Esophagus: foreign body

• Cause: bones and fish hooks are most common foreign body encountered.
• Common sites: thoracic inlet or between heart base and cardia.
• Signs: salivation, repeated swallowing and regurgitation.
• Diagnosis: radiography, esophagoscopy.
• Treatment: removal by endoscopy or surgery.
• Prognosis:
  • Guarded if chronic or moderate/severe esophageal damage.
  • Good if prompt removal and minor esophageal trauma.
  • Guarded/poor if perforation.
    
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• Regurgitation.
• Dysphagia or odynophagia.
• Anorexia.
• Retching.
• Hypersalivation.

• Respiratory signs (due to regurgitation and aspiration), eg cough, pyrexia if aspiration, dyspnea.

Chronic obstruction

• Dehydration plus or minus electrolyte loss (due to persistent regurgitation).
• Inappetence, anorexia, weight loss.

• Collapse and shock if esophageal perforation Esophagus: perforation.

• Persistent regurgitation/lack of oral intake → dehydration → electrolyte imbalance.
• Pressure necrosis may lead to:
  • Penetration of the cervical esophagus → contamination and cellulitis of the cervical tissue.
  • Thoracic perforation → catastrophic mediastinitis and pleurisy.

• Hours to days.

• Regurgitation.
• Dysphagia.

• Known ingestion of foreign body.
• History of scavenging or chewing.
• Regurgitation Regurgitation.

• Dysphagia.
• Repeated swallowing.

• Hypersalivation.
• May appear to resolve, then when perforation occurs:
  • Pyrexia.
  • Dehydration.
  • Depressed.
  • Tachypnea.
  • Dyspnea.
  • Cough.
  • Collapse.

Esophagoscopy

• Allows direct visualization  of foreign body  , may permit removal Esophagoscopy.
• Also allows examination of esophagus after removal for assessment of potential damage.

Radiography

• Plain cervical and thoracic radiograph Radiography: thorax may be sufficient if foreign body is radio-opaque .
• May only see secondary changes, eg evidence of inhalation pneumonia or mediastinal/pleural fluid if perforation has occurred .
• Contrast radiography to detect radiolucent foreign body or perforation.

Biochemistry

• Potassium concentrations Blood biochemistry: potassium to identify potential electrolyte abnormalities, eg hypokalemia Hypokalemia.
• Complete blood count - neutrophilia and left shift if perforation or pneumonia.

• Esophageal neoplasia/granuloma Esophagus: neoplasia.
• Esophageal stricture Esophagus: stricture.
• Esophagitis, eg post-anesthetic/chemical, eg doxycycline Doxycycline.
• Bronchesophageal fistula.

• IV fluids - LRS or 0.9% NaCl + KCl as required.
• Antibiotics - amoxycillin or cephalosporin; more aggressive if perforation.
• Gastric antisecretory drugs, eg IV ranitidine/cimetidine.
• PEG tube placement may be useful in severe damage.

Removal

• If no evidence of perforation/mediastinitis on radiograph:
  • Esophagoscopic Esophagoscopy retrieval with forceps or push objects into stomach, +/- retrieval from stomach.
  • Open, rigid esophagoscope plus or minus muscle relaxants.
  CARE not to lacerate or perforate mucosa.
• Post-procedure radiography r/o perforation.
• If evidence of perforation/mediastinitis on radiographs, or failed esophagoscopy:
  • Esophagotomy.

Cervical esophagotomy

• Allows access to foreign bodies in the cervical esophagus and cranial thoracic esophagus as far as the second rib.

Transthoracic esophagotomy

Treatment

• Esophagoscopic removal and minimal damage:
  • IV fluids (24-48 h).
  • Antibiotics (7-14 days).
  • Antisecretories (21 days), eg H-2 blockers IV then PO + carafate (oral) slurry as mucosal protectant.
  • Fast 24 h then clear liquids for 24 h, followed by re-introduction of soft food if regurgitation persists.

 Esophagotomy

• Place gastrostomy tube, bypass esophagus for >7 days.
• Provide all food/fluid via peg tube.
• Test-feed after 5-7 days - PEG feeding.
• Endoscopic re-examination and check for stricture.
• Antibiotics (7-14 days) + antisecretory agents (21 days) + carafate (21 days).
• Return to normal.

Antiobiosis

• Appropriate antibiotics directed at oral and esophageal contaminants should be routinely instigated, eg amoxycillin Amoxicillin , cephalosporins Cefalexin , clindamycin Clindamycin.
• Amoxycillin Clavulanate or enrofloxacin Enrofloxacin if perforation/mediastinitis.

Other

• Tube thoracostomy Drainage: thorax may be indicated if pleural infection develops.
• Drains may be employed if cervical contamination occurs.

• Highly variable.
• Depends on duration, location and nature of foreign body and degree of esophageal damage.

• Removal of obstruction allows normal eating.

• Damage/perforation of esophagus during removal.
• Severe pressure necrosis of esophagus → esophageal rupture.
• Esophageal stricture develops → recurrence of regurgitation 7-14 days after obstruction removed.

Refereed papers

• Recent references from PubMed and VetMedResource.
• Spielman B L, Shaker E H & Garvey M S (1992) Esophageal foreign body in dogs - a retrospective study of 23 cases. JAAHA 28 (6), 570-574 VetMedResource.
• Houlton et al (1985) Thoracic esophageal foreign bodies in the dog - a review of 90 cases. JSAP 26 (9), 521-536 VetMedResource.
• Zimmer J F (1984) Canine esophageal foreign bodies - endoscopic surgical and medical management. JAAHA 20 (4), 669-677 VetMedResource.

Other sources of information

• Washabau R J (1996) Swallowing disorders. In: Manual of canine and feline gastroenterology Eds L D A Thomas, J W Simpson & E J Hall. Cheltenham: BSAVA. pp 67.