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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 22  |  Issue : 4  |  Page : 230-233

Poor radiographic access: Cause of delayed diagnosis of esophageal foreign body in a 5-year-old


1 Department of Radiology, Ahmadu Bello University Teaching Hospital, Ahmadu Bello University, Zaria, Nigeria
2 Department of Surgery, Ahmadu Bello University Teaching Hospital, Ahmadu Bello University, Zaria, Nigeria
3 Department of Pediatrics, Ahmadu Bello University Teaching Hospital, Ahmadu Bello University, Zaria, Nigeria

Date of Submission11-Jan-2019
Date of Acceptance08-Jul-2019
Date of Web Publication29-Nov-2019

Correspondence Address:
Dr. Suleiman Lawal
Department of Radiology, Ahmadu Bello University Teaching Hospital, Zaria
Nigeria
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DOI: 10.4103/smj.smj_3_19

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  Abstract 


Foreign-body ingestion is a global public health problem especially among children under-5 years of age. The diagnosis is difficult in children who cannot communicate, especially if the event was not witnessed. We present a child who presented with foreign-body ingestion simulating upper respiratory tract infection. This case highlights the crucial role of radiology in the diagnosis, treatment, and complications of esophageal foreign bodies in children.

Keywords: Children, foreign body, oesophagus, radiography


How to cite this article:
Lawal S, Muhammad H, Bello N, Zubair MA, Yunusa SI, Yakubu A. Poor radiographic access: Cause of delayed diagnosis of esophageal foreign body in a 5-year-old. Sahel Med J 2019;22:230-3

How to cite this URL:
Lawal S, Muhammad H, Bello N, Zubair MA, Yunusa SI, Yakubu A. Poor radiographic access: Cause of delayed diagnosis of esophageal foreign body in a 5-year-old. Sahel Med J [serial online] 2019 [cited 2019 Dec 7];22:230-3. Available from: http://www.smjonline.org/text.asp?2019/22/4/230/272139




  Introduction Top


Foreign-body ingestion is a usual cause for concern globally that requires urgent attention, since time immemorial, and has continued to evolve over time. Four out of five cases of foreign-body ingestion occur in children under-5 years old.[1],[2] Ingestion is frequently inadvertent in children and seldom homicidal, particularly in adults. In the pediatric age group, coins are the most frequently ingested objects,[1] whereas adults usually have food impactions (meat bolus and fish bones) and dentures.[2],[3]

Majority of these objects pass through the gastrointestinal tract and are excreted spontaneously;[3] however, some objects may become lodged, thus requiring interventional procedure in about 10%–20% and surgery in 1%.[4]

The diagnosis is difficult in children who cannot communicate, especially if the event was not witnessed. In such a case, the presentation may mimic other medical conditions, for example, presentation with fever, dyspnea, cough, dysphagia, and drooling of saliva could be mistaken as upper respiratory tract infection.

This case is being presented to highlight how foreign-body ingestion can simulate upper respiratory tract infection and to emphasize the crucial role of radiology in the diagnosis, treatment, and complications of esophageal foreign bodies in children.


  Case Report Top


R. Z is a 5-year-old male child who was referred to the emergency pediatric unit of Ahmadu Bello University Teaching Hospital, Zaria, Nigeria, from a peripheral hospital, on account of cough, unabating fever, refusal of feeds, and drooling of saliva, after 2 days of management with broad-spectrum antibiotics. The patient was well until 3 days prior to presentation when he started rejecting food and was noted to be drooling saliva. There was an associated history of dysphasia but no cough or chest pain. The patient gave no history of foreign-body ingestion, and there was also no eye witness report of such.

On general examination, the child was not in obvious respiratory distress, not pale, and anicteric but mildly febrile with a temperature of 38.2°. The breath sounds were 16 circles per minute, central trachea, equal chest expansion and air entry, percussion note was resonant, and breath sounds were normal. The other systemic examinations were normal. The normal throat examination, however, raised the suspicion of a distal esophageal foreign body; hence, a clinical provisional diagnosis of foreign-body impaction was made.

Plain radiographs of the chest; posterior-anterior (PA) [Figure 1] and lateral views were requested. Blood sample was also taken for full blood count and differential which was normal. The chest radiographs confirmed the foreign body to be a peg metal clip, lodged in the upper thoracic esophagus. There was no other chest radiographic abnormality noted.
Figure 1: Posteroanterior chest radiograph showing an inverted U-shaped opacity of metallic density in the upper thorax, just to the left of the midline (arrow)

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A radiological diagnosis of esophageal foreign-body impaction in the proximal esophagus was made. The metallic clip [Figure 2] was successfully removed using a flexible endoscope, and under general anesthesia, with no complications postprocedure although as at then, it has moved down to the gastroesophageal junction.
Figure 2: Picture of the extracted peg metal clip

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  Discussion Top


The inherent curiosity of children often leads them to ingest various kinds of objects rather than the appropriately sized foodstuff. Any object small enough to pass through the hypopharynx can be swallowed.[3],[5] Although 2 year olds are the most common patients, their age ranges between 6 months and 5 years, the index patient's age is borderline upper limit. Older children and adolescents are a subgroup of patients at risk for accidental foreign-body ingestion due to the high (70%) prevalence rate of anatomic esophageal abnormalities such as benign rings and strictures.[5] Limited radiologic study was done for this patient due to insufficient funds; therefore, the presence of anatomic abnormality could not be excluded. There is a slight male preponderance, with a reported male-to-female ratio being 1.5:1[4] as is the situation in this index case who happens to be a male.

Impaction of foreign bodies usually occurs at areas of normal physiologic narrowing, i.e. the level of the cricoids, tracheal bifurcation, bronchus, and just proximal to the esophagogastric junction. The upper esophagus, at the level of the cricoid ring, however, remains as the most common location;[1],[6] the site of the foreign body in this patient as shown in the radiographs is at the proximal thoracic esophagus, i.e. it has moved passed the cricopharyngeal narrowing.

Symptoms are often varied, and most patients present usually within 24 h,[6] though this patient presented to us 3 days later, they presented earlier to a peripheral hospital. Sometimes, ingestion could also be discovered incidentally during a radiographic examination for other reasons. Due to the proximity of the upper airways and the esophagus, respiratory symptoms such as cough, stridor, and chest pain could mimic upper respiratory tract infection and lead to a missed diagnosis, and subsequently, long-standing foreign-body retention, especially in nonwitnessed ingestion. Other features of chronic retention include failure to thrive, weight loss, migration of the foreign body, and fatal esophagovascular fistula. A foreign body lodged more than 24 h poses a greater risk of perforation, mediastinal abscess formation, and airway compromise.[3],[7] Interestingly, none of these were present in this case despite the delay in removal.

The initial investigation of patients is usually plain radiographs whose diagnostic accuracy has been found to be high by Cheng and Tam [1] in their study involving 1265 patients. Radiographs of the chest, neck, and upper abdomen “as indicated” are necessary to locate and characterize the foreign body and also to identify complications. A foreign body lodged in the esophagus has a coronal orientation in a PA chest radiograph because of the configuration of the esophagus. If the foreign body is oriented sagittally, then it is in the trachea. In this index patient, the foreign body was in the esophagus; hence, it has the configuration of the former.

When the foreign body is not radiopaque and the presence of a retained object is suspected, contrast-enhanced esophagography is indicated. A dilute solution of inert barium sulfate or water-soluble nonionic contrast agent should be used, as these minimize complications to the lungs and mediastinum in case of aspiration or esophageal perforation.[4],[8],[9] Where initial radiographic studies fail to demonstrate the foreign body or perforation, and contrast esophagographic studies also not informative, and the patient still remains symptomatic, computed tomography can help to delineate small foreign bodies, especially those lodged in the hypopharynx and cervical esophagus.[4] It is also helpful in assessing associated complications such as mediastinitis, abscess formation, as well as complications following removal, such as perforation and airway compromise.

Patients could be managed conservatively (temporization) or by intervention depending on finding at the initial radiographic examination. Temporization is employed if a patient presents within 24 h, and a single smooth object is present in the distal esophagus in a rather stable patient. Parents are asked to look for an object in the stool, and a repeat radiograph could be performed. However, where the patient presents late and the object is still retained, and in those who are symptomatic, intervention is necessary, which could be surgical or nonsurgical.[2],[3],[5],[6]

Nonsurgical techniques include digestion with proteolytic enzymes (e.g., grains or fish bones) and displacement into the stomach with the use of gas-forming agents.[5],[7] Mechanical extraction under endoscopy or fluoroscopy with fluoroscopic catheter balloon can be undertaken. Both have a high success rate for removal of a variety of objects.[7],[8] The latter avoids the morbidity and costs of endoscopy, general anesthesia, and hospitalization. The index patient had the metal clip removed by the use of a flexible endoscope under general anesthesia. Magnetic catheters, which are safe, effective, quick, and relatively cheaper than endoscopy or surgery, are also utilized in metallic foreign-body removal.[3],[8]


  Conclusion Top


Dysphagia, persistent drooling of saliva, and cough in the under-fives should raise suspicion of an unwitnessed foreign-body ingestion. Radiography and endoscopy should be carried out for the confirmation of diagnosis and possible intervention.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the parent given his consent for the images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cheng W, Tam PK. Foreign-body ingestion in children: Experience with 1,265 cases. J Pediatr Surg 1999;34:1472-6.  Back to cited text no. 1
    
2.
Adedeji TO, Sogebi OA, Bande S. Clinical spectrum of ear, nose and throat foreign bodies in North Western Nigeria. Afr Health Sci 2016;16:292-7.  Back to cited text no. 2
    
3.
Onotai LO, Nwogbo AC, Uyawanne N, Peterside A. Foreign body (peg pin) in the upper esophagus of Nigerian children: Report of two cases. Int J Med Med Sci 2016;6:327-31.  Back to cited text no. 3
    
4.
Taylor RB. Esophageal foreign bodies. Emerg Med Clin North Am 1987;5:301-11.  Back to cited text no. 4
    
5.
Higo R, Matsumoto Y, Ichimura K, Kaga K. Foreign bodies in the aerodigestive tract in pediatric patients. Auris Nasus Larynx 2003;30:397-401.  Back to cited text no. 5
    
6.
Naidoo RR, Reddi AA. Chronic retained foreign bodies in the esophagus. Ann Thorac Surg 2004;77:2218-20.  Back to cited text no. 6
    
7.
Pugmire BS, Lim R, Avery LL. Review of ingested and aspirated foreign bodies in children and their clinical significance for radiologists. Radiographics 2015;35:1528-38.  Back to cited text no. 7
    
8.
Shih CW, Hao CY, Wang YJ, Hao SP. A new trend in the management of esophageal foreign body: Transnasal esophagoscopy. Otolaryngol Head Neck Surg 2015;153:189-92.  Back to cited text no. 8
    
9.
Iwama I. Overlooked radiographic finding results in delayed diagnosis of a retained oesophageal foreign body. BMJ Case Rep 2014;2014. pii: bcr2014204856.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]



 

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