By Sunil Bochare MD
University Health, San Antonio TX
sunil.bochare@uhtx.com
Chief Complaint
Fever, stridor and concern for foreign body ingestion.
History
A 13-month-old previously healthy female was brought to an Urgent Care clinic by her parents for fever and concern about a possible foreign body ingestion. Three weeks prior, the mother recalled hearing choking sounds while cleaning another room. The infant recovered quickly at the time, but over the following week developed daily vomiting and a notable aversion to solid foods. The vomiting improved, but she continued to refuse solids—an unusual pattern given her previously normal diet.
The parents monitored her stools, seeing no evidence of a foreign body passage, though they noted intermittent diarrhea. On the day of presentation, she developed fever, and the father became concerned about abnormal breathing sounds. She was evaluated at Urgent Care, where intermittent inspiratory stridor was noted and a chest X-ray revealed a 1.9 cm circular radiopaque object in the mid-esophagus. Given the concern for a retained foreign body—possibly a coin or button battery—she was transferred to the Emergency Department for further evaluation and management.
Initial Evaluation
In the ED, the patient was febrile to 37.8°C but appeared well without signs of respiratory distress. The X-ray from Urgent Care was reviewed, confirming a mid-esophageal radiopaque object. Given the unclear timeline, concern for mucosal injury, and potential for complications, GI was consulted, and she was taken emergently to the OR for endoscopic removal.
Hospital Course
EGD Findings
A coin was successfully removed from the mid/proximal esophagus. The surrounding mucosa showed deep ulceration at 3 and 9 o’clock, with fibropurulent material and visible pus—raising concern for esophageal perforation, retropharyngeal phlegmon, and possible fistula formation.
The patient was admitted NPO with IV fluids and started on broad-spectrum IV antibiotics (Zosyn and Vancomycin, later narrowed to Unasyn). She was supported with high-flow nasal cannula and racemic epinephrine for intermittent stridor and tachypnea.
Imaging
- MRI and CT Chest: Mediastinitis, phlegmon, and aspiration pneumonia, but no tracheoesophageal fistula or vascular involvement.
- Esophagram: No contrast extravasation or fistula, but persistent esophageal wall thickening and inflammation.
Course
- Respiratory symptoms improved over 48 hours.
- Completed 6 days of IV antibiotics; transitioned to PO Augmentin for 7 more days.
- Gradual reintroduction of oral feeds was successful: from Pedialyte to clears, formula, and eventually pureed solids without difficulty.
- Discharged in good condition with normal vital signs and appropriate oral intake.
Follow-Up
At follow-up (age 18 months), the patient was thriving. She was eating a regular diet, gaining weight, and had no symptoms of dysphagia, vomiting, or choking. Parents reported normal daily bowel movements and no concerns for drooling or feeding issues.
Although GI recommended a surveillance EGD to evaluate for possible esophageal stricture due to the severity of the ulcerations, the family elected to defer the procedure. They were educated on warning signs and agreed to follow up as needed.
Final Diagnoses
Impacted esophageal foreign body (coin), likely present for 2–3 weeks
- Deep esophageal ulceration with phlegmon and concern for perforation
- Mediastinitis
- Aspiration pneumonia
Learning Pearls
- Delayed recognition of esophageal foreign bodies can lead to serious complications.
A history of choking followed by subtle, persistent feeding issues should prompt early imaging—even weeks later. - Coins lodged in the esophagus beyond 24 hours can cause mucosal erosion, ulceration, and perforation.
Even in asymptomatic or mildly symptomatic children, imaging is essential when suspicion is high. - Post-removal surveillance should be considered.
Deep ulceration may lead to esophageal stricture, and a follow-up EGD should be discussed with caregivers—especially if symptoms recur. - Always rule out button battery ingestion.
While this case involved a coin, it was not possible to exclude a button battery on initial imaging. Emergent removal was appropriate given the unknown time of ingestion and potential for tissue injury. - Multidisciplinary care matters.
This patient benefited from coordination between GI, ID, radiology, anesthesia, and pediatric hospitalists. Monitoring for airway involvement and cardiovascular proximity (carotids) was key.
AAP Guidelines on Esophageal Foreign Body Ingestion (Adapted from Kramer et al., 2015)
When to suspect ingestion
- Choking episode, drooling, gagging, vomiting, dysphagia, food refusal, stridor, or persistent cough
- Children under 3 are at highest risk due to exploratory behavior
When to image
- Any child with witnessed or suspected ingestion, even if asymptomatic
- Plain AP and lateral neck/chest X-rays recommended first
- Radiolucent objects (e.g., plastic, wood) may require CT or contrast esophagram
Emergent removal required if:
- Button battery in esophagus (must remove within 2 hours)
- Signs of airway compromise
- Sharp object in esophagus or symptoms of perforation
Timing for removal
- Coins in the esophagus:
– <24 hrs: Urgent (but not emergent)
– 24 hrs: Removal is more urgent due to increased risk of ulceration and perforation
Post-removal follow-up
- Consider repeat imaging or endoscopy if:
- Symptoms persist
- Significant ulceration was seen
- Concern for stricture, fistula, or perforation
Multidisciplinary care
- GI, ENT, Radiology, and Pediatric Surgery should collaborate for complex cases, particularly if there’s:
- Delayed diagnosis
- Multiple objects
- Evidence of perforation or mediastinitis
References
- Kramer RE, et al. Management of ingested foreign bodies in children: Pediatrics. 2015;135(5):1172–1179.
- Lee JH. Foreign body ingestion in children. Clin Endosc. 2018;51(2):129–136.
