Corpi estranei ingeriti

Che cos'è un corpo estraneo ingerito?

Virtually any object small enough to pass through the pharynx may be swallowed.

The objects most frequently ingested by younger children are coins, but also include small toys, pencils, pen lids, button batteries, safety pins, needles, buttons and hairgrips. These are often radio-opaque.

Food-related items, such as chicken and fish bones, are more often ingested by older children and adults and tend to be radiolucent. It is rare to see adults with accidental non-food related foreign body ingestion - rarely, dentures can be swallowed. Intentional foreign body ingestion can occur in psychiatric patients, prisoners or "drug mules". ¹

Il tricobezoario è una rara condizione in cui l'ingestione di capelli porta alla formazione di una palla di capelli nello stomaco.

More than 80% of ingested foreign bodies will pass without any need for intervention. However, 10-20% will need endoscopic removal and up to 1% require surgical management. ¹

• Mouthing and tasting environmental objects is a normal developmental stage in young children and this can result in accidental ingestion. ²

• The ingestion of foreign bodies is most commonly a problem in young children aged 6 months to 3 years.² The most common age is between 1-2 years.

• Coins have been the foreign body most commonly ingested in infants and children but, with the reduction in coin usage, these have decreased and magnets have become more common. ²

• Si verifica molto meno frequentemente nei bambini più grandi e negli adulti, ma colpisce raramente anche questi gruppi. Di solito si verifica accidentalmente, ma può derivare da ingestione deliberata.

• I pazienti con malattie psichiatriche, o disabilità intellettiva, o coloro che sono prigionieri o sono 'corrieri della droga'/'body-packers' (coinvolti nel contrabbando di droghe illecite nascoste nel tratto gastrointestinale) sono inclini a problemi causati dall'ingestione intenzionale di corpi estranei.

• Data from the United States has shown an increase in foreign body ingestion in adults from 3 per 100,000 people to 5.3 per 100,000 between 1995 and 2017. 14% of these were reported to be deliberate and 86% accidental. ³

• A study in the United States showed that there are as many presentations to EDs with swallowed foreign bodies as there are presentations with STEMIs. ⁴

• This is highly variable and depends on whether it is a child or an adult. In children, the event is usually witnessed, or reported by the child.

• It is common for there to be no symptoms and for parents to bring in a child where they have witnessed the ingestion.

• Symptoms can include stridor, pain, drooling, fussiness, chest pain, abdominal pain, fever, feeding refusal, wheezing, and respiratory distress. ⁵

Corpi estranei orofaringei

• This is a common finding with coins or small toys being the most typical in children, and fish bones in adults. ⁶

• I pazienti di solito hanno una chiara sensazione di qualcosa intrappolato che è relativamente ben localizzato.

• There is usually discomfort which can range from mild to quite severe.

• Potrebbe essere presente salivazione e incapacità di deglutire.

• Il compromesso delle vie aeree può verificarsi se grandi oggetti sono intrappolati.

• Una presentazione ritardata con infezione o perforazione può verificarsi con oggetti estranei che rimangono bloccati a questo livello. ⁶

• However, complications are less common with foreign bodies in this region. ⁷
  

Corpi estranei esofagei

• Negli adulti, di solito si verifica una presentazione acuta dopo l'ingestione di un oggetto o di un alimento che rimane bloccato.

• Si tende ad avvertire una vaga sensazione di qualcosa bloccato al centro del petto o nella regione epigastrica, indicando che l'oggetto è probabilmente al livello dell'incrocio aortico o dello sfintere esofageo inferiore.

• Potrebbe esserci disfagia per il resto del pasto, provocando presentazione o accumulo/sbavamento di saliva se c'è un'ostruzione esofagea completa.

• I bambini con impatto esofageo tendono ad avere una presentazione meno chiara, anche se potrebbe esserci stato un evento di deglutizione osservato.

• Soffocamento, vomito, conati di vomito, dolore al collo e/o alla gola sono presentazioni più comuni nei bambini con corpi estranei esofagei.¹

Corpi estranei sottoesofagei

• Questi possono presentare una serie di sintomi, a seconda del grado di progressione del corpo estraneo attraverso l'intestino.

• Possono essere presenti sintomi vaghi, come distensione e disagio addominale, febbre, vomito ricorrente, emissione di sangue rettale/melena e/o altri sintomi di ostruzione intestinale acuta o subacuta.

Sintomi dovuti a perforazione gastrointestinale

• A foreign body can perforate the gastro-intestinal tract. This needs urgent referral for surgical assessment.

• Symptoms depend on where in the GI tract the perforation occurs.

• Bowel perforation tends to cause pain, frequently accompanied by a sensation of abdominal distension and bloating, often accompanied by nausea, vomiting, anorexia, fever, and obstipation. ⁸

• Pain can sometimes be followed by a pain-free interval followed by worsening pain again, representing decompression of an injured bowel segment immediately after the perforation. ⁸

• Gastric perforation most commonly results in abdominal distension and pain; other symptoms can include ileus, respiratory distress, fever, emesis, hematemesis, PR bleeding, refusal to feed, vomiting, and decreased activity. ⁹

• Oesophageal perforation from a swallowed foreign body is rare but critical and potentially life-threatening. It tends to cause acute mediastinitis with chest pain, dyspnoea, and severe odynophagia (pain associated with swallowing), along with signs of pneumonitis/pleural effusion.¹⁰

• Crepitus in the neck or chest walls is a sign of oesophageal perforation.

Esame del paziente con ingestione o intrappolamento di corpo estraneo certo o sospetto

Examination does not always result in clear findings but remains an important part of the assessment. Examination includes:

• Assessment of the airway and respiratory function to exclude or highlight any compromise.

• Checking the vital signs to exclude impending catastrophic presentation due to airway obstruction or acute GI perforation, or fever in case of delayed presentation.

• Examining the mouth and the oropharynx with a bright light.

• Gentle palpation of the neck to assess the tracheal position.

• Respiratory examination.

• Cardiovascular examination.

• Abdominal examination.

• Consideration of indirect laryngoscopy and/or fibre-optic examination of the pharynx - this is unlikely to be available in general practice but may be possible in an emergency care setting if the appropriate equipment and a sufficiently experienced practitioner is available.

• This clinical scenario is unlikely to be confused with another illness.

• There may be an underlying cause, for example a space-occupying oesophageal pathology - eg, carcinoma esofageo - 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.

• Una presentazione acuta di mediastinite può essere dovuta a perforazione da corpo estraneo ingerito, o alla forma primaria della malattia.

• Ascesso retrofaringeo can cause similar symptoms to impacted objects in the upper oesophageal area.

• Pneumomediastinum can present similarly, where there is a pneumotorace into the mediastinal portion of pleura.

• Underlying oesophageal conditions including eosinophilic oesophagitis (10% in adults, up to 50% in children), motility disorder, stenosis and diverticula are frequent. ¹

Gli esami del sangue sono solitamente poco utili, ad eccezione delle presentazioni croniche o dei pazienti febbrili in cui FBC/ESR possono fornire indizi utili sulla causa dei sintomi.

Radiografie semplici

• Plain x-rays remain a useful first-line imaging modality for suspected airway, oesophageal, or gastric foreign bodies. Metallic foreign bodies are readily visible and can be roughly localised on plain films, as can glass and even some plastic toys.²

Other imaging

• Contrast x-rays, CT scans, or MRI scans may be more useful than plain x-rays for visualisation of radiolucent objects.²

Studies have shown that most foreign bodies pass without the need for intervention. A study looking at 117 adults with ingested foreign bodies, where the most common foreign body was a razor blade, confirmed that size and sharpness of the foreign body was not a predictor for need for intervention.¹³

Studies have shown that removal of foreign bodies by experienced hands, at well-equipped endoscopy units and under conscious sedation, in most cases leads to high success rates, with complications (if they do occur) tending to be minor.¹⁴

Gestione delle emergenze

• Patients with airways obstruction should be seen urgently in ED.

• Agisci rapidamente per individuare e rimuovere qualsiasi corpo estraneo che possa causare un'ostruzione acuta delle vie aeree superiori.

• Quando l'ostruzione delle vie aeree è pericolosa per la vita e un corpo estraneo non può essere rimosso, ottenere urgentemente il parere di un senior del pronto soccorso/anestesista/otorinolaringoiatra e/o considerare la cricotirotomia come procedura salvavita.

• 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.¹¹

• Indications of the need for urgent transfer to hospital include:

  • Compromissione delle vie aeree.

  • Salivazione eccessiva.

  • Incapacità di deglutire i liquidi.

  • Sepsi.

  • Sospetto di perforazione intestinale.

  • Evidenza di sanguinamento attivo.

  • Storia chiara di ingestione di una batteria a bottone.

Gestione conservativa

• Stable patients who have swallowed small, smooth objects, who have no evidence of oesophageal entrapment, otherwise negative imaging, and 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. More than 75% of foreign bodies will pass spontaneously.²¹

• Patients who have swallowed items that are over 2.5 cm in diameter or 6 cm in length should be considered for endoscopy.¹⁵

• Button batteries seen in the oesophagus will need emergency removal as they often contain lithium and can cause serious harm or death within hours. ¹⁵

• Button batteries seen in the stomach or further along the gastro-intestinal tract may be suitable for observation.

• If more than one magnet has been ingested, or a magnet plus a metal object, then this will usually require an urgent endoscopy due to the risks of bowel necrosis.¹⁵ However, observation may sometimes be suggested.²

Gestione interventistica

Those with foreign objects lodged in the oesophagus will usually require some form of intervention to prevent ulceration and/or other complications; although options include endoscopy, laparoscopy, laparotomy and oesophagotomy, endoscopy is the most commonly used intervention.³

• Both flexible and rigid endoscopy remove oesophageal foreign bodies successfully.¹⁶

• Endoscopic removal of foreign bodies generally has a low probability of complications, including impaction, perforation and obstruction.¹⁷

• I pazienti adulti con intrappolamento esofageo di bolo alimentare o altri oggetti correlati al cibo dovrebbero essere considerati per un rinvio a un gastroenterologo, poiché vi è una significativa incidenza di lesioni esofagee come il carcinoma in questi pazienti.

• I pazienti con segni di ostruzione dell'intestino tenue o peritonite devono essere sottoposti a intervento chirurgico - l'endoscopia non dovrebbe ritardare l'intervento.

Traffico di droga

• Narcotic 'body packers'/'drug mules' should be followed up and monitored as inpatients due to the risk of drug toxicity.¹⁸ They may need surgical intervention if there is any evidence of systemic effects of leaking narcotics.^{19 20}
  

A 2019 retrospective review noted complications in 9% of paediatric cases.²¹

Corpi estranei orofaringei

• Graffi e lacerazioni della mucosa orofaringea.

• Perforazione.

• Ascesso retrofaringeo.

• Infezione dei tessuti molli o ascesso.

Corpi estranei esofagei

• Graffi, lacerazioni o abrasioni della mucosa.

• Oesophageal necrosis (typically seen in button batteries).

• Ascesso retrofaringeo.

• Stenosi esofagea.

• Perforazione esofagea e successivo ascesso paraesofageo.

• Mediastinite.

• Pneumotorace and/or pneumomediastinum.

• Pericardite/tamponamento cardiaco.

• Fistola tracheo-esofagea (soprattutto batterie a bottone ingerite nei bambini).

• Fistole aorto-esofagee o altre lesioni vascolari mediastiniche.

Corpi estranei gastrici/intestino tenue

• Entrapment of an object within a Diverticolo di Meckel.

• Perforazione che porta a peritonite e sepsi avanzata.

• Ostruzione intestinale acuta o subacuta dell'intestino tenue.

• Metal poisoning (monete).

• ²²On the whole, prognosis is good, especially with appropriate investigation, management, and follow-up.

• Complications are more likely in adults over the age of 50 years, impaction over 24 hours, bone-type foreign bodies, foreign bodies larger than 30mm, and impaction higher than the mid-oesophagus.¹

• It is difficult to prevent toddlers from examining things with their mouths as this is a normal and beneficial developmental stage. However, basic home-safety measures, such as cupboard catches and vigilance about not leaving small objects within children's reach, are helpful.

• Discussion with the parents of children who have swallowed foreign bodies is recommended to reduce the risk of repetition in the same child or siblings.