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Referral and warning signs
When to refer
Urgent Referral to Hospital (H/RR) with Endoscopy capability: ALL cases of suspected oesophageal foreign body. Button battery ingestion (EMERGENCY). Sharp object ingestion. Complete obstruction (unable to swallow saliva). Signs of airway compromise. Symptoms persisting >24 hours.
Red flags
- Inability to swallow saliva / Drooling.
- Respiratory distress / Stridor.
- Button battery ingestion.
- Sharp object ingestion.
- Chest pain.
- Fever / Signs of sepsis (suggests perforation).
Signs and symptoms
- Sudden onset of difficulty or pain on swallowing (dysphagia, odynophagia).
- Sensation of something stuck in the throat or chest.
- Inability to swallow saliva -> Drooling.
- Retching or vomiting.
- Chest pain or discomfort.
- Coughing or choking (if object irritates airway entrance).
- Patient may be able to point to level of obstruction ('pointing sign').
- Respiratory distress (if large object compresses trachea - rare).
Risk factors
- Children (coins, small toys, batteries).
- Adults (food bolus - meat, fish/chicken bones, dentures).
- Underlying oesophageal stricture, web, ring, or motility disorder.
- Intellectual disability.
- Poor dentition.
- Alcohol intoxication.
Diagnosis
Clinical assessment
History of ingesting object or sudden onset dysphagia during eating. Assess airway status. Observe for drooling. Palpate neck. Visualize oropharynx (may see FB in tonsil/pharynx).
Investigations
- X-ray (Neck, Chest, Abdomen): Can identify radio-opaque objects (coins, bones, batteries). May show air trapping/soft tissue swelling but often normal for non-opaque objects (food).
- Contrast Swallow (Barium or Gastrografin): Can help locate obstruction (use water-soluble contrast if perforation suspected).
- Endoscopy (Oesophagoscopy): Gold standard for diagnosis and removal. Allows direct visualization.
Diagnostic criteria
Clinical history +/- visualization on X-ray or endoscopy.
Differential diagnosis
- Pharyngitis / Tonsillitis (pain, but usually can swallow).
- Peritonsillar abscess (trismus, deviated uvula).
- Epiglottitis (drooling, stridor, toxic appearance).
- Globus pharyngeus (sensation of lump without obstruction).
- Oesophagitis (infectious, reflux).
- Angioedema.
Management
Non-pharmacological management
- Airway Assessment: Ensure airway is patent. If compromised, manage airway first.
- Keep patient NPO (Nil Per Os).
- Positioning for comfort.
- If object visible in pharynx/tonsil: Attempt removal with long forceps under direct vision ONLY if safe and easily accessible. (LOC: HC3/H)
- Food Bolus Impaction:
- - May pass spontaneously.
- - Trial of Glucagon IV (relaxes lower oesophageal sphincter) - hospital setting.
- - Endoscopic removal if persists.
- Other Objects: Require endoscopic removal.
Pharmacological treatment
- Analgesia if needed.
- IV fluids if unable to swallow/dehydrated.
- Antibiotics if perforation suspected or significant delay/mucosal injury (e.g., Amoxicillin as per UCG).
Monitoring
Monitor airway, swallowing ability, signs of complications (pain, fever). Observe after removal for potential mucosal injury.
Complications
- Airway obstruction (if FB large or aspirated).
- Oesophageal perforation -> Mediastinitis, Sepsis.
- Oesophageal stricture (late complication).
- Mucosal abrasion/laceration.
- Aspiration pneumonia.
- Pressure necrosis (especially button batteries -> perforation/fistula).
- Bleeding.
Prevention
- Cut food into small pieces, chew thoroughly.
- Careful removal of bones from fish/meat.
- Keep small objects away from young children.
- Proper denture fitting.
- Addressing underlying oesophageal pathology.
Patient education
- Explanation of the problem and likely location.
- Need for investigation (X-ray/endoscopy).
- Importance of keeping NPO.
- Procedure for removal (endoscopy).
- Prevention advice (chewing food well, avoiding small objects for kids).
Uganda-specific notes
Fish bones are a common FB in adults. Coins common in children. Access to endoscopy is limited to referral hospitals. X-ray useful for radio-opaque objects. Button batteries require immediate action if identified.
Surgical Management
- Endoscopic Removal: Flexible or rigid oesophagoscopy to visualize and remove the foreign body using various forceps, snares, or nets. Performed by ENT or Gastroenterologist.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 21, Section 21.3.2