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Is ultrasound useful in detection and follow-up of gastric foreign bodies in children?
Clinical Imaging 37 (2013) 1043–1047
Contents lists available at ScienceDirect
Clinical Imaging journal homepage: http://www.clinicalimaging.org
Is ultrasound useful in detection and follow-up of gastric foreign bodies in children? Mihajlo Jecković a,⁎, Sudha A. Anupindi b, Svetlana Balj Barbir a, Jovan Lovrenski a a b
Institute for Children and Youth Health Care of Vojvodina, Department of Radiology, Hajduk Veljkova 10, 21000 Novi Sad, Serbia The Children's Hospital of Philadelphia, University of Pennsylvania Perleman School of Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA
a r t i c l e
i n f o
Article history: Received 5 March 2013 Received in revised form 30 June 2013 Accepted 1 August 2013 Keywords: Child Foreign body Gastric foreign body Ultrasound
a b s t r a c t Objective: The objective was to show potential value of ultrasound in detection and follow-up of gastric foreign bodies. Material and methods: Medical records of 18 children with gastric foreign bodies were evaluated retrospectively. Results: The following gastric foreign bodies were identified: eight coins, five button batteries, domino, lollipop stick, hairclip, screw nut, and small plastic cylinders. All were confirmed by ultrasound. The batteries, domino, and two coins were removed endoscopically, the screw nut was removed surgically, while the rest were recovered in the stool. Conclusions: Ultrasound examination of water-filled stomach can be useful in diagnostic workup of gastric foreign bodies in children, especially radiolucent ones. © 2013 Elsevier Inc. All rights reserved.
1. Introduction
2. Material and methods
Young children accidentally swallow small objects, particularly parts of toys. Most swallowed foreign bodies (FBs) pass harmlessly through the gastrointestinal tract, but some of them can become lodged or have associated damage locally to the surrounding structures. At times, the outcome can be devastating especially in situations where the FB is toxic. These FBs must be identified and removed as soon as possible [1]. The diagnosis is usually made by plain film radiography where radiopaque FBs are easily seen and results in prompt treatment and intervention, if necessary. However, when the FB is not visible on radiography, ultrasound (US) can be very helpful. Ultrasonography can be performed quickly, inexpensively, with the least discomfort to the child and has been proven as an appropriate technique in identifying the type of FB and its location [2]. More specifically, US may be potentially an effective method of evaluation in the follow-up of gastric FBs, obviating the need for serial radiographs and thereby reducing radiation exposure in children. The aim of this retrospective study is to report our experience of using US to detect and follow-up gastroduodenal FBs in children and to show the potential value of this method. To date, our series is one of the largest as the current pediatric imaging literature is comprised of mostly case reports.
This was a retrospective study of children in whom a gastric FB was found with radiography or US in the Institute for Children and Youth Health Care between January 1, 2010, and October 31, 2011. This study complied with the institutional review board criteria. After clinical examination, depending on the symptoms and clinical data, all children suspected of having swallowed an FB were sent for a radiograph of the abdomen and/or chest. Abdominal US examination was performed in all patients suspected of having FB located in the stomach, at the time of presentation, using Sonoline Adara and Accuson X 300 (Siemens, Erlangen, Germany) Ultrasound System with a 5–10 MHz linear transducer and 2.5–6 MHz convex transducer. In most cases, children had ingested water before or during the US examination in order to get the appropriate acoustic window for FB visualization. The examinations were performed with the patients in the incomplete right decubitus position. In this way, water together with the FB moves into the distal body of the stomach and antrum, so the FB is directly visualized. Color Doppler was not used in these US examinations unless a mural abnormality was noted. Once the FB was confirmed, US examinations were repeated every other day to see if the FB left the stomach, except in the case of button batteries that were removed immediately. The stool of each subject was checked daily to confirm if the FB passed. If an FB did not empty from the stomach within 7 days, the consulting gastroenterologist and/or surgeon would decide whether to wait for passage of FB via stool or there is need for endoscopic or surgical removal. All medical and surgical records for each patient were reviewed for demographics, type of imaging study, type of FB ingested, method of removal, and any complications of procedures performed. The USs were reviewed by two radiologists in consensus and analyzed for the
⁎ Corresponding author. Institute for Children and Youth Health Care of Vojvodina, Department of Radiology, Hajduk Veljkova 10, 21000 Novi Sad, Serbia. Tel.: + 381641147144. E-mail address: [email protected] (M. Jecković). 0899-7071/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.clinimag.2013.08.004
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following: location, size and number of the FB, echogenicity and configuration of FB, and finally the integrity of the gastric wall for signs of perforation such as free fluid or free air.
3. Results Our study population included a total of 18 patients, 10 male and 8 female patients. The mean age of the children was 2 years (range of 8 months to 7 years). All children were cognitively and developmentally normal. Gastric FBs were confirmed in all patients by US. The following FBs were identified: coins n= 8 (Fig. 1), button batteries n= 5 (Figs. 2 and 3), domino n= 1 (Fig. 4), lollipop stick n= 1 (Fig. 5), hairclip n=1 (Fig. 6), screw nut n= 1 (Fig. 7), and multiple small plastic cylinders n= 1 from a toy (Fig. 8). The majority of ingested FBs were radiopaque and easily identified on abdominal radiography. However, three of the FBs, the lollipop stick, the domino, and the plastic toy pieces, were radiolucent and not detected on the radiographs. All of the FBs, including the radiolucent ones, were identified in the stomach using US. In general, on US, the FBs were depicted by a distinct appropriate shape, usually elongated, tubular appearing, with hyperechoic edges and central hypoechoic areas. The appearance of button battery and coin was quite similar on US imaging, with little or no differentiating features. If a perpendicular angle of approach of the US beam was achieved to the plane of the coin or button battery surface, each appeared as hyperechoic straight lines with posterior acoustic shadowing (Figs. 1 and 2). If a coin or battery was turned at an angle to the US beam, they were seen as two curved, parallel, hyperechoic lines, which represented the outline of a coin or outline of a button battery (Fig. 3). The button batteries were more easily recognized on the radiographs. The numerous small plastic parts presented as multiple hypoechoic small particles with the shape of rice grains (Fig. 8). The threads of the metal screw were seen as a series of parallel hyperechoic lines (Fig. 7). The number and distribution of different FBs in our patients are summarized in Table 1. There was no perigastric fluid, free fluid, loss of integrity of the stomach wall, gastric wall thickening, or free air in any of the cases. The different FBs were removed either endoscopically or surgically, or passed with the feces. All batteries were removed endoscopically right away (on the day of ingestion). In the one case of button battery in our study group, on endoscopy, erosive changes and mucosal ulcers
Fig. 1. Ultrasound image of perpendicularly affected coin in the stomach (a). Photo of coin with actual measurement (b).
Fig. 2. Perpendicular angle of approach of the US beam to the button battery surface, with its appearance as hyperechoic straight lines (arrow) with posterior acoustic shadowing.
were noted in esophagus (Fig. 9). For all of the rest of the FBs removed endoscopically, there was no inflammation noted at the time of the scope. The domino was removed endoscopically 10 days after ingestion. Six coins were found in the stool 3 to 7 days after swallowing,
Fig. 3. Ultrasound image of a button battery turned at an angle to the US beam, shown as two curved, parallel, hyperechoic lines (arrows) (a); photo of endoscopically removed button battery (b).
M. Jecković et al. / Clinical Imaging 37 (2013) 1043–1047
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Fig. 6. Ultrasound transverse image of the stomach with the hairclip inside (arrows) (a) and photo of the hairclip (b).
day after ingestion. The average hospital length of stay for these children was 1.5 days. There were no complications in our study group.
4. Discussion
Fig. 4. Ultrasound images of the wider (a) and narrower (b) surface of the domino (arrows) inside the water-filled stomach.
and two coins were removed endoscopically after 2 weeks. The screw nut was removed surgically after 15 days. The lollipops stick was recovered in the stool 3 days after ingestion, the hairclip after 5 days and the plastic cylinders passed with the feces on the third and fourth
Foreign body ingestion is relatively common and a potentially serious problem in the pediatric population. According to literature, the peak age for FB ingestion is in preschool years, most commonly children aged 6 months to 3 years, with almost equal frequency in boys and girls [1,3]. This was confirmed in our study. This is the oral developmental period when children explore their surroundings. This often leads to the accidental swallowing of the object being explored [1,4]. It is also important to note that FB ingestion can be associated with developmental delay or cognitive impairment
Fig. 5. Ultrasound images of the lollipops stick (arrows) before (a) and after the filling of the stomach with water (b); photo of the lollipops stick (c).
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Fig. 7. Ultrasound view of the metal screw nut shown as hyperechoic structure (arrow), with posterior acoustic shadowing (a), and the photo of the same one (b).
among all ages [1,5]. In our study, all children were developmentally normal, and no child had autism, mental retardation, or any other comorbid condition. Children can swallow a full spectrum of different FBs. The most common FB we saw in our group was the coin, and the second most frequent were the button batteries. It is interesting to say that small flat batteries are more often swallowed by younger children (8 months–2 years) which, to the parent’s surprise, they easily find and remove from a toy. Coins, on the other hand, are more commonly swallowed among children ages 2–4 years of life. In daily clinical practice, we see a greater number of children who swallow coins, but larger coins usually get stuck in the proximal esophagus, which is not accessible to direct US investigation. We have therefore focused on the FBs that are smaller and easily visible in the stomach. Button batteries require special attention because they are prone to complications, especially when lodged in the esophagus, as they may leak the concentrated hydroxides and cause a focal caustic burn and eventually a perforation of the esophagus. Similar injuries caused by button batteries in the stomach or lower gastrointestinal tract
Fig. 8. A large number of small plastic parts of toy presented on US as multiple hypoechoic small particles with the shape of rice grains.
are very unusual, but their prompt removal must be ensured in any case since a recent in vitro study suggested that button butteries in the presence of stomach acid, even for several hours, may begin to dissolve and release their potentially toxic contents [1,2,4,5]. Considering this, as a precaution, all ingested button butteries in our patients were immediately removed endoscopically. The confirmation by US that the battery is in the stomach and therefore within the reach of an endoscope can be very useful. Because button batteries can mimic coins on US, radiographs should be used in conjunction with US to make a prompt diagnosis to prevent devastating consequences. Traditionally, children are referred for radiography to confirm and localize ingested FBs [6]. If the ingested object is radiopaque, radiography is an effective diagnostic method. However, in case of a radiolucent FB, a radiograph may be nondiagnostic. Obtaining a contrast-enhanced radiographic study may help in this situation, although some experts, because of risk of aspiration, recommend endoscopy rather than a contrast study [1,3]. Often, serial follow-up films are necessary to determine whether the FB has left the stomach and if it is progressing satisfactorily in an antegrade fashion. This increases the amount of radiation received by the patient [2]. Another limitation of radiography is that the exact location of the FB can be difficult to determine because of superimposed loops of bowel, particularly superimposed over the stomach [6]. Because radiographs expose children to ionizing radiation and are an added cost, limiting the number of radiographs in the evaluation of FB is an important consideration [1]. Recently, US has been proven useful in the diagnosis of all FBs, including radiolucent ones, retained in the superficial soft tissues and in the parenchymal organs [7–10]. Currently, the publications in the pediatric imaging literature have been limited to primarily case reports. The role of US in the investigation of gastric FBs and its usefulness in preoperative localization of FB position have also been reported [2,6,11–13]. Our modestly larger series shows how US is uniquely valuable for this purpose in pediatric cases and has several advantages including lack of radiation burden, reproducibility, and being inexpensive. There are also some advantages of US imaging of gastric FB in children compared with adults. A child’s relatively small size allows the use of high-frequency transducers with good resolution, and because of the lack of subcutaneous fat, there are minimal reverberation artifacts that usually cause degradation of the US images [6]. Besides being safer and repeatable, US depicts FBs of any nature as hyperechoic structures. Preexamination ingestion of water facilitates the US visualization of FBs in the stomach because it reduces air artifacts. Visibility depends on the size of the object and is optimum when the long axis of the object is perpendicular to the US beam [2]. The perpendicular or near-perpendicular angle of approach to the surface of an FB provides a strong reflection back to the transducer and also produces a reverberation artifact, which are both helpful in identifying the object [6]. The presence of acoustic shadowing is variable and depends on the composition of the FB and the incidence of the beam. The comet-tail artifact is characteristic of metallic objects [2]. The role of color Doppler in the evaluation of FB is unclear as we did not routinely apply it in our US examinations. However, it may be useful in assessing acute inflammation when there is gastric or duodenal wall thickening. Generally, the majority of ingested FBs pass through the gastrointestinal tract without a problem, although serious complications such as bowel perforation, obstruction, or erosion into adjacent organs can occur. However, less than 1% of FB ingestions cause serious morbidity [3,5,14]. Patients who have swallowed blunt, radiopaque objects are usually followed with weekly radiography, and parents are instructed to watch for the passage of the object in stool. Most objects will pass within 4 to 6 days of ingestion, but some may take up to 4 weeks. Endoscopic or surgical intervention is recommended when significant symptoms develop or if the object fails to progress through the gastrointestinal tract in 3 to 4 weeks. It is recommended that
M. Jecković et al. / Clinical Imaging 37 (2013) 1043–1047
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Table 1 The distribution of FBs in different age groups Age groups
8–18 months 18 months–4 year 5–7 years Total
Types of ingested FBs Coins
Battery
Domino
1 7
2 3
1
8
5
1
Hairclip
Plastic cylinders
1
1
1
1
Screw nut
1 1
Lollipop stick
1 1
Total patients
4 12 2 18
characterizing the FB. In addition, there is variability in the reported time period when the FBs passed as this is dependent on the recall of the caregiver of the child. In conclusion, our study suggests that water-filled stomach US, as a radiation-free imaging modality, might have a significant role in the diagnostic workup of swallowed FBs in children, especially radiolucent ones. However, it is necessary to conduct a more extensive study to define whether US of gastric FBs can be used as an equally efficient tool as radiographs in everyday clinical practice.
References
Fig. 9. The endoscopy picture of erosive changes and ulcerations of esophageal mucosa after button battery ingestion.
sharp objects should be removed endoscopically before they have passed beyond the duodenal curve because they are more likely to cause complications. Sharp objects that cannot be removed endoscopically are considered for surgical removal if the object remains in the same location for 3 days [3]. In our study, the screw nut was beyond the reach of the endoscope and was removed surgically 15 days later after swallowing because of its size, lack of progression, and potential risk of complication. Besides the button batteries, as mentioned before, the domino and two coins were also removed endoscopically because they did not pass out of the stomach within a 2-week period. All others FBs passed without difficulties and were found in the stool within 1 week from ingestion. There were limitations of the study which included small sample size and operator technique differences when performing the US and
[1] Conners GP. Foreign body ingestions: managing the vast array of objects children swallow. Pediatric Emergency Medicine Practice [serial on the Internet]. 2005 Jun [cited 2012 January 29]; 2(6):[about 20 p.]. Available from: https://www. ebmedicine.net/topics.php?paction=dLoadTopic&topic_id=162 [2] Spina P, Minniti S, Bragheri R. Usefulness of ultrasonography in gastric foreign body retention. Pediatr Radiol 2000;30:840–1. [3] Uyemura MC. Foreign body ingestion in children. Am Fam Physician 2005;72: 287–91. [4] Melek M, Cobanoglu U, Bilici S, Beger B, Kizilyidiz BS, Melek Y. Management and treatment of foreign bodies ingestion in childhood. East J Med 2011;16: 194–8. [5] Hunter TB, Taljanovic MS. Foreign bodies. Radiographics 2003;23:731–57. [6] Piotto L, Gent R, Kirby CP, Morris LL. Preoperative use of ultrasonography to localize an ingested foreign body. Pediatr Radiol 2009;39:299–301. [7] Chau WK, Lai KH, Lo KJ. Sonographic findings of intraabdominal foreign bodies due to retained gauze. Gastrointest Radiol 1984;9:61–3. [8] Gooding GAW. Ultrasonography of foreign bodies. WJM 1994;160(5):455. [9] Graham DD. Ultrasound in the emergency department: detection of wooden foreign bodies in the soft tissues. J Emerg Med 2002;22(1):75–9. [10] Suri A, Singh KJ, Nagpal BM, Satija L, Debnath J, Sahni L. Foreign body needles in liver and abdominal wall. MJAFI 2000;56(3):250–1. [11] Coulier B. Diagnostic ultrasonography of perforating foreign bodies of the digestive tract. J Belge Radiol 1997;80(1):1–5. [12] Drakonaki E, Chatzioannou M, Spiridakis K, Panagiotakis G. Acute abdomen caused by a small bowel perforation due to a clinically unsuspected fish bone. Diagn Interv Radiol 2011;17:160–2. [13] Rioux M, Langis P. Sonographic detection of clinically unsuspected swallowed toothpicks and their gastrointestinal complications. J Clin Ultrasound 1994;22(8): 483–90. [14] Moorjani V, Wong C, Lam A. Ingested foreign body mimicking an appendicolith in a child. Br J Radiol 2006;79:173–4.
Contents lists available at ScienceDirect
Clinical Imaging journal homepage: http://www.clinicalimaging.org
Is ultrasound useful in detection and follow-up of gastric foreign bodies in children? Mihajlo Jecković a,⁎, Sudha A. Anupindi b, Svetlana Balj Barbir a, Jovan Lovrenski a a b
Institute for Children and Youth Health Care of Vojvodina, Department of Radiology, Hajduk Veljkova 10, 21000 Novi Sad, Serbia The Children's Hospital of Philadelphia, University of Pennsylvania Perleman School of Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA
a r t i c l e
i n f o
Article history: Received 5 March 2013 Received in revised form 30 June 2013 Accepted 1 August 2013 Keywords: Child Foreign body Gastric foreign body Ultrasound
a b s t r a c t Objective: The objective was to show potential value of ultrasound in detection and follow-up of gastric foreign bodies. Material and methods: Medical records of 18 children with gastric foreign bodies were evaluated retrospectively. Results: The following gastric foreign bodies were identified: eight coins, five button batteries, domino, lollipop stick, hairclip, screw nut, and small plastic cylinders. All were confirmed by ultrasound. The batteries, domino, and two coins were removed endoscopically, the screw nut was removed surgically, while the rest were recovered in the stool. Conclusions: Ultrasound examination of water-filled stomach can be useful in diagnostic workup of gastric foreign bodies in children, especially radiolucent ones. © 2013 Elsevier Inc. All rights reserved.
1. Introduction
2. Material and methods
Young children accidentally swallow small objects, particularly parts of toys. Most swallowed foreign bodies (FBs) pass harmlessly through the gastrointestinal tract, but some of them can become lodged or have associated damage locally to the surrounding structures. At times, the outcome can be devastating especially in situations where the FB is toxic. These FBs must be identified and removed as soon as possible [1]. The diagnosis is usually made by plain film radiography where radiopaque FBs are easily seen and results in prompt treatment and intervention, if necessary. However, when the FB is not visible on radiography, ultrasound (US) can be very helpful. Ultrasonography can be performed quickly, inexpensively, with the least discomfort to the child and has been proven as an appropriate technique in identifying the type of FB and its location [2]. More specifically, US may be potentially an effective method of evaluation in the follow-up of gastric FBs, obviating the need for serial radiographs and thereby reducing radiation exposure in children. The aim of this retrospective study is to report our experience of using US to detect and follow-up gastroduodenal FBs in children and to show the potential value of this method. To date, our series is one of the largest as the current pediatric imaging literature is comprised of mostly case reports.
This was a retrospective study of children in whom a gastric FB was found with radiography or US in the Institute for Children and Youth Health Care between January 1, 2010, and October 31, 2011. This study complied with the institutional review board criteria. After clinical examination, depending on the symptoms and clinical data, all children suspected of having swallowed an FB were sent for a radiograph of the abdomen and/or chest. Abdominal US examination was performed in all patients suspected of having FB located in the stomach, at the time of presentation, using Sonoline Adara and Accuson X 300 (Siemens, Erlangen, Germany) Ultrasound System with a 5–10 MHz linear transducer and 2.5–6 MHz convex transducer. In most cases, children had ingested water before or during the US examination in order to get the appropriate acoustic window for FB visualization. The examinations were performed with the patients in the incomplete right decubitus position. In this way, water together with the FB moves into the distal body of the stomach and antrum, so the FB is directly visualized. Color Doppler was not used in these US examinations unless a mural abnormality was noted. Once the FB was confirmed, US examinations were repeated every other day to see if the FB left the stomach, except in the case of button batteries that were removed immediately. The stool of each subject was checked daily to confirm if the FB passed. If an FB did not empty from the stomach within 7 days, the consulting gastroenterologist and/or surgeon would decide whether to wait for passage of FB via stool or there is need for endoscopic or surgical removal. All medical and surgical records for each patient were reviewed for demographics, type of imaging study, type of FB ingested, method of removal, and any complications of procedures performed. The USs were reviewed by two radiologists in consensus and analyzed for the
⁎ Corresponding author. Institute for Children and Youth Health Care of Vojvodina, Department of Radiology, Hajduk Veljkova 10, 21000 Novi Sad, Serbia. Tel.: + 381641147144. E-mail address: [email protected] (M. Jecković). 0899-7071/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.clinimag.2013.08.004
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following: location, size and number of the FB, echogenicity and configuration of FB, and finally the integrity of the gastric wall for signs of perforation such as free fluid or free air.
3. Results Our study population included a total of 18 patients, 10 male and 8 female patients. The mean age of the children was 2 years (range of 8 months to 7 years). All children were cognitively and developmentally normal. Gastric FBs were confirmed in all patients by US. The following FBs were identified: coins n= 8 (Fig. 1), button batteries n= 5 (Figs. 2 and 3), domino n= 1 (Fig. 4), lollipop stick n= 1 (Fig. 5), hairclip n=1 (Fig. 6), screw nut n= 1 (Fig. 7), and multiple small plastic cylinders n= 1 from a toy (Fig. 8). The majority of ingested FBs were radiopaque and easily identified on abdominal radiography. However, three of the FBs, the lollipop stick, the domino, and the plastic toy pieces, were radiolucent and not detected on the radiographs. All of the FBs, including the radiolucent ones, were identified in the stomach using US. In general, on US, the FBs were depicted by a distinct appropriate shape, usually elongated, tubular appearing, with hyperechoic edges and central hypoechoic areas. The appearance of button battery and coin was quite similar on US imaging, with little or no differentiating features. If a perpendicular angle of approach of the US beam was achieved to the plane of the coin or button battery surface, each appeared as hyperechoic straight lines with posterior acoustic shadowing (Figs. 1 and 2). If a coin or battery was turned at an angle to the US beam, they were seen as two curved, parallel, hyperechoic lines, which represented the outline of a coin or outline of a button battery (Fig. 3). The button batteries were more easily recognized on the radiographs. The numerous small plastic parts presented as multiple hypoechoic small particles with the shape of rice grains (Fig. 8). The threads of the metal screw were seen as a series of parallel hyperechoic lines (Fig. 7). The number and distribution of different FBs in our patients are summarized in Table 1. There was no perigastric fluid, free fluid, loss of integrity of the stomach wall, gastric wall thickening, or free air in any of the cases. The different FBs were removed either endoscopically or surgically, or passed with the feces. All batteries were removed endoscopically right away (on the day of ingestion). In the one case of button battery in our study group, on endoscopy, erosive changes and mucosal ulcers
Fig. 1. Ultrasound image of perpendicularly affected coin in the stomach (a). Photo of coin with actual measurement (b).
Fig. 2. Perpendicular angle of approach of the US beam to the button battery surface, with its appearance as hyperechoic straight lines (arrow) with posterior acoustic shadowing.
were noted in esophagus (Fig. 9). For all of the rest of the FBs removed endoscopically, there was no inflammation noted at the time of the scope. The domino was removed endoscopically 10 days after ingestion. Six coins were found in the stool 3 to 7 days after swallowing,
Fig. 3. Ultrasound image of a button battery turned at an angle to the US beam, shown as two curved, parallel, hyperechoic lines (arrows) (a); photo of endoscopically removed button battery (b).
M. Jecković et al. / Clinical Imaging 37 (2013) 1043–1047
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Fig. 6. Ultrasound transverse image of the stomach with the hairclip inside (arrows) (a) and photo of the hairclip (b).
day after ingestion. The average hospital length of stay for these children was 1.5 days. There were no complications in our study group.
4. Discussion
Fig. 4. Ultrasound images of the wider (a) and narrower (b) surface of the domino (arrows) inside the water-filled stomach.
and two coins were removed endoscopically after 2 weeks. The screw nut was removed surgically after 15 days. The lollipops stick was recovered in the stool 3 days after ingestion, the hairclip after 5 days and the plastic cylinders passed with the feces on the third and fourth
Foreign body ingestion is relatively common and a potentially serious problem in the pediatric population. According to literature, the peak age for FB ingestion is in preschool years, most commonly children aged 6 months to 3 years, with almost equal frequency in boys and girls [1,3]. This was confirmed in our study. This is the oral developmental period when children explore their surroundings. This often leads to the accidental swallowing of the object being explored [1,4]. It is also important to note that FB ingestion can be associated with developmental delay or cognitive impairment
Fig. 5. Ultrasound images of the lollipops stick (arrows) before (a) and after the filling of the stomach with water (b); photo of the lollipops stick (c).
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Fig. 7. Ultrasound view of the metal screw nut shown as hyperechoic structure (arrow), with posterior acoustic shadowing (a), and the photo of the same one (b).
among all ages [1,5]. In our study, all children were developmentally normal, and no child had autism, mental retardation, or any other comorbid condition. Children can swallow a full spectrum of different FBs. The most common FB we saw in our group was the coin, and the second most frequent were the button batteries. It is interesting to say that small flat batteries are more often swallowed by younger children (8 months–2 years) which, to the parent’s surprise, they easily find and remove from a toy. Coins, on the other hand, are more commonly swallowed among children ages 2–4 years of life. In daily clinical practice, we see a greater number of children who swallow coins, but larger coins usually get stuck in the proximal esophagus, which is not accessible to direct US investigation. We have therefore focused on the FBs that are smaller and easily visible in the stomach. Button batteries require special attention because they are prone to complications, especially when lodged in the esophagus, as they may leak the concentrated hydroxides and cause a focal caustic burn and eventually a perforation of the esophagus. Similar injuries caused by button batteries in the stomach or lower gastrointestinal tract
Fig. 8. A large number of small plastic parts of toy presented on US as multiple hypoechoic small particles with the shape of rice grains.
are very unusual, but their prompt removal must be ensured in any case since a recent in vitro study suggested that button butteries in the presence of stomach acid, even for several hours, may begin to dissolve and release their potentially toxic contents [1,2,4,5]. Considering this, as a precaution, all ingested button butteries in our patients were immediately removed endoscopically. The confirmation by US that the battery is in the stomach and therefore within the reach of an endoscope can be very useful. Because button batteries can mimic coins on US, radiographs should be used in conjunction with US to make a prompt diagnosis to prevent devastating consequences. Traditionally, children are referred for radiography to confirm and localize ingested FBs [6]. If the ingested object is radiopaque, radiography is an effective diagnostic method. However, in case of a radiolucent FB, a radiograph may be nondiagnostic. Obtaining a contrast-enhanced radiographic study may help in this situation, although some experts, because of risk of aspiration, recommend endoscopy rather than a contrast study [1,3]. Often, serial follow-up films are necessary to determine whether the FB has left the stomach and if it is progressing satisfactorily in an antegrade fashion. This increases the amount of radiation received by the patient [2]. Another limitation of radiography is that the exact location of the FB can be difficult to determine because of superimposed loops of bowel, particularly superimposed over the stomach [6]. Because radiographs expose children to ionizing radiation and are an added cost, limiting the number of radiographs in the evaluation of FB is an important consideration [1]. Recently, US has been proven useful in the diagnosis of all FBs, including radiolucent ones, retained in the superficial soft tissues and in the parenchymal organs [7–10]. Currently, the publications in the pediatric imaging literature have been limited to primarily case reports. The role of US in the investigation of gastric FBs and its usefulness in preoperative localization of FB position have also been reported [2,6,11–13]. Our modestly larger series shows how US is uniquely valuable for this purpose in pediatric cases and has several advantages including lack of radiation burden, reproducibility, and being inexpensive. There are also some advantages of US imaging of gastric FB in children compared with adults. A child’s relatively small size allows the use of high-frequency transducers with good resolution, and because of the lack of subcutaneous fat, there are minimal reverberation artifacts that usually cause degradation of the US images [6]. Besides being safer and repeatable, US depicts FBs of any nature as hyperechoic structures. Preexamination ingestion of water facilitates the US visualization of FBs in the stomach because it reduces air artifacts. Visibility depends on the size of the object and is optimum when the long axis of the object is perpendicular to the US beam [2]. The perpendicular or near-perpendicular angle of approach to the surface of an FB provides a strong reflection back to the transducer and also produces a reverberation artifact, which are both helpful in identifying the object [6]. The presence of acoustic shadowing is variable and depends on the composition of the FB and the incidence of the beam. The comet-tail artifact is characteristic of metallic objects [2]. The role of color Doppler in the evaluation of FB is unclear as we did not routinely apply it in our US examinations. However, it may be useful in assessing acute inflammation when there is gastric or duodenal wall thickening. Generally, the majority of ingested FBs pass through the gastrointestinal tract without a problem, although serious complications such as bowel perforation, obstruction, or erosion into adjacent organs can occur. However, less than 1% of FB ingestions cause serious morbidity [3,5,14]. Patients who have swallowed blunt, radiopaque objects are usually followed with weekly radiography, and parents are instructed to watch for the passage of the object in stool. Most objects will pass within 4 to 6 days of ingestion, but some may take up to 4 weeks. Endoscopic or surgical intervention is recommended when significant symptoms develop or if the object fails to progress through the gastrointestinal tract in 3 to 4 weeks. It is recommended that
M. Jecković et al. / Clinical Imaging 37 (2013) 1043–1047
1047
Table 1 The distribution of FBs in different age groups Age groups
8–18 months 18 months–4 year 5–7 years Total
Types of ingested FBs Coins
Battery
Domino
1 7
2 3
1
8
5
1
Hairclip
Plastic cylinders
1
1
1
1
Screw nut
1 1
Lollipop stick
1 1
Total patients
4 12 2 18
characterizing the FB. In addition, there is variability in the reported time period when the FBs passed as this is dependent on the recall of the caregiver of the child. In conclusion, our study suggests that water-filled stomach US, as a radiation-free imaging modality, might have a significant role in the diagnostic workup of swallowed FBs in children, especially radiolucent ones. However, it is necessary to conduct a more extensive study to define whether US of gastric FBs can be used as an equally efficient tool as radiographs in everyday clinical practice.
References
Fig. 9. The endoscopy picture of erosive changes and ulcerations of esophageal mucosa after button battery ingestion.
sharp objects should be removed endoscopically before they have passed beyond the duodenal curve because they are more likely to cause complications. Sharp objects that cannot be removed endoscopically are considered for surgical removal if the object remains in the same location for 3 days [3]. In our study, the screw nut was beyond the reach of the endoscope and was removed surgically 15 days later after swallowing because of its size, lack of progression, and potential risk of complication. Besides the button batteries, as mentioned before, the domino and two coins were also removed endoscopically because they did not pass out of the stomach within a 2-week period. All others FBs passed without difficulties and were found in the stool within 1 week from ingestion. There were limitations of the study which included small sample size and operator technique differences when performing the US and
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