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Chapter 10: Foreign Bodies and Caustic Ingestion
4. Place Nasogastric Feeding Tubes under Supervision
Nasogastric feeding tubes may be placed during endoscopy. Placement
without direct supervision may increase the risk of a perforation.
5. Use Imaging
a. Radiographic Imaging
Radiographic imaging plays a minimal role in initial presentation. A
barium esophagram is inadequate to detect mucosal irregularities and
motility disturbances, leading to a significant false negative rate. It may
be used to rule out a suspected perforation, but should not replace an
endoscopic exam, unless the patient presented more than 48 hours
after the inciting event.
b. Nuclear Medicine
Nuclear medicine may be used in detecting esophageal injury after
pediatric ingestion. Technetium 99m-labeled sucralfate has high
sensitivity and specificity in determining the presence of an esophageal
injury, which allows for screening of injuries, but does not determine
severity or enable intervention.
6. Consider Endoscopy
a. Indications for Endoscopy
y
y
Endoscopy is recommended for any adult having ingested a strong
alkali or acid, regardless of the lack of presenting signs or symptoms.
y
y
Pediatric endoscopy can be reserved for children with significant oral
burns, dysphagia, or stridor. Studies have shown asymptomatic
children were not found to develop sequelae. However, if glucose test
tablets or a battery is suspected, the patient should be taken emer-
gently to the operating room, despite the absence of symptoms.
y
y
In children who lack a strong history and have only one presenting
sign or symptom, the risk of significant injury is low, and endoscopy
can be deferred or held, pending the results of a nuclear medicine
study. If a technetium 99m-labeled sucralfate study results in positive
findings, the patient should undergo endoscopy.
b. Timing of Endoscopy
In stable patients, upper endoscopy should be performed during the
first 24–48 hours after ingestion. The full extent of mucosal injury will
not be visible in the first 24 hours. After several days, necrotic tissue
sloughs off, the esophageal wall becomes weak, and the patient is at
higher risk of perforation during endoscopy or nasogastric tube
placement.