs two or three hours after a meal or in the middle of the night when the stomach is empty. The pain may come and go for several days or weeks. Discomfort is relieved by eating and taking antacid medications. It is not clear if helicobacter infection without ulcer causes abdominal pain.

Other symptoms include:

• Weight loss
• Poor appetite
• Bloating
• Burping
• Nausea
• Vomiting
• Dark stools (gastritis)

Some people experience only very mild symptoms or none at all.

Exams and tests

In addition to taking a complete history from you and your child, and doing a thorough physical examination of your child, your child's pediatric GI specialist may perform tests to confirm if your child's symptoms are a result of ulcers.

Upper GI Endoscopy (EGD)

This test allows the pediatric gastroenterologist to examine the lining of the esophagus, stomach and duodenum (first part of small bowel) using a camera in a flexible tube called an endoscope. The procedure is done in the operating room under general anesthesia so that the child will not feel any pain. Your child's doctor will pass the endoscope through his or her mouth and examine the esophagus, stomach and the duodenum. After examining the upper GI tract and taking pictures, the doctor will collect biopsies (very small pieces of the tissue lining), which will be sent to a pathologist (a doctor who studies tissue, blood and other samples) to examine under a microscope for inflammation and other signs of disease. If an ulcer is bleeding, the doctor will use the endoscope to inject drugs that promote clotting or to guide a heat probe that cauterizes the ulcer.

Before the procedure your doctor will talk with you and your child and answer your questions. Some children may get a medication to help them relax before being taken to the operating room area. After the procedure your child will be taken to the recovery room, allowed to fully awaken, and then be brought out to you. The physician will discuss the preliminary findings of the procedure and show pictures taken during the procedure. Your child will be allowed to go home once he or she is fully awake and able to drink liquids. The total time spent at the hospital will depend on the testing and the time for the child to wake up. It is best to expect to spend four or five hours at the hospital.

If an ulcer is found, the pediatric GI specialist will test your child for H. pylori. This test is important because treatment for an ulcer caused by H. pylori is different than treatment for an ulcer caused by other things.

H. pylori is diagnosed through blood, breath, stool and tissue tests. Most common is the blood test, which is done with a finger stick. For the breath test, the child drinks a solution. Their exhaled breath is collected and tested to confirm the presence or absence of H. pylori. If you are asked to conduct a stool test, you will be given a stool collection kit to take home. You will be given instructions for taking the sample to a laboratory for testing.

Treatments

H. pylori peptic ulcers are treated with drugs that kill bacteria, reduce stomach acid and protect the stomach lining. Antibiotics are used to kill the bacteria. Bismuth subsalicylate, a component of Pepto-Bismol, is used to protect the stomach lining from acid. It also kills H. pylori. Proton pump inhibitors, which suppress acid production by halting the mechanism that pumps the acid into the stomach, might be used.

Treatment usually involves a combination of antibiotics, acid suppressors and stomach protectors. Antibiotic regimens recommended for patients may differ across regions of the world because different areas have begun to show resistance to particular antibiotics.

Gastritis treatment is based on the cause of the inflammation. Medications to decrease stomach acid release may be prescribed.

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Doç.Dr.E.Mahir Gülcan 22:23  No comment

Endoscopic foreign body removal

The ingestion of foreign bodies is most commonly a problem in young children aged 6 months to 5 years, but can affect children of all ages (those younger than 6 months can occasionally ingest materials with the aid of older siblings during play). It may be an event witnessed by parents. It occurs much less frequently in older children and adults but does affect these groups rarely. It usually occurs accidentally but can result from deliberate ingestion. Patients with mental illness,^[1] intellectual impairment, prisoners^[2] or 'drug-mules'/'body-packers'^[3] (those involved in the smuggling of illicit drugs concealed in the gastrointestinal tract) are prone to problems caused by purposeful ingestion of foreign bodies. Trichobezoar is a rare condition where hair ingestion leads to formation of a hair ball in the stomach.^[4]

Virtually any object small enough to pass through the pharynx may be swallowed. Items commonly ingested by children include coins, small toys, pencils, pens and their tops, batteries, safety pins, needles and hairpins - they are mainly radio-opaque. Food-related items, such as fish and chicken bones, are more often ingested by older children and adults and tend to be radiolucent. In adults, dentures or parts from dentures can be swallowed accidentally and are reported in the literature.^[5] The swallowing of foreign bodies during dental procedures does not occur very often.^[6]

The majority of ingested foreign bodies will pass safely through the gut and be passed with faeces (those that reach the stomach have an 80-90% chance of passage),^[7] but some will cause damage to the gastrointestinal (GI) tract and/or become lodged.^[8]Patients swallowing foreign bodies are usually asymptomatic but symptoms can result. It may even lead to life-threatening obstruction of the upper GI and respiratory tracts.

Epidemiology

It is difficult to estimate the incidence of accidental ingestion of foreign bodies in children, but it is common. A five-year survey in a large urban American emergency department found 255 cases of oesophageal foreign body affecting children, 214 of which followed a witnessed ingestion.^[9] A cross-sectional survey found that of 1,500 parents, 4% reported the swallowing of a coin by their child - the most common object swallowed by youngsters.^[10]

Presentation

This is highly variable and depends on whether it is a child or an adult. In children the event may have been witnessed, reported by the child, or be suspected/discovered subsequently when a child becomes ill. Any symptoms or signs are also largely dependent on where any lodged object is impacted. About 75% of children who have an impacted foreign body will have it at the level of the upper oesophageal sphincter, with roughly 70% of affected adults having impaction at the level of the lower oesophageal sphincter.^[7]

Oropharyngeal foreign bodies

• Overall, about 60% of foreign bodies become trapped at this level (commonly at, or just below, the level of the cricopharyngeus muscle).
• Patients usually have a clear sensation of something being trapped that is relatively well localised.
• Small linear items such as bones and toothpicks are often trapped at this level, from the tonsils/posterior tongue to the vallecula and upper oesophagus.
• There is usually discomfort ranging from mild to quite severe.
• Drooling and an inability to swallow may be present.
• Airway compromise may occur if large objects are trapped.
• A delayed presentation with infection or perforation may occur with objects that become stuck at this level.

Oesophageal foreign bodies

• In adults, there is usually an acute presentation following ingestion of an object or food item that becomes stuck.
• There tends to be a vague sensation of something being stuck in the centre of the chest or epigastric region, indicating that the object is probably at the level of the aortic cross-over or the lower oesophageal sphincter.
• There may be dysphagia for the remainder of the meal, prompting presentation or salivary pooling/drooling if there is complete oesophageal obstruction.
• This presentation appears to be more common in those who use dentures, eat meat and concurrently consume alcohol.^[7]
• Children with oesophageal impaction tend to have a less clear-cut presentation, although there may have been a witnessed swallowing event.
• Gagging, vomiting, retching, neck and/or throat pain are more common presentations in children with oesophageal foreign bodies.
• Children with partial oesophageal obstruction may present with a chronic course featuring inability to feed, failure to thrive, fever, recurrent aspiration pneumonitis/pneumonia or respiratory embarrassment/stridor (due to tracheal impingement).

Sub-oesophageal foreign bodies

These may present with a range of symptoms depending on the degree of progression of the object through the gut. Vague symptoms, such as abdominal distension and discomfort, fever, recurrent vomiting, passing rectal blood/melaena and/or other symptoms of acute or subacute intestinal obstruction, may be present.

Symptoms due to gastrointestinal (GI) perforation

If an object perforates the oesophagus, it tends to cause acute mediastinitis with chest pain, dyspnoea and severe odynophagia (pain associated with swallowing), along with signs of pneumonitis/pleural effusion.^[11] Perforation below the level of the oesophagus will cause symptoms and signs of acute/subacute peritonitis.

Examination of the patient with definite/suspected foreign body ingestion/entrapment

This is often unhelpful, but careful examination should be carried out for acute clinical and medicolegal reasons:

• Assess the airway and respiratory function to exclude/highlight any compromise.
• Check vital signs to exclude impending catastrophic presentation due to airway obstruction or acute GI perforation, or fever in case of delayed presentation.
• Open the mouth and observe the oropharynx with a bright light.
• Consider indirect laryngoscopy and/or fibre-optic examination of the pharynx if you have appropriate equipment and a sufficiently experienced practitioner available.
• Gently palpate the neck and assess tracheal position/compression.
• Formally examine the chest and listen to the lungs.
• Perform a cardiovascular examination.
• Carefully examine the abdomen.

Differential diagnosis

• This clinical scenario is unlikely to be confused with another illness, with the possible exception of space-occupying oesophageal pathology - eg oesophageal carcinoma causing obstruction of a normal food bolus.
• Always consider the possibility that a foreign body has been inhaled, particularly if a patient presents acutely with respiratory compromise or with chronic chest symptoms.
• An acute presentation of mediastinitis may be due to perforation by a swallowed foreign body, or the primary form of the disease.^[11]
• Retropharyngeal abscess can cause similar symptoms to impacted objects in the upper oesophageal area.
• Pneumomediastinum can present similarly, where there is a pneumothorax into the mediastinal portion of pleura.

Investigations

Blood tests are usually unhelpful, with the exception of chronic presentations or febrile patients where FBC/ESR may provide useful clues as to the cause of symptoms.

• Plain X-rays:
  Where there is a history of a swallowed radio-opaque object that may be located within the upper gastrointestinal (GI) tract, plain X-ray should be carried out to confirm or refute the possibility of oesophageal entrapment. This need not be done urgently if occurring out-of-hours and the patient is well, but should be performed at the earliest opportunity when radiology services are available. If there is a suspicion of swallowing a button battery, then X-rays and further treatment should be performed urgently.
  • Where the ingested object is not radio-opaque, X-ray investigations are unlikely to help and will probably only delay more relevant investigations such as upper GI endoscopy.
  • Very small children can be imaged using a mouth-to-anus radiograph.
  • In adults, a PA and lateral chest radiograph and/or plain abdominal X-ray are more useful.
  • Only about 20-50% of food bones will be visible on X-rays.^[7]
  • Coins in the oesophagus usually appear in a coronal alignment on frontal radiographs (ie seen as a disc).
  • Coins in the trachea are more usually seen in a saggital orientation on frontal radiographs, due to the incompleteness of tracheal cartilage rings posteriorly (ie seen 'edge-on').
• CT scans:
  • CT scanning of the thorax/abdomen is highly useful for locating entrapped objects of various types and considered superior by many to plain X-ray imaging.^[7]
  • CT scanning is the investigation of choice if there is reason to suspect perforation or abscess formation.
  • Not all cases of acute dysphagia/odynophagia due to food bones should have CT scanning, as only a minority (17-25%) of those who have the sensation of a trapped foreign body after eating will actually have one present, the remainder having the sensation due to mucosal injury.
• Endoscopy:
  • Urgent endoscopy is mandatory in cases where there is airway obstruction or evidence of other severe complications.
  • Where there is a clear history of swallowing objects, such as toothpicks and/or aluminium bottle caps/can rings, endoscopy is the investigation/procedure of choice, as there is a high rate of complications with such objects.^[7]
  • Where the history of ingestion of such objects is not so clear-cut, consider CT first to detect the object.^[7]
  • Definite indications for endoscopy are objects that are sharp, non-radio-opaque, elongated, or where there are multiple swallowed objects or a high risk of oesophageal injury (eg button batteries).^[7]
  • Endoscopy is also indicated for gastric or proximal-duodenal foreign bodies that have a diameter of >2 cm, a length of >5-7 cm or are eccentrically-shaped and prone to enlodgement/perforation, such as open safety pins.^[7]
  • Endoscopy is a relatively safe procedure in experienced hands, but costly, and should therefore be avoided as a routine intervention if possible.
• Other tests:
  • Barium swallows are sometimes used to detect non-radio-opaque items but CT is usually preferred, as there is a better yield and barium must be avoided where there is reason to suspect perforation (gastrografin usually being used in its place).
  • Hand-held metal detectors can be used to trace the passage of metallic objects through the GI tract and reduce exposure to ionising radiation during follow-up; their specificity of localisation is poor, particularly in the upper GI tract. They can, however, indicate where it is likely that there is a trapped metal oesophageal object that requires further investigation.

Management

• Act quickly to locate and remove any object that may be causing acute upper airway obstruction.
• Where airway obstruction is life-threatening and an object cannot be removed then obtain urgent senior A&E/anaesthetic/ENT advice and/or consider cricothyroidotomyas a life-saving procedure.
• Patients outside of hospital with significant airway/gastrointestinal (GI) obstruction should be transferred as an emergency, in a sitting position, with a suction catheter available for them to use to remove obstructed saliva.
• Children with upper GI obstruction and/or airway compromise should be allowed to stay in their parent's arms whilst being transferred to, or assessed in, hospital, to reduce anxiety and worsening airway embarrassment.
• Indications of instability or a need for urgent transfer to hospital include:
  • Airway compromise.
  • Drooling.
  • Inability to swallow fluids.
  • Sepsis.
  • Suspicion of intestinal perforation.
  • Evidence of active bleeding.
  • Clear history of ingestion of a button battery.
• Those with objects lodged in the oesophagus will usually require some form of intervention to prevent ulceration and/or other complications; options include endoscopy, removal with a Foley® catheter, bougienage (use of a stiff rod to push objects such as coins past the lower oesophageal sphincter) and medical therapy to dilate the lower oesophageal sphincter.
• Stable patients who have swallowed small, smooth objects, who have no evidence of oesophageal entrapment, otherwise negative imaging, and with no evidence of damage, can often be managed conservatively with follow-up at 24 hours or so to check that they remain well; passage of objects in stool may take days to weeks and parents should observe for their presence.
• Patients with stomach or small-intestine foreign bodies of width <2 cm or length <6 cm can be discharged home with instructions on symptoms that should prompt their re-attendance; patients with larger or sharp objects in these areas should be referred to a gastroenterologist who may carry out serial X-rays.
• Narcotic 'body packers'/'drug mules' should be followed up and monitored as inpatients due to the risk of drug toxicity; they may need bowel irrigation and/or surgical intervention if there is any evidence of systemic effects of leaking narcotics (endoscopy is not recommended, as it tends to release drugs from the packages).^[3][7]
• Adult patients with oesophageal entrapment of food bolus or other food-related objects should be considered for referral to a gastroenterologist, as there is a significant incidence of oesophageal lesions such as carcinoma in these patients.^[7]Hyoscine may be useful in cases of food bolus obstruction.^[12]

Complications

• Oropharyngeal foreign bodies:
  • Scratches and lacerations of oropharyngeal mucosa.
  • Perforation.
  • Retropharyngeal abscess.
  • Soft-tissue infection or abscess.
• Oesophageal foreign bodies:
  • Scratches, lacerations or abrasions of mucosa.
  • Oesophageal necrosis (beware swallowed button batteries in children).
  • Retropharyngeal abscess.
  • Oesophageal stricture.
  • Oesophageal perforation and subsequent para-oesophageal abscess.
  • Mediastinitis.
  • Pneumothorax and/or pneumomediastinum.
  • Pericarditis/cardiac tamponade.
  • Tracheo-oesophageal fistula (especially swallowed button batteries in children).
  • Aorto-oesophageal fistulae or other mediastinal vascular injury.
• Gastric/small-intestine foreign bodies:
  • Entrapment of an object within a Meckel's diverticulum.
  • Perforation leading to peritonitis and advanced sepsis.
  • Acute or subacute small-intestinal obstruction.
  • Metal poisoning (coins).^[13]

Prognosis

On the whole, prognosis is good, especially with appropriate investigation, management and follow-up. Most patients with ingested foreign bodies will suffer no significant sequelae. However, a minority of people will have complications and, given that this is a relatively common phenomenon, a significant number of people die as a result of foreign body ingestion - estimated at 1,500 deaths annually in the USA.^[7]

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Doç.Dr.E.Mahir Gülcan 21:43  No comment