The difficulty identifying unknown swallowed foreign bodies on plain X-ray

Article Outline

• Summary
• Introduction
• Case report
• Discussion
• References
• Copyright

Summary 

We highlight a case report, where a child was delayed surgical removal of a battery from their oesophagus, due to mis-interpretation of an ‘unknown’ foreign body on plain radiography.

Keywords: Oesophageal foreign body, Coins, Button battery

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Introduction 

Swallowed foreign bodies in children are a common problem [2], [3]. These patients require prompt diagnosis and therapy [1] to reduce morbidity and mortality. The commonest foreign body swallowed by children are coins [2]. Patients who have ingested a sharp object or button batteries require urgent treatment due to the increased risk of complications [1]. Waltzman et al. [3] performed a randomised clinical trial of the management of oesophageal coins. They found that 25–30% of oesophageal coins in children would pass spontaneously without complications. These patients may be initially managed by an observational period in the range of 8–16h.

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Case report 

A 10-month-old child admitted under the paediatric team with a 1-week history of persistent wheeze. She had no known airway disease and did not respond to bronchodilator therapy. The paediatricians ordered a chest X-ray that revealed a circular opacity in the superior mediastinum (Fig. 1).

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• Figure 1. 

  Chest X-ray where battery was mis-interpreted as a coin.

That evening (11p.m.) the child was referred to the ENT on call team with a ‘pound coin’ lodged in the upper oesophagus. There was concern that the foreign body was exerting external pressure on the trachea causing the wheeze.

On examination the child was upset but all observational parameters were in normal range. The wheeze was not clinically audible. In view of the above, a decision was made to list the child as the first case on the emergency operating list the following morning. The child had an uneventful night.

Rigid pharyngosocopy revealed a button battery lodged in the upper oesophagus. There was evidence of erosion of the oesophageal mucosa, which made extraction difficult.

The child made an uneventful recovery after one night on the PICU and five nights on the paediatric surgical ward.

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Discussion 

The case demonstrates two important lessons. Firstly it points out the difficulty in identifying the character of a foreign body based on plain radiography. If the history is unclear, one should consider the worst-case scenario to avoid potential life threatening complications. Secondly it highlights the importance of including the neck in any imaging of a child with wheezing that does not respond to medical therapy to exclude a foreign body. Lateral chest radiography is also a useful adjunct. It will help determine the position of any foreign body in the mediastinum and would rule out the possibility of a further foreign body lying in the same plane.

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References 

1. Smith MT, Wong RK. Esophageal foreign bodies: types and techniques for removal. Curr. Treat Options Gastroenterol. 2006;9(1):75–84
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2. Okoye IJ, Imo AO, Okwulehie V. Radiologic management of impacted coin in the oesophagus—A case report. Niger. J. Clin. Pract. 2005;8(1):56–59
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   • MEDLINE
3. Waltzman , et al. A randomized clinical trial of the management of esophageal coins in children. Paediatrics. 2005;116(3):752–753
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