Presentation and Management of an Unusual Foreign Body Stone in a Child

Introduction

Children put almost everything into their mouths and swallow. The foreign body ingestions in children are common between the ages of 6 months to 3 years. Fortunately, most of the foreign bodies ingested pass through gastrointestinal tract spontaneously without any major complications.^1,2

Foreign body ingestion in children is accidental and mostly involves objects found in the home environment. Foreign bodies that are commonly ingested include coins, button batteries, toys, magnets, safety pins, screws, needles, marbles, stones, and bones.^3,5

There are variable presentations of foreign body ingestions and depends on the size, shape, location, and material of the foreign bodies. Usually, large sharp foreign bodies cause majority of the complications and morbidities.⁶

The common clinical presentation in patients with a foreign body ingestion includes abdominal or chest pain, dysphagia, drooling, vomiting, foreign body sensation, coughing, stridor, and anorexia. Major respiratory symptoms are more common for weeks or months after ingestion, that include stridor, fever, chest pain, wheezing, pneumonia, and hemoptysis.⁷

Esophageal foreign body presents with a sore throat, or difficulty in swallowing saliva or food, drooling, and foreign body sensation in the throat. If an esophageal foreign body is not passed spontaneously within 24 hours, it must be removed, suspecting the possibility of an anatomical anomaly or esophageal perforation.^8,9

Coins, button batteries, magnets, and sharp foreign bodies in the esophagus require an emergency removal within 2 hours if the child is symptomatic. In asymptomatic children, they may be removed within 24 hours.¹⁰

Here, we report an unusual case of a 5-month infant who presented with accidental ingestion of a sharp stone.

Case Report

A 5-month infant was brought with an alleged history of ingestion of a foreign body ie, sharp-edged stone of size 5 × 4 × 2 cm while playing. The infant’s mother noticed ingestion of the sharp-edged stone by the child and she tried to remove foreign body digitally from the mouth of the child, but it moved further inside the infant. The parents showed the child to a local doctor, and an X-ray test of the infant’s chest was done approximately 1 hour after the ingestion of the foreign body (Figure1). It showed a foreign body in the upper right chest near midline suggesting esophgeal perforation, and was referred to us. The child showed an excess salivation from the mouth with a good cry. There was no cough or strider and no respiratory distress. Repeat X-ray test of the chest after 6 hours of ingestion of the foreign body showed that the sharp-edged stone was being landed in the right pleural cavity in the chest (Figure 2). Hence, right thoracotomy was done under general anesthesia. There was a linear tear in the upper third of the thoracic esophagus due to a foreign body and it had landed into the right pleural cavity (Figure 3). It was a sharply pointed stone of size 5 × 4 × 2 cm, which was removed, and esophageal repair was done, intercostal drain was kept, and thoracotomy incision was closed. The child had uneventful post-operative period. Intercostal drain was removed on the 4th postoperative day, and the child was discharged on the 6th postoperative day. During the follow-up at 2 weeks, 1 month, and 3 months, the child was asymptomatic and with no complications.

Discussion

Foreign body ingestion events mostly occur in children between 6 months and 3 years of age.^1,2 The present case was of a 5-month-old infant. The majority of the ingested foreign bodies pass spontaneously through the gastrointestinal tract without complications; however, 10%-20% need endoscopic removal or a non-surgical intervention, and less than 1% will require surgery secondary to complications.^11,12 In our case, this infant was symptomatic and presented with complication of esophageal perforation.

In our study, plain X-ray test played an important role in identification of the location, size, and shape of the ingested foreign body. The X-ray test identification rate has ranged from 64%-96.04% in different reported studies.^10,13,14

Sharp foreign bodies, such as pins, screws, and needles can cause complications, such as esophageal perforation, trachea-fistula, peritonitis, aorto-esophageal fistula, and even death.^15,17 Sharp or pointed foreign bodies can cause perforation in 15%-35% of patients. As seen in this case, the sharp stone caused esophageal perforation. However, an early diagnosis and prompt operative removal reduced the complications related to the ingestion of sharp or pointed foreign bodies. Therefore, it is preferable to remove sharp foreign bodies from the esophagus or stomach as early as possible.¹⁷

There was no mortality seen in this case due to early diagnosis of the complication and early surgery. The prognosis of the foreign body ingestion in children is good with most patients who tolerate passage of ingested foreign body without intervention. Even if intervention is needed, mortality and morbidity are low.^1,17 Early recognition of foreign body ingestions and appropriate management can significantly reduce the morbidity due to complications.

Awareness of the parents and people involved in child care and active surveillance during daily activities is essential in order to keep hazardous materials out of the children’s reach.¹⁷

Conclusion

Early recognition of foreign body ingestions and its complications and appropriate early management can significantly reduce the morbidity and mortality.

Conflict of Interest

None.