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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 5  |  Issue : 2  |  Page : 109-111

Trivial and fatal complications of esophageal foreign bodies in neonates


Division of Pediatric Gastroenterology, Department of Gastroenterology, PGIMER, Chandigarh, India

Date of Web Publication8-Apr-2016

Correspondence Address:
K P Srikanth
Division of Pediatric Gastroenterology, Department of Gastroenterology, PGIMER, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4847.161718

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  Abstract 

Esophageal foreign bodies in children are one of the most common GI emergencies and require prompt attention. Neonatal esophageal foreign bodies are relatively uncommon and pose significant challenge in detection and management, owing to lack of appropriate clinical history. We encountered two neonates with esophageal FBs, with a trivial dysphagia managed immediately with endoscopic retrieval and another case with multitude of complications, with critical illness. Absolute dysphagia, aspiration into respiratory tract, severe pneumonia, significant delay in detection and probably lack of awareness in primary care physician led to complications in second case. These cases highlight the importance of appropriate historical details and high index of suspicion in managing such patients.

Keywords: Anklet, dropper, esophagus, foreign body, neonate


How to cite this article:
Srikanth K P, Thapa B R, Chadha V, Menon J. Trivial and fatal complications of esophageal foreign bodies in neonates. J Clin Neonatol 2016;5:109-11

How to cite this URL:
Srikanth K P, Thapa B R, Chadha V, Menon J. Trivial and fatal complications of esophageal foreign bodies in neonates. J Clin Neonatol [serial online] 2016 [cited 2021 Apr 12];5:109-11. Available from: https://www.jcnonweb.com/text.asp?2016/5/2/109/161718


  Introduction Top


Ingestion of foreign bodies (FBs) in children is very common and they are the frequently encountered gastrointestinal (GI) emergencies in the pediatric age group. [1] Most of them pass out of their own without any squeal. Coin is the most common FB, followed by button battery, which can be lethal and end-up in devastating complications. In neonatal period these are very rarely reported. Usually, elder siblings are responsible for inserting FBs in the mouth of neonates and infants. We encountered two neonates with esophageal FB, in one neonate with medicine dropper in the esophagus, which is probably the first case of such radiolucent FB in the esophagus during 1 st week of life and in an another 20 days neonate with severe pneumonia subsequent to impacted radiopaque esophageal FB. These were endoscopically retrieved.


  Case Reports Top


Case 1

A 4-day-old male neonate, first in birth order from an affluent family presented to the pediatric gut clinic with an alleged history of medicine dropper being accidentally swallowed in while administering an antitussive medicine. The baby had difficulty in swallowing and there was drooling of saliva. Immediately after the ingestion the neonate was irritable, with mild respiratory difficulty and vomiting. Initially, neonate underwent chest radiograph, which did not reveal any FB as it was radiolucent. Computer tomography of the chest done prior to referral, revealed a homogenous double density in the upper part of the thoracic esophagus [Figure 1]. Neonate was started on intravenous fluid and referred to pediatric gastroenterology services after 24 h of ingestion. After written and informed consent in the prescribed format, FB was retrieved with video-flexible endoscope (Olympus; 150 series, 9 mm) using the rat tooth forceps under sedation with ketamine without any cardio-respiratory complications [Figure 2]. At the site of impaction, there was circumferential erosion. The procedure was uneventful, and the neonate was discharged on the same day after establishing the breastfeeding.
Figure 1: Computer tomography chest showing isodense shadow (arrow) in the upper esophagus

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Figure 2: Foreign body (medicine dropper) retrieved from the upper esophagus using rat tooth forceps

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Case 2

A 20-day-old male neonate presented with 3 days history of drooling of saliva, frothing in mouth, rapid breathing, excessive irritability, and seizures. During first 17 days of life, he was taken breastfeeding and never had similar problems. Before arriving at our institute child was managed at a community hospital where he was stabilized and intubated for the respiratory failure. On arrival at the pediatric emergency room, the baby was on bag and tube ventilation, with compensated shock; he was stabilized and continued on the mechanical ventilation. Examination revealed bilateral crackles and managed in the lines of pneumonia with severe sepsis. With adequate support, respiratory parameters improved over a period of 3 days and child was extubated. In order to initiate enteral nutrition, nasogastric tube insertion was attempted, however even on repeated attempts, tube coiled back to mouth, thus the possibility of esophageal stenosis, the web or a tracheoesophageal fistula was considered and child was subjected to upper GI nonionic contrast study, which revealed a radiopaque FB, partially obstructing the esophagus. Upper GI endoscopy with flexible video endoscope revealed radiopaque hangout of anklet in the upper esophagus, which was removed using rat tooth forceps under ketamine sedation without any cardio-respiratory complications. A chest skiagram done initially revealed a radiopaque FB in the upper part of the esophagus [Figure 3], but it was not recognized immediately. At the site of impaction, there were deep linear erosions, and, however, there was no evidence of perforation. Within 3 h feed was initiated without any choking or respiratory difficulty. Neonate is discharged from hospital after 24 h. On follow-up, both the neonates are asymptomatic and are growing well.
Figure 3: The radio opaque foreign body (anklet hangout) noted in the upper esophagus

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  Discussion Top


The occurrence of FB ingestion in neonates is very rare with only a few reported cases in the literature, and this can pose both diagnostic and therapeutic challenges. [2],[3],[4] FB in the esophagus is the most common pediatric GI emergency and need immediate attention and retrieval, otherwise leads to a multitude of complications such as dysphagia, ulceration, hemorrhage, and perforation of the esophagus. [5] Various types of FBs have been retrieved from the esophagus in the neonatal period and at times they are multiple. [6] The most common site of impaction being the upper part of the esophagus as in the index patients owing to the narrowness of the segment, however, there is no large data to prove this fact in neonates. The FBs in this population ranged from inert substances like a coin, cotton buds and jewelry to fatal articles such as button batteries, sharp objects like pin, screws, stone (pebble), etc. The radiopaque FBs can be easily detected by chest skiagram, but the radiolucent ones can be challenging and difficult to assess and interpret in the absence of appropriate history. One has to be vigilant about the nonaccidental ingestions in neonates and should initiate appropriate investigations when suspected. Various methods have been adopted in their retrieval, which include rigid endoscope, rigid bronchoscope, direct laryngoscopy and recently most of the retrievals, are being done using fiberoptic flexible endoscope, as it is easy in maneuvering in narrow space as was done in the present cases. [7] One has to be vigilant in the process, as impacted FBs would have breached the wall, leading to leakage of esophageal contents into the mediastinum or to the other adjacent organs, which may require open surgical intervention. Almost all the reported FB in neonate period has been removed endoscopically, only one case required surgical removal due to impaction. [8] To the best of our knowledge, this is the first case report of medicinal dropper being stuck in the esophagus, and the occurrence of severe pneumonia, respiratory failure and sepsis in second neonate due to aspiration.

The historical events, dysphagia and high index of suspicion gives a clue to early diagnosis. X-ray chest can pick up radiopaque FBs whereas radiolucent objects are missed, requiring water-soluble contrast study in such cases. Timely endoscopic intervention by an expert is the best choice in the neonatal period as exemplified by our cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Litovitz T, Schmitz BF. Ingestion of cylindrical and button batteries : a0 n analysis of 2382 cases. Pediatrics 1992;89:747-57.  Back to cited text no. 1
    
2.
Thapa BR, Kaur B, Nagi B, Dilawari JB. Unusual foreign body (stone) in the esophagus of a neonate mimicking tracheoesophageal fistula. Indian Pediatr 1993;30:943-5.  Back to cited text no. 2
[PUBMED]    
3.
Chowdhury CR, Bricknell MC, MacIver D. Oesophageal foreign body : a0 n unusual cause of respiratory symptoms in a three-week-old baby. J Laryngol Otol 1992;106:556-7.  Back to cited text no. 3
    
4.
Tasneem Z, Khan MA, Uddin N. Esophageal foreign body in neonates. J Pak Med Assoc 2004;54:159-61.  Back to cited text no. 4
    
5.
Pfau PR. Removal and management of esophageal foreign bodies. Tech Gastrointest Endosc 2014;16:32-9.  Back to cited text no. 5
    
6.
Medatwal A, Gupta PP, Gulati RK. Multiple foreign bodies in a neonate. Indian Pediatr 2008;45:928-30.  Back to cited text no. 6
    
7.
Tarnowska A, Roik D, Chmielik LP, Brzewski M. An unusual oesophageal foreign body in neonate - Case report. Pol J Radiol 2010;75:58-60.  Back to cited text no. 7
    
8.
Zameer M, Kanojia RP, Thapa BR, Rao KL. Foreign body oesophagus in a neonate : a0 common occurrence at an uncommon age. Afr J Paediatr Surg 2010;7:114-6.  Back to cited text no. 8
[PUBMED]  Medknow Journal  


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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