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PED-EM-L  September 2002

PED-EM-L September 2002

Subject:

Re: esophageal FB

From:

Marty <[log in to unmask]>

Reply-To:

Marty <[log in to unmask]>

Date:

Tue, 24 Sep 2002 13:46:15 -0500

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (141 lines)

I recently read Lance Brown's review of foreign bodies ( Brown L. , A
Literature Based Approach to the Identification and Management of Pediatric
Foreign Bodies, Pediatric Emergency Medciine reports, VOl 7 NO 9, Sept 2002,
in which he covers the evidence for these problems.  I highly reccomend
reading this over as it i does a nice job of summarizing the literature.

Take home points:
1. FB in the stomach pass 99% of the time in children with normal anatomy
2. Complications when they arise, are associated with esophageal fb's.
3. The higher the fb in the esophagus, the les likely it is to pass.

Regarding coins:
Nearly all coins pass the intestinal tract if they traverse the esophagus.
In Connors study , of 73 kids with E coins, 58 were middle or proximal,
underwent removal procedures. The 15 distal passed spontaneously. 5 were
asymptomatic at presentation.
Prolonged retention lead to esophageal ulceration, erosion or local swelling
noted in 7 who underwent endoscopic removal more than 64 hours after
ingestion. ( Connors GP, Chamberlain JM, Oscheschlager DW, Arch Pediatr
Adoles Med 1995; 149:36-39)

In a study of 116 e coins, 22% of proximal, 33% of middle and 37% of distal
e coins passed spontaneously within 24 hours. (Soprano JV, Fleisher GR,
Mandl KD, The Spontaneous Passage of esophageal coins in kids, Arch Pediatr
Adol Med 1999;153:1073-1076.

Basically, if Soprano is correct most coins in the esophagus do not pass on
their own if present in the ED>

The reccomendation based on the studies is that when an esophageal coin is
found on radiographic study, it be removed. Observation for distal coins for
up to 24 hours is reasonable as more than 33% of these do pass .

The home based study ( Connors, Am J Emerg Med 1995; 13: 638-640) flies in
the face of these reccomendations. In this study Connors reported as many as
85 % of coins ingestions may be managed at home without any untoward
results.  Maybe the patients presenting to an ED are different.

So, here in Memphis, we get an XRAY if a coin ingestion is suspected. If the
coin is proximal ( clavicle level) we do a blind foley extraction with the
patient unsedated. If the coin is middle or distal they are given ice chips
and some give Viscous Lidocaine 2% ( dose not to exceed 5 mg/kg or 1/4 ml
per kilo ). And repeat the imaging ( we have a protable C-arm in the ED
which allows us to snap a picture quickly and avoid the trip to the Rad
department.
If the coin is middle to distal  and does not pass with ice chips , we have
thep atient go home, and return in the AM. Most have passed by then. Some
require removal.
Of course, the patients has to be asymptomatic ( no pain, no drolling, no
airway distress) and the parents have to be able to return ( live close by,
have transportation)

I have not seen anyone develop airway distress during the observation
periods, if they were asymptomatic at presentation.

Hope this helps, though I am sure Greg can add much more having done the
research than I.

Martin Herman,M.D.


Martin I. Herman,MD,FAAP,FACEP


-----Original Message-----
From: Pediatric Emergency Medicine Discussion List
[mailto:[log in to unmask]]On Behalf Of Conners, Gregory
Sent: Tuesday, September 24, 2002 9:12 AM
To: [log in to unmask]
Subject: Re: [PED-EM-L] esophageal FB


"Airway problem" is pretty non-specific. I have looked pretty hard at the
literature, and have not found a single case of a child who has aspirated an
esophageal coin, whether symptomatic or asymptomatic. It is clear that
children may be asymptomatic but have an esophageal coin. It is likely that
children with previously occult/asymptomatic foreign bodies in the esophagus
can later develop respiratory problems, including partial airway
obstruction, as local swelling develops outside but near the airway, but
that is not something that happens either suddenly or in the first 8-12
hours. If you look in the literature for kids who were truly documented to
be asymptomatic initially then later developed important problems that would
not have been picked up by informed parents, they are very rare indeed. That
is why many primary care physicians and many poison control centers feel
safe in instructing families about observing (otherwise healthy) children
who are asymptomatic after coin ingestion, at home. When my colleagues and I
gathered data from 67 asymptomatic coin-swallowing children who had been
managed by 5 New York state poison control centers using that strategy, we
found on phone follow-up that 66 were fine 6 months - 3 years later, and
that one had developed GI type symptoms the next day, and had a coin
appropriately removed from the esophagus. This suggests the safety of that
strategy, but certainly cannot be said to prove it. Ref: Conners GP, Cobaugh
DJ, Feinberg R, Lucanie R, Caraccio T, Stork CM. Home observation for
asymptomatic coin ingestion:  acceptance and outcomes. Acad Emerg Med
1999;6:213-217.

I personally do not admit kids while waiting for a coin to pass into the
stomach from the distal esophagus unless I am uncertain about their parents'
ability to observe or their willingness to follow-up. However, I have found
that giving a drink of water in the ED may resolve the problem; even if it
does not, water in the stomach should not delay a removal procedure very
long. I personally do not wait for coins to spontaneously pass from the
proximal or middle esophagus.

Greg Conners MD MPH
University of Rochester


> ----------
> From:         Maureen McCollough Hill[SMTP:[log in to unmask]]
> Reply To:     Maureen McCollough Hill
> Sent:         Monday, September 23, 2002 4:52 PM
> To:   [log in to unmask]
> Subject:      esophageal FB
>
> we may have had this discussion before.   has anyone heard of a child
> developing an airway problem who originally had an ASYMPTOMATIC
> esophageal coin FB  that was allowed to be observed for 8-12 hrs to see
> if it passes??   one study from NY poison center followed asymptomatic
> kids by phone for 6 months who had swallowed a coin.  Some were probably
> initially in the esophagus and passed on their own.     and if you
> observe these kids, do you admit them??
>
> thanks,
> maureen
>
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>   http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html
>

For more information, send mail to [log in to unmask] with the
message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
  http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html

For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
  http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html

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