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28 Esophagitis
• If the esophagus becomes scarred or develops strictures, endoscopically
guided esophageal dilatation may be necessary.
425
Disease Course
• Most cases of esophagitis from almost any cause will improve within several
weeks of initiation of appropriate treatment.
Related Evidence
Papers of particular interest have been highlighted as:
** Of key importance
Practice Guideline
Papadopoulou A, Koletzko S, Heuschkel R, Dias JA, Allen KJ, Murch SH, Chong
S, Gottrand F, Husby S, Lionetti P, Mearin ML, Ruemmele FM, Schäppi MG,
Staiano A, Wilschanski M, Vandenplas Y; ESPGHAN Eosinophilic Esophagitis
Working Group and the Gastroenterology Committee. Management guidelines
of eosinophilic esophagitis in childhood. J Pediatr Gastroenterol Nutr. 2014
Jan;58(1):107-18. https://doi.org/10.1097/MPG.0b013e3182a80be1. PMID:
24378521. http://www.ncbi.nlm.nih.gov/pubmed/24378521 **
ACG clinical guideline: Evidenced based approach to the diagnosis and manage-
ment of esophageal eosinophilia and eosinophilic esophagitis (EoE). Dellon ES,
Gonsalves N, Hirano I, Furuta GT, Liacouras CA, Katzka DA; American College
of Gastroenterology. Am J Gastroenterol. 2013 May;108(5):679-92; quiz 693.
https://doi.org/10.1038/ajg.2013.71. PMID: 23567357. http://www.ncbi.nlm.
nih.gov/pubmed/23567357 **
Review
Segal D, Chande N.The management of eosinophilic esophagitis in adults. J Clin
Gastroenterol. 2013 Aug;47(7):570-7. https://doi.org/10.1097/
MCG.0b013e318288a3c2. PMID: 23507765. http://www.ncbi.nlm.nih.gov/
pubmed/23507765
426
C. V. Pollack, Jr. et al.
Dellon ES. Eosinophilic esophagitis. Gastroenterol Clin North Am. 2013
Mar;42(1):133-53. https://doi.org/10.1016/j.gtc.2012.11.008. PMID: 23452635.
http://www.ncbi.nlm.nih.gov/pubmed/23452635
Rosoáowski M, Kierzkiewicz M.Etiology, diagnosis and treatment of infectious esoph-
agitis. Prz Gastroenterol. 2013;8(6):333-7. https://doi.org/10.5114/pg.2013.39914.
PMID: 24868280. http://www.ncbi.nlm.nih.gov/pubmed/24868280
Dellon ES. Eosinophilic esophagitis: diagnostic tests and criteria. Curr Opin
Gastroenterol. 2012 Jul;28(4):382-8. https://doi.org/10.1097/
MOG.0b013e328352b5ef. PMID: 22450900. http://www.ncbi.nlm.nih.gov/
pubmed/22450900 **
Liacouras CA, Furuta GT, Hirano I, Atkins D, Attwood SE, Bonis PA, Burks AW,
Chehade M, Collins MH, Dellon ES, Dohil R, Falk GW, Gonsalves N, Gupta
SK, Katzka DA, Lucendo AJ, Markowitz JE, Noel RJ, Odze RD, Putnam PE,
Richter JE, Romero Y, Ruchelli E, Sampson HA, Schoepfer A, Shaheen NJ,
Sicherer SH, Spechler S, Spergel JM, Straumann A, Wershil BK, Rothenberg
ME, Aceves SS.Eosinophilic esophagitis: updated consensus recommendations
for children and adults. J Allergy Clin Immunol. 2011 Jul;128(1):3-20.e6; quiz
21-2. https://doi.org/10.1016/j.jaci.2011.02.040. PMID: 21477849. http://www.
ncbi.nlm.nih.gov/pubmed/21477849 **
Canalejo Castrillero E, García Durán F, Cabello N, García Martínez J. Herpes
esophagitis in healthy adults and adolescents: report of 3 cases and review of the
literature. Medicine (Baltimore). 2010 Jul;89(4):204-10. https://doi.org/10.1097/
MD.0b013e3181e949ed. PMID: 20616659. http://www.ncbi.nlm.nih.gov/
pubmed/20616659
Noffsinger AE.Update on esophagitis: controversial and underdiagnosed causes. Arch
Pathol Lab Med. 2009 Jul;133(7):1087-95. https://doi.org/10.1043/1543-2165-
133.7.1087. PMID: 19642735. http://www.ncbi.nlm.nih.gov/pubmed/19642735 **
Orlando RC.Pathogenesis of reux esophagitis and Barrett's esophagus. Med Clin
North Am. 2005 Mar;89(2):219-41, vii. PMID: 15656926. http://www.ncbi.nlm.
nih.gov/pubmed/15656926
Case Study
Brnciü N, Mijandrusiü-Sinciü B, Viskoviü I. Candida esophagitis. Wien Klin
Wochenschr. 2005 Aug;117(15-16):520. PMID: 1616080. http://www.ncbi.nlm.
nih.gov/pubmed/16160801
Use PubMed Clinical Queries to nd the most recent evidence. Use this search
strategy:
“Esophagitis”[Mesh] OR “Esophagitis”
Chapter 29
Foreign Body Aspiration
CharlesV.Pollack,Jr., RichardM.Cantor, andVictoriaG.Riese
Name andSynonyms
Foreign Body Aspiration (esophageal/tracheal)
Incidence/Epidemiology
• Swallowed and inhaled foreign bodies both may cause chest pain with or
without shortness of breath.
• Both swallowed and inhaled foreign bodies are more common among young
children, but esophageal food bolus impaction may occur at any age and is
more common in the elderly, often presenting as chest pain.
• Foreign body aspiration may be life threatening at any age; cases in which
food is the aspirated agent are referred to as “café coronary.”
C. V. Pollack,Jr. ()
Department of Emergency Medicine, Thomas Jefferson University,
Philadelphia, PA, USA
R. M. Cantor
Department of Emergency Medicine and Pediatrics, State University of NewYork Upstate
Medical University, Syracuse, NY, USA
V. G. Riese
Librarian Consultant, Eldersburg, MD, USA
C. V. Pollack, Jr. (ed.), Differential Diagnosis of Cardiopulmonary Disease,
https://doi.org/10.1007/978-3-319-63895-9_29
427© Springer Nature Switzerland AG 2019
428
Symptoms can include choking, coughing, wheezing, upper airway obstructive breathing, and if severe,
cyanosis.
The foreign body can be lodged in the esophagus and compress the trachea, it can lie in the trachea
itself, or it can lie in a mainstem bronchus.
The foreign body may be of various materials, including chunks of food, pieces of toys, coins, and—worst
of all—a peanut, which may increase in size as it absorbs secretions.
Bronchoscopy usually is performed to remove the foreign body. The anesthetic plan must be tailored to
the type of foreign body and the amount of the patient’s distress.
Anesthetic induction: An inhalational technique may need to be performed to avoid muscle relaxation and
prevent the foreign body from changing position with relaxation. The dilemma is inducing the patient
having a full stomach with an inhalational technique. If intravenous access has been obtained, rapid
sequence induction may be considered; however, avoid cricoid pressure, which may compress the object
and cause tracheal or esophageal lacerations.
C. V. Pollack, Jr. et al.
Features associated with aspiration of a foreign body. This is a common emergency
situation in a child with a foreign body that becomes lodged in either the trachea or
the esophagus that can result in airway compromise. The patients undergo bronchoscopy to retrieve the foreign body and are generally kept spontaneously ventilating in order to remove the object. [Rasmussen G, Deshpande J.Pediatric anesthesia.
In: Muravchick S, editor. Subspecialty care. Philadelphia: Current Medicine; 1998.
236 p. (Miller RD editor, Atlas of anesthesia; vol. 5). ISBN: 0-443- 07905-6] Caption
from original
29 Foreign Body Aspiration
429
430
C. V. Pollack, Jr. et al.
Foreign bodies, sex, age and clinical manifestations of 121 cases with dangerous
esophageal foreign bodies. [Peng A, Li Y, Xiao Z, Wu W.Study of clinical treatment
of esophageal foreign body-induced esophageal perforation with lethal complications. Eur Arch Otorhinolaryngol. 2012 Sep;269(9):2027–36.] Caption from
original
Differential Diagnosis
• The differential diagnosis is limited in cases of acute presentation, because
the patient usually reports what has happened. Large foreign body aspiration
in an unresponsive patient may be identied during direct laryngoscopy for
rescue endotracheal intubation. Patients with an esophageal food bolus impaction may present with lower chest pain and retching, suggesting an atypical
acute coronary syndrome.
Pathophysiology andEtiology
• Foreign body aspiration in patients above toddler age generally is accidental.
Symptoms are driven by the size of the foreign body, which in turn determines
the location of “lodging.”
• Esophageal food bolus impaction generally is associated with inadequate
chewing and often occurs in the setting of concomitant alcohol consumption.
29 Foreign Body Aspiration
431
Esophageal foreign bodies. In the last several decades, endoscopy has become the
method of choice in the management of esophageal foreign bodies, although a trial
of sublingual nitroglycerin and intravenous glucagon is warranted. At times this will
allow the offending bolus to pass. The most common location of the impaction is the
distal esophagus at the level of the diaphragm; however, compressions at the level
of the cricopharyngeus, aortic arch, and left main-stem bronchus may also be the
site of impaction. It is also helpful to identify foreign bodies as sharp or dull, pointed
or blunt, and toxic or nontoxic (eg, batteries). Also, food-related impactions should
be distinguished. If the foreign body is known, invitro simulation may be helpful in
choosing the right accessory for use during the procedure. [Bozymski EM, Kenney
CM.Esophageal therapeutics. In: Orlando RC, editor. Atlas of esophageal diseases.
2nd ed. Philadelphia: Current Medicine; 2002. 248 p. ISBN: 1-57340- 181-1]
Caption from original
Type and location of esophageal foreign bodies. [Russell R, Lucas A, Johnson J,
Yannam G, Grifn R, Beierle E, Anderson S, Chen M, Harmon C.Extraction of
esophageal foreign bodies in children: rigid versus exible endoscopy. Pediatr Surg
Int. 2014 Apr;30(4):417–22.] Caption from original
Presentation
Typical/“Classic”
• Aspirated foreign bodies typically present as choking, coughing, and/or shortness of breath
432
• Dyspnea
• Audible wheezes may be present.
• Large proximal aspirated foreign bodies may present as cardiac arrest.
• Esophageal foreign bodies typically present as lower chest pain and an inability to swallow; the patient often is spitting out saliva.
• There often is a history of achalasia or previous similar episodes.
C. V. Pollack, Jr. et al.
Atypical
• Especially in children, no reliable history may be available, making the etiology of typical symptoms more obscure.
• Smaller aspirated foreign bodies may not cause symptoms until days or week
later, when secondary inammation or infection has developed.
Primary Differential Considerations
• For aspirated foreign bodies, consider:
• Epiglottitis
• Retropharyngeal or peritonsillar abscess
• Caustic ingestion
• Anxiety
• For esophageal foreign bodies, consider:
• Esophageal injury
• Anxiety (“globus hystericus”)
• Caustic ingestion
History andPhysical Exam
• Except in toddlers, the history usually is very helpful.
• On physical exam, assessing patency of the airway and adequacy of oxygenation is the priority.
Findings That Conrm Diagnosis
• Visualization of the foreign body
• History of aspiration and subsequent coughing/gagging/choking
29 Foreign Body Aspiration
• History of swallowing incompletely chewed food and subsequent inability to
handle oral secretions
Factors That Suggest Diagnosis
• Suggestive history
Factors That Exclude Diagnosis
• Clinically difcult to exclude, even with few symptoms; passage of time with
diminishing symptoms is helpful.
Ancillary Studies
Laboratory
433
• No diagnostic laboratory ndings
Electrocardiography
• Useful only if myocardial ischemia is a diagnostic consideration
Imaging
• Aspirated foreign bodies:
• Plain chest radiography may be helpful in patients with bronchial foreign
bodies, when asymmetric lung volumes may be appreciated.
• Chest CT may be helpful inlocalizing more distal foreign bodies.
434
C. V. Pollack, Jr. et al.
Radiographic ndings in patients with airway foreign body. [Jaswal A, Jana U,
Maiti PK. Tracheo-bronchial foreign bodies: a retrospective study and review of
literature. Indian J Otolaryngol Head Neck Surg. 2014 Jan;66(S1):156–60.] Caption
from original
Foreign body in right main bronchus. [Tsikoudas A, Sheikh S.An interesting case
of a wandering foreign body in the tracheobronchial tree. Eur Arch Otorhinolaryngol.
2005 May;262(5):426–7.] Caption from original