Gastrointestinal Foreign Bodies in Children: Bezoars & Ingestion

Bezoars

• It's an Arabic word that means antidote to poison.
  • They are GIT foreign bodies formed due to intraluminal (inside intestine) accumulation of swallowed exogenous matter in the stomach or the intestines.
• Predominantly composed of food or fiber, although variants have also been reported.
• The peak age at onset of symptoms in the 2nd decade of life is 10 to 20 years.

Risk Factors for Bezoars

• Bezoars are more common in females as compared to men
• Associated with Neuropsychiatric illness
• Recent intra-abdominal surgery
• Altered gastric mobility due to gastroparesis, drug-induced systemic illness End-Stage Renal Disease, and diabetes minutes.

Types of Bezoars

Trichobezoar

Bezoar is composed of ingested hairs.

• Due to the effect of the gastric acid, it forms a casta-like mass in the stomach.
• It's more common in females than men.
• It is strongly associated with trichotillomania (pulling out own hairs urgently)

Clinic Features Associated with Trichobezoar

• Vomiting, abdominal pain, loss of appetite, weight loss.
• In addition, some patients may also develop abdominal distension. About 5 to 10% of patients tend to develop satellite masses in the intestine, which can lead to subacute intestinal obstruction in some individuals.

Also read: Abdominal Tuberculosis in Children: Symptoms, Diagnosis &

Rapunzel Syndrome

• Refers to a large trichobezoar that has a long tail-like extension reaching into the duodenum as long as ileocaecal regions, which reaches into the intestine
• Some may develop additional malabsorption features, and some may develop pancreatitis in case the ampulla of vater gets involved.

Phytobezoar

• Bezoar is composed of undigested plant material, with often some rare ingested animal fibers.
• They do not form masses like Tricobezors, but they can also cause gastric outlet obstruction and intestinal obstruction.
• Whenever the patient is digesting cellulose, hemicellulose, lignins (wood), and tannins (unripe fruits).
• When gastric acid acts on tannins, they tend to form a thick coagulum-like material on which cellulose, hemicellulose, and lignin get deposited, leading to the formation of phytobezoars.

Lactobezoar

• It is related to milk and is seen in very low birth weight newborns or preterm newborns.
• When newborns are fed hypertonic formula-based feeds based on milk protein, they tend to develop curd-like (casein, calcium, and fats) deposits that may organize in the stomach, leading to the development of trichobezoar.
• If whey protein-based feed is used, they do not lead to lactobezoar.
• Lactobezoar can also produce features of gastric outlet obstruction and intestinal obstruction or constipation.

Pharmacobezoar

• Usually associated with antacids, laxatives, and enteric coated tablets.
• Underlying gastric dysmotility or anatomic abnormalities may often predispose the patient.

Common agents implicated

• Nonabsorbable antacid
• Bulk laxatives when not taking an adequate amount of water
• Nifedipine, verapamil, procainamide
• Ferrous sulfate
• Sucralfate, theophylline
• Cholestyramine, meprobamate

Problems that can happen

• It is not due to stomach or intestinal obstruction but also to a drug.
• As the drug does not dissolve, it may lead to treatment failure.
• In the case of the sudden release of bezoars, toxicity can develop.

Also read: Alagille Syndrome – Clinical Features And Diagnosis

Complications of Bezoars

• Malabsorption patients show the development of hypoproteinemia, iron deficiency anemia, and steatorrhea, all of which can further lead to failure to thrive.
• Perforation of the gut—gastric problem and intestinal side effects.
• GIT bleeding: small ulcers tend to form on the lesser curvature, and these ulcers, especially in trichobezoar, tend to bleed.
• GIT obstruction.

Investigations 

• Abdominal plain X-ray shows the feature of obstruction sometimes.
• USC is often useful for screening
• CT is diagnostic. Sometimes oral contrast is used.
• According to Nelson's 21st ED on CT, bezoars appear as a nonhomogeneous, non-enhancing mass within the lumen of the stomach or intestine.
• In the oral contract, it can form an outline around the trichobezoar.

Management of Bezoars

• 1st line therapy endoscopic removal
• 2nd line therapy surgical removal whenever endoscopic therapy fails or is not effective surgical removal use 

Individual types

• Trichobezoars: most require surgical therapy
• Phytobezoars: endoscopy can be combined with fragmentation or can be given oral Coca-Cola to dissolve phytobezoars and be combined with endoscopic therapy
• Many times endoscopy is combined with local instillation of cellulose enzymes.
• Lactobezoar: withholding feeding for 24 to 48 hours, shifting to IVF fluids, and then changing formula can help resolve the condition.
• It can be combined with gastric lavage using saline.

Also read: Reye's Syndrome: Understanding A Rare But Serious Illness

Nelson says 

• Sunflower seed bezoars produce fecal impaction and are reported to cause rectal pain and constipation.
• Endoscopic removal is indicated, as these bacteria are refractory to enema or lavage management.
• In addition to material which says any patient who has gone under surgery in the past 6 months, especially with post-op symptoms related to mobility problems, constipation, etc
• These patients should avoid raw fruits and seeds such as watermelon, pumpkin, chia, etc.

Foreign Body Ingestion in Children

• Most cases of foreign body ingestion (something moving into the gut) occur between 6 months and 6 years of age.
• Approximately 90% of foreign bodies are radioactive and can be seen in an X-ray.
• The most common foreign bodies are ingested overall and in the Western world.
• In children, coins followed by button batteries
• Adolescents and adults ingest in the form of food particles or meat pieces.
• In the case of India, different data is found on children's peanuts, followed by coins, buttons, and batteries.
• Conservative management is indicated for most foreign bodies that have passed through the esophagus and entered the stomach.
• Most objects pass through the intestine in 4–6 days, although some take as long as 3–4 weeks.
• Cathartics should be avoided.
• In older children and adults, oval objects larger than 5 cm in diameter or 2 cm in thickness tend to lodge in the stomach and should be endoscopically retrieved.

Magnet Ingestion

• If a single magnet is ingested, complications are less likely. It can be observed whether it is passing through the stool or not.
• If 2 or more magnets are ingested, the magnetic poles attract each other and create the risk of obstruction, fistula development, and perforation.
• When multiple magnets are ingested, endoscopic retrieval is emergent.
• Abdominal pain or peritoneal signs require urgent surgical intervention.

Button Battery Ingestion in Children

• There has been a 7-fold increase in the relative risk of severe morbidity because of BB ingestion in the last 2 decades.
• BB ingestion comprises 7–25% of all foreign body ingestions in children
• Most battery ingestions occur in children under 6 years of age, with a peak at 1 year of age.

Also read: Autoimmune Hepatitis: Types, Clinical Presentation, Diagnosis And

Mechanism of Injury 

Potential mechanism

• Local pressure necrosis
• Corrosive damage from leakage of battery content can cause alkaline injury
• Heavy metal toxicity can contain lithium, cesium, and other compounds and cause toxicity
• Electric injury or electrolysis—the most imprecise mechanism.
• Please note that injuries are most commonly seen in batteries over 20 mm in diameter and in children under 6 years of age.

How does electrolysis cause injury?

• Whenever Button battery gets ingested, it gets lodged in GIT, but, most commonly, it is lodged in the esophagus (alkaline environment)
• Due to lodging, +ve and -ve battery terminals will be joined, and current will start flowing in.
• Whenever current flow starts at the -ve end of the button battery, OH- radicals can cause extensive liquefaction necrosis (significant for more than 2 hrs of ingestion). Hence, they need to be removed before 2 hours, leading to transmural inflammation and vascular damage.
• It is also called an electro thermal injury

Complication of Button Battery 

Respiratory

• Nasal septal perforation
• Intranasal synechiae
• Tympanic membrane perforation
• Facial nerve paralysis
• Recurrent laryngeal nerve injury
• Thyroid hemorrhage
• Trachea-esophageal fistula
• Battery aspiration
• Pulmonary hemorrhage
• Bronchial stenosis and pneumonia

(Above is more common in button battery aspiration rather than button battery ingestion.)

GIT

• Esophageal perforation
• Esophageal stenosis
• Stomach perforation
• Small intestine perforation

Others

• Aorto - esophageal or another major arterial branch fistula
• Massive hemorrhage
• Mediastinitis
• Spondylodiscitis
• Periorbital cellulitis

Also read: Juvenile Dermatomyositis (JDM): Causes, Symptoms, Diagnosis, and Treatment

Management of Button Battery Ingestion in Children

• Diagnosis management and prevention of button battery ingestion in childhood: A European society for pediatric gastroenterology hepatology and a nutrition position paper (2020-21 guideline) 
• Suspected/proven button battery ingestion
• Manage the Vitals if unstable.
• Check for any airway batteries, and take the help of a pulmonologist and an ENT surgeon.
• If ingestion happens in a child of more than 1 year in less than 12 hours, the child is stable and able to swallow, then immediately give 10 ml of honey orally to the child.
• Honey coat around the battery and reduce thermal injury
• An X-ray should be taken of this child of chest and abdominal in 2 views: AP view and lateral view. Finding where the battery can be present has 2 possibilities

Button Battery in the Esophagus

Whether ingestion happens less than 12 hrs or more than 12hrs 

For less than 12 hrs

• Urgent endoscopic removal is needed (preferably within 2 hours of ingestion).
• If more than a 1-year-old child swallows the battery in less than 12 hours, then sucralfate (10 mL) or honey can be given until endoscopic removal.
• Post-endoscopy by local irrigation using a 0.25% acetic acid dose of 50–150 mL can be given. It neutralizes OH molecules.
• It should be done only if there is no perforation or no fistula present. 

For more than 12 hours

• CT scan
• Surgical opinion
• Endoscopy

The Button Battery is Beyond Esophagus

Within 12hrs

• Check whether the patient is symptomatic or asymptomatic.
• If a patient is symptomatic/co-exiting magnet ingestion, the treatment will be the same.
• If the battery is placed in the stomach, then it will go for urgent endoscopic removal within 2 hours.
• If the battery is the intestine, then it will preferably go for surgical consultation.
• For asymptomatic, prefer X-rays repeated in 7 to 14 days under observation.
• An X-ray can be done earlier if a patient shows symptoms.
• If there is still no passage, then go for surgical removal.

More than 12 hours

• CT scan
• Endoscopy to document esophageal damage.
• In the stomach if no vascular damage happens in the stomach, removal can be done via endoscopy.
• In the case of the intestine or colon, for symptomatic, take a surgical opinion and possibly surgical removal.
• An asymptomatic X-ray is to be done in 7 to 14 days. If not passed the passage, then opt for surgical removal.

Also read: Allergic Rhinitis in Children: Symptoms, Causes, Diagnosis & Treatment

Points to Remember

• The advised dose for both honey and sucralfate is 10ml (2 teaspoons) Every 10 minutes, with a maximum of 6 doses of honey and 3 doses of sucralfate, respectively
• Batteries larger than 15 mm that do not pass the pylorus within 48 hrs are less likely to pass spontaneously and generally require removal.
• Batteries beyond the duodenum pass per rectum in 85% within 72 hr.

Conceptual things: How do x-ray views help in diagnosing ingestion vs. aspiration?

• Coin/ BB IN esophagus—where the flat surface is seen on AP view and edge on Lateral view.
• Coin/BB in trachea—the flat surface is seen on lateral view and edge on AP view

Hope you found this blog helpful for your NEET SS Pediatrics Gastroenterology preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.