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Introduction- Foreign body aspiration | OMG: Interesting Cases in Pediatric Radiology
Introduction- Foreign body aspiration | OMG: Interesting Cases in Pediatric Radiology
aspirationasthmabodychaptercomorbidedemaepisodeexpiratoryforeignimagingingestionlaryngealNoneobjectspediatricpylorusradiologicradiologyremovalswallow
Case- Not all wheezing is asthma | OMG: Interesting Cases in Pediatric Radiology
Case- Not all wheezing is asthma | OMG: Interesting Cases in Pediatric Radiology
airwayanteriorantibioticsaspirateaspiratedaspirationbodybronchoscopychaptercoughingepigastricexpiratoryfilmsforeignhistorylatexmainstemminimal peribronchial thickeningneb treatmentsno pneumonia or air trappingNoneobjectsobstructionpediatricpost tussive emesisposteriorradiologicsteroidstracheaworkup
Case- Foreign Body Aspiration | OMG: Interesting Cases in Pediatric Radiology
Case- Foreign Body Aspiration | OMG: Interesting Cases in Pediatric Radiology
atelectasisbronchoscopybronchuschapterchestforeignleftmainstemNonepintopossible LLL atelectasis or pneumoniaradiopaquescan
Case- Vaginal Foreign Bodies- 11 year old female | OMG: Interesting Cases in Pediatric Radiology
Case- Vaginal Foreign Bodies- 11 year old female | OMG: Interesting Cases in Pediatric Radiology
abdominalbodiesbodychapterdiarrheafemalesfluidforeignhematuriahistoryHysterotomy finds golf tee in uterusimagingNoneobject foundobjectspainpyelonephritisscansensitivesuspicious of UTIultrasoundvaginal
Case- Vaginal Foreign Bodies- 10 year old female | OMG: Interesting Cases in Pediatric Radiology
Case- Vaginal Foreign Bodies- 10 year old female | OMG: Interesting Cases in Pediatric Radiology
adhesionanesthesiabodycervixchaptercoronalechogenicflapforeignimageimagesMRIMRI showed a smooth image in upper vaginaNoneobject foundorificeultrasounduppervaginalvaginal adhesion hiding the cervix
Case- Vaginal Foreign Bodies- 5 year old female | OMG: Interesting Cases in Pediatric Radiology
Case- Vaginal Foreign Bodies- 5 year old female | OMG: Interesting Cases in Pediatric Radiology
abdomenbleedingchaptermetalMRINoneobject foundultrasoundX-ray revealed object
Foreign Body- Ingested batteries | OMG: Interesting Cases in Pediatric Radiology
Foreign Body- Ingested batteries | OMG: Interesting Cases in Pediatric Radiology
alkalinebodyburningbuttonchaptercontentsesophagusfilmsforeignhaloimagesingestioninjurylateralleakingmagnetsNoneprovenstepsuspected
Case- Ingested Foreign Bodies- Coins | OMG: Interesting Cases in Pediatric Radiology
Case- Ingested Foreign Bodies- Coins | OMG: Interesting Cases in Pediatric Radiology
behaviorbodybuttonchapterdiagnosticesophagusforeignhistoryimagingingestionNonepercentilepinsrefluxRemoval of penny from esophagus endoscopicallyrespiratorysignssuspected possible reflux diseaseswallowingsymptomsthresholdvomiting
Case- Ingested Foreign Bodies- Long sharp objects | OMG: Interesting Cases in Pediatric Radiology
Case- Ingested Foreign Bodies- Long sharp objects | OMG: Interesting Cases in Pediatric Radiology
Asymptomatic with unremarkable exambluntchaptercomplicationsesophagushoursmucosalNoneobjectsperforationperitonitispylorussharpunremarkable
Case- Migration of Ingested Foreign Bodies | OMG: Interesting Cases in Pediatric Radiology
Case- Migration of Ingested Foreign Bodies | OMG: Interesting Cases in Pediatric Radiology
abdominalbodychaptercomplicationsingestionlumenmesomigratedmigrationneedleNonepalpaterarerectal
Case- Ingested Foreign Bodies | OMG: Interesting Cases in Pediatric Radiology
Case- Ingested Foreign Bodies | OMG: Interesting Cases in Pediatric Radiology
abdominalbowelbowel restchapterconstipationdiarrheahistoryingestionIngestion of a piece of wire bristle from BBQIV antibioticslaparoscopic explorationNoneovarianpainPain continuespain palliationpalpationperitonitissurgical removal recommendedsymptomsvomitingwire
Case- Ingested Foreign Bodies- Magnets | OMG: Interesting Cases in Pediatric Radiology
Case- Ingested Foreign Bodies- Magnets | OMG: Interesting Cases in Pediatric Radiology
abdominalAbdominal US suggests appendicitisattractchapterFistulafistulasGastroenteritisingestionmagnetmagnetsNoneperforationsrebound tendernesstendernessWorsening pain
Case- Ingested Foreign Bodies- Magnets | OMG: Interesting Cases in Pediatric Radiology
Case- Ingested Foreign Bodies- Magnets | OMG: Interesting Cases in Pediatric Radiology
abdominalchapterday 3 pain reappearsdischarged with instructions that object would pass in stoolendoscopyfeverguardinghandheldingestionIV fluidsmagnetmagnetsmetalmetallicNoneobjectobservationpainpalerebound tendernessrigid abdomensurgicalsurgical consult obtained.typevomiting
Case- Ingested Foreign Bodies- Trichobezoars (hair balls) | OMG: Interesting Cases in Pediatric Radiology
Case- Ingested Foreign Bodies- Trichobezoars (hair balls) | OMG: Interesting Cases in Pediatric Radiology
alopeciachaptercommoncomorbiditygastrichairingestionintestinaljejunumNoneobstructivepalpablepicapsychiatricSurgical removalsyndrometractulcerationswebsite
Transcript

good morning everybody and I'm always excited when there's pediatric content anywhere so when Nancy Michelle and I were we're talking we were trying to figure out a topic and I had some experience with some foreign bodies in MRI and such in my experience so we

thought it would be interesting to talk about interesting cases in pediatric radiology okay our objectives for today are to identify potential risk factors that present in Pediatric Radiology patients discuss some pre screening

assessments for common pediatric comorbid conditions using a case base case based methodology and reviews and radiologic images of unique pediatric cases so we know that kids have a tendency to put things into small

objects into their mouths and other or orifices their nose their ears their vaginas so we are going to be discussing some cases throughout this presentation and we know that kids not only ingest objects but they also insert them and

they may actually inhale them as well most of these objects will pass spontaneously 10 to 20 percent of those that they swallow will require removal by endoscopy and about 1% require surgical removal and why is this a

problem with kids we know that kids are in the oral phase of development so they their teeth are not formed so they have inadequate dentition so they can't chew things so those pieces of hotdog those peanuts and and such are difficult for

them to chew which we know is the first phase of digestion their epiglottis is higher so it can make it more difficult for them to swallow and they have immature swallowing coordination so hence things are more likely to get

stuck so the incidence of foreign bodies is about six months to four years of age makes sense there's a slight predominance of males I can tell you I have a son and a daughter my daughter never put anything in her mouth or nose

or whatever but my son was certainly broke that record there's a slight predominance of males the most common objects are coins earrings marbles barrettes and rocks and objects that are typically longer than five centimeters

or greater than two centimeters in diameter are less likely to pass through the pylorus which makes sense and most pass within four to six days but some take up to four weeks of ingestion so why do we need radiologic imaging so

x-rays we know that the object would have to be radio opaque to be visualized on x-ray we know there's a challenge in cooperating for expiratory films and I'll talk about that in a couple of more slides we want to avoid CT scan if

possible because of the radio the exposure but ultrasound is really up and coming in terms of determining the location and the status of the object and provides dynamic imaging when you're thinking about foreign body foreign body

ingestion so ingestion versus aspiration foreign body aspiration is the fifth leading cause of death among one to three year olds and the primary cause of unintentional death in infants so the initial choking episode may be

unwitnessed it doesn't take very long for it for a six-month-old who's sitting up to grab something and put it in his mouth and toys pieces of toys account for ninety percent of these cases there's often a delay in diagnosing

these cases in patients that have a history of asthma croup or pneumonia because they always COFF so when they have an episode of coughing say oh it just must be the start of an asthma flare not thinking about foreign body

aspiration in the mix and of course early and up too late complications maybe it's fixing cardiac arrest dis Nia and laryngeal edema because as I said the epiglottis is high those Airways are narrow so there can be swelling

they swallow or ingest something and not

all wheezing is asthma I'm going to start with some interesting cases so a six-year-old has a one-month history of a cough URI and it progresses to wheezing chest x-rays obtained and

you see minimal peribronchial thickening but there's no pneumonia or air trapping he's treated with antibiotics and nebulizers and steroids and he gets better in a couple of days but about two weeks later he returns for similar

symptoms so while he's being worked up two weeks later he has post tussah emphasis and expels a tooth so this is okay this is the x-ray that was done at the initial start of his coughing where foreign body was not suspected in the

initial workup and so the foreign body was missed but in hindsight the mother recalls and I teach a physical assessment course and I always talk about it's all in the history it's all in the history it's all in the history

but in hindsight the mother stated that just before the child started with the coughing episodes a few weeks prior he had lost a tooth and he guessed when it fell out they never found the tooth and they just assumed that he had swallowed

it but in fact he had actually aspirated the tooth so the incidence of foreign body aspiration it's most common again those boys in boys less than 3 years of age with the peak age being one to two years it's usually noted in the right

mainstem because that's the path of least resistance but it can get lodged in the larynx or the trachea the most commonly aspirated objects are peanuts legumes seeds popcorn hardware marbles and balls so infants and toddlers would

be food tends to be the culprit older children coins and paper clips have also been implicated with foreign body aspiration and inflatable objects are the most dangerous so hence stay away from those latex

balloons because kids can aspirate and though objects in the airway expand even further and can cause more obstruction of their Airways and complete airway obstruction in cases where they're in

there eating uncut hotdogs grapes or gel candies and in my experience in the pediatric ICU at Children's Hospital of Philadelphia I've taken care of several children who had air complete airway obstruction and subsequent demise and

hot dogs on autopsy pieces of hotdogs you know being removed from the airway so I could certainly speak to that so there should always be a high index of suspicion and a low threshold for radiologic studies look in the nose

first you'll be amazed at what kids can fit up there plain x-ray films anterior posterior and lateral views the objects are seen in about 62% of the cases an expert Ori films chest films help with a diagnosis so there was a study down back

in 1979 that looked at expert ory films that which correctly diagnosed 47 out of 50 cases of kids with foreign bodies in their airway so it's difficult if the if the if the foreign body is in the trachea because you would have the

changes would be bilateral but what expiratory films helped to do is eliminate the need for fluoroscopy CT and bronchoscopy so you could see in the picture on on your left and the picture on the right it's you could see that

there is a the either the tack or the physician wears a lead glove and applies epigastric pressure to prevent lung expansion and to help visualize a foreign body so you could see the picture on the right where there's

actually hyperinflation that seen let's

go through some more cases foreign body aspiration 20 month old has a two-day history of fever fussiness non-productive cough and he's not eating quite so much his Pio intake is

decreased chest x-rays is obtained and it's unsure if it's left lower lobe atelectasis versus pneumonia and his condition gets worse so they decide to do a CT scan of the chest and note that there's a point 5cm by 0.4 cm object

obstructing the left mainstem bronchus so the next step is wrong kosgeb II to see what's in there and you could see on the let's see we could see an uncooked pinto bean was removed on bronchoscopy so so obviously uncooked being a little

harder than it being soft being cooked and softer and these I thought these were very interesting images the one on the left is a CT scan of the paranasal sinuses and you could see on the arrow that there's a button battery which I'm

going to talk about in a few moments button battery in the right NER and a used eraser piece of eraser in the left narrow our middle picture here is a raid there's a radiopaque foreign body in the left mainstem bronchus which is a peanut

right here in the airway and here is a fish bone that's in the hypopharynx and that's just on a plane neck x-ray so you could see all different foreign bodies

in there okay so foreign bodies she put it where so females may present with

abdominal pain and what we think about with females with abdominal pain we think about constipation gastritis UTIs pyelonephritis or renal stones and we but what about a vaginal foreign body four percent of cases of girls with

genital complaints in the emergency room have been found to have a vaginal foreign body those bought foreign bodies include toilet paper hair ties safety pins pencils candy and more common in three to nine year olds of course in

history you would ask about tampon use but these foreign bodies can my great all the way up through the cervix and the signs and symptoms that they present with our vaginal bleeding dysuria hematuria foul odor and lower

abdominal pain okay so when you're looking at diagnosing vaginal foreign bodies x-rays are really less sensitive to objects that are made of wood and plastic you may not see it on an x-ray ultrasound and MRI are sensitive to

differences in water content and inflammation and again ultrasound can provide dynamic imaging so you may be able to see as that object has migrated CT scan is less sensitive especially if the objects been there for a while and

has retained fluid and the clinical picture and the imaging may not exactly reveal the diagnosis so this case is an 11 year old with menarche she has a history of ADHD she's been complaining of abdominal pain 7 on a scale of 1 to

10 and she's had a fever for two days her pain is worse with activity it's improved when she takes a warm bath she's not as active as usual and her Pio in takis is down a little bit but she has no sore throat no congestion no

coughs s pain nausea vomiting diarrhea no hematuria no dysuria no headache and no rash she's had vaginal bleeding for about two days and suspicious of a UTI her abdominal ultrasound she notes some free fluid in the pelvis and they do a

history t'me and find a golf tee found in her uterus which created an abscess and required a washout and dream and I'll show you some of that okay so we could see here you could see the foreign body noted here on CT scan and here's

the piece of the golf tee so you're able to see that I'm glad I'm doing this before lunch instead of after lunch right

okay all right let's go over another case we have a ten-year-old with smelly

and bloody leukorrhea itching and vulva irritation always want to rule out sexual abuse of course when there's any vaginal discharge or any vaginal bleeding as well okay they're on trans abdominal ultrasound

there was an echogenic image that was noted in the upper part of her vagina and she had a badge on ah Skippy under general anesthesia and what that noted was a vaginal adhesion that was hiding the cervix so they decided to do an MRI

and the MRI showed a smooth image in the upper vagina so here's a couple of our images here on the Left we have a coronal MRI t2-weighted images sequence in the upper part of the vagina they can see a foreign body okay on that janaki

right here on the right you can see an adhesion that's kind of hiding the cervix and there's a flap on the side a flap of tissue that's how that's hiding a small orifice which is leading to the cavity of the foreign body and this is

the foreign body that was found it's a plastic dolls house glass and they suspect that it had been present there for several years okay next case a

five-year-old with excessive vaginal bleeding bleeding has no other symptoms

her she had a normal ultrasound of the lower abdomen there was no evidence of trauma or sexual abuse again very very important part of your history to obtain so they get a decide to do an MRI of her abdomen to see what's going on because

then ultrasound was negative and the metal detector went off when she went in the scanner so they pull her out and they get an x-ray a plain abdominal film that was done later and see a foreign body anybody want to take a guess at

what that might be metal so it definitely definitely shows up whoops those are actually keys to her diary so she was writing in her diary and she didn't want her mother to find that she

was writing so she stuck the keys inside and I guess never took them out again so that was those were two keys so very interesting cases okay let's talk about

but at button batteries and I say yikes because these are scary scary things

button batteries or disk batteries are made of lithium are very popular now they are they are popular because they have a very high capacity for energy and voltage they are very resistant they have a longer shelf life and they're

very stable at cold temperatures and they are pressing in watches these fobs remote control devices hearing aids calculators keychains and electronic toys so they the great thing is a lot of advantages but they have a lot of

potential for injury because of all of these you know all these benefits of them they are smooth and shiny very attractive to children especially the average age being two years 56% of cases are unwitnessed when kids ingest them

and they represent approximately 2% of all ingested foreign bodies but they probably are the most dangerous things that kids can ingest and 36% of patients are initially asymptomatic so it's very challenging to diagnose and even if they

ingest a battery that's already a bit spent meaning that it's a dead battery they are still at risk to cause injury if they swallow okay so these batteries generate an electric current when it meets the moist environment of the GI

tract and the battery contents leak and even though the outside casing remains intact the contents are still leaking there's a heavy metal toxicity burning burning burning and aside the symptoms of ingestion if

missed the child will choke or gag you'll see bloody saliva may have chest pain a new onset of wheezing or stridor and they may have a history of a viral syndrome so they've been coughing but coincidentally have ingested something

in the meantime they may have dark stools because of the bleeding or a rash and obviously the the worst case scenario may cause tracheal esophageal fistula media cyanide Asst and may erode major blood vessels and may actually

cause hemorrhage so button batteries can about 60 to 70 percent can become lodged in the esophagus and the more likely ones there's different sizes there's 20 millimeters and 15 millimeters and even though that doesn't sound like a lot of

difference the 20 millimeter ones are the ones that are more likely to become lodged and the duration of the lithium button battery the LV bfb the lit lithium button battery foreign body ingestion ingestion really has no

correlation with the length of how when it happened with the chances of its impaction it's kind of random where it gets stuck along the way so one of the treatments for suspected foreign body with button battery is that Children's

Hospital of Philadelphia we have adopted is to give that they suggest that the kids take honey on the way to the hospital if that's suspected and what the honey does is provides a protective barrier for the throat and helps to

neutralize the alkaline levels so even though it's they're not NPO for this impending surgical removal they find that there's a benefit of ingesting honey so even after removal by endoscopy of button batteries the injury can occur

days two weeks later and that's because of the leftover alkali the alkaline environment and the weakened tissues that are occurred so it takes a long time for this for these injuries to heal so in foreign body ingestion should

really be treated as button battery ingestion unless they're proven otherwise okay so in terms of imaging AP and lateral chest films are obtained along with neck and abdominal films because we

don't know where that button battery is along the pathway so it may look like a coin on x-ray but the difference we should treat it as a button battery and less proven otherwise and assume that there's some acid leaking and try to

remove that foreign body as quickly as possible so what you see on x-ray is you look for the halo it's a little bit hard in the lighting of this room but there's actually kind of a halo around that round object that's gonna differentiate

it from a coin and sideways it's not quite completely round like a coin would be there's a step off because if you notice that a button battery has a little bit of a lip on it so there's a step off sign that's seen on the lateral

film here and here are some other images so here's a button battery that's in the esophagus and you could see on close-up that there's a double ring and that is it's in the esophagus just above the Carina and that it's a little bit hard

to see on that image and here's another image where it's in that this is a 2.0 millimeter one and it's stuck in the mid esophagus okay and this is the step off so it's not quite it'll look a little bit different than a coin the step off

on the lateral view hence the reason to get ap and lateral films and then this is actually a child that swallowed magnets and so that magnets have all kind of stuck together okay and here's a lateral film of a button battery and

here's a more focused view where you could actually see the rim so you see in this these images a rounded radio-opaque foreign body with a double rim and the halo sign by the arrow and that's concerned for a button battery that's

overlying the stomach

so take-home points are watching out for children at higher risk one of the case studies that I discussed was an adolescent with ADHD you know who very very active watch out for kids with a

history of EEE for you know Jacinta philic esophagitis because sometimes those kids put things in their mouths watch for history kids that are at higher risk our kids that have

strictures so those pathway is narrowed kids with developmental delay who obviously need to be supervised especially with those very attractive-looking button batteries that fall out pretty easily from the

back of of devices and kids know kids are so tech savvy at even age two they

know if they know more how to work an iPhone than I do so they also know how to disconnect things as well kids with attention-seeking behavior and

that will come into play a little further in our presentation forty percent of all foreign body ingestions are unwitnessed so which is kind of scary so history is important but sometimes we don't always have a history

of what happened and diagnosing and treating early and disposing of used batteries because even the used batteries can still cause damage so kids less than age three years have with a vague history of foreign body ingestion

where they've been to the ER before force ingesting something and if they have a suggested suggestive chest x-ray should be presumed to have a foreign body of a lithium button battery and treated managed very quickly and those

patients with the button batteries often get IV steroids before and after and that can help to improve the outcomes but obviously that we need more research okay I'm gonna pass the mic over to Michelle who's gonna move on further

we're gonna move on to coins and other metallic objects so coins are the most commonly ingested for our body in children other things that we see pretty often are needles safety pins straight pins earrings keys screws and toys keys

obviously we've already seen here and toys the signs and symptoms can vary a lot of times we'll see vomiting drooling dysphasia difficulty swallowing the feeling of having a lump or stump something lodged in their

throat and then the respiratory symptoms of coughing choking and stridor but what we really need to remember is sometimes there are no symptoms at all especially initially so our first case today is a four year old who comes into the

emergency room for the third time she has vomiting of undigested food an Associated weight loss she's been to the this is her third visit the first two she was giving fluid challenges tolerated those and was sent home with a

GI visit scheduled for the future to work her up for possible reflux disease one physical exam now this has been going on for months she is now severely wasted she's three years old she weighs ten kilos she's below the point four

percentile she is on the threshold of severe malnutrition although she has no other physical signs that would lead to an underlying disease process but in all of this the only imaging they had gotten in the prior edie visits was abdominal

injury imaging nobody ever thought to do a chest x-ray because she didn't have any respiratory symptoms so lo and behold here's the circular dense object just below the clavicles and it as Laurie talked about with the button

batteries they can tell or highly suspect that this is a coin because there's no rim around it so on further evaluation and talking to this child and really asking her she did admit to swallowing a coin in the summer but

hatton told anybody because she was afraid she would get in trouble so as Laurie said they're often 40% unwitnessed so we don't know that it's happened and even when you ask they may be apprehensive to share that

information with you so a lot of times it's about the verbage you know making it friendly and it's okay we just want to know what's making you sick or we want to make you feel better so have you you know

eaten anything unusual did you accidentally swallow something that maybe you shouldn't have so that we're not scaring these kids she had this removed and escaped eclis without complication she had a great

recovery and there are before-and-after pictures it's pretty amazing that it could actually have gotten that far without a further evaluation with that kind of weight loss the take-home points for this would be that retained

esophagus foreign bodies are common in the emergency room Department but most often they present with little diagnostic difficulty however the signs and symptoms you're seeing may not reflect what's actually happening and in

young children they may not be forthcoming with the history it may not be witnessed they may not be willing to share so you really have to dig and there is a need for a low threshold of suspicion to avoid diagnostic delay and

potential complications with timely treatment so we're going to move on to

long sharp objects up to 90% and I think Laurie mentioned that to of ingested foreign bodies passed through the GI tract without complication however there

are exceptions to that and foreign bodies greater than four centimeters by two centimeters are those most likely to get caught up either in the constrictions of the esophagus in the pylorus or

the ileocecal Junction so our second case today is a nine-year-old who presented to the emergency department with the history of swallowing a pin ten hours ago again he did this at school doing a project but was afraid to tell

anyone but then when he came home he was afraid that something would happen so he finally confessed and he was he was asymptomatic but the parents decided to follow up just to make sure because it was a pin

he had an unremarkable exam they did do the x-rays so you can see there so there's the pin and if something to notice here is right now it is going with the point side down on the blunt side up and here it is here luckily

these show no evidence of impaction or perforation so they decided to just admit him with serial x-rays to follow through and hopefully it would pass most of the time they do pass and most of the time watch this pin they will go blunt

side down which decreases your risk of injury perforation or impaction so here we are moving so that those images were ten hours and now we're at about fifteen hours and you can see well on this one first of all it's starting to rotate

you'll see that looks a little concerning to me just the way it's facing but the blunt side is actually starting to go down and then over here were further down into the colon and then when we move on four hours later 26

hours after he initially ingested this he passed spontaneously past this with no complications was discharged to him the following morning so pretty amazing and that was just about the blunt end so the take homes here is that

you really can have spontaneous passage wait watchful waiting is okay to do as long as there are no signs or symptoms to be concerned about at that point however anything sharp or cutting does need an urgent examination because there

is a high risk of serious complications so there's complications most likely to occur with long sharp objects mucosal abrasions bleeding GI perforations peritonitis and medius tinnitus so this

one is a little bit more rare in that

this is a farm body that migrates so migration of the foreign body towards abdominal organ and it is rare but it can and does happen so here we have a 2 year old with a sewing needle ingestion who they followed for three months

without evidence of expulsion but this kid continued to have intermittent abdominal pain fussiness just overall crankiness and the parents decided that they were tired of just following this so they went for a second opinion and

they awry when they got for their second opinion they did indeed get more x-rays and it showed this and I'll show you in a minute they it showed the sewing needle in the lower abdominal quadrant they could not see it by practice Coupee

excuse me but what they did which in as you read along it didn't look like they had done anywhere else was they did a complete hands-on physical exam as well and they could actually palpate by rectal exam and then determined that it

had migrated and maybe you know maybe the migration had occurred over time and was not there when it was looked at earlier so this child ended up with a mini laparotomy do to the concerns of the migration out of

the lumen the needle was found in the meso : he had a significant recovery and three month post procedure follow-up showed no complication here this one's a little harder to see sorry I'm pointing problems it's the long straight can you

guys say it so again our take-home points although they are rare make em migrate outside if not removed early radiological follow-up as well as physical examination is important to identify potential complications and any

foreign body suggested to have migrated outside of the lumen should be considered for removal without delay because of the potential for traumatic complications okay alright she swallowed

a what this is a 16 year old who

presented to the GI clinic with a 2-day history of sharp abdominal pain and I know we all think oh my gosh a teenager with abdominal pain how often do we see that it was accompanied by sweats she'd had one episode of non bloody vomiting

decreased oral intake and some diarrhea although she no longer has vomiting and diarrhea denies fever or trauma she does have a history of irritable bowel and chronic constipation and an ovarian cyst rupture so again you have a lot going on

with the abdomen with this kiddo and you know somewhat broad symptoms so on further examination she describes this pain as clearly different from any of her pain associated with IBS and constipation she specifically said it

feels like there is a bubble that is about to burst it was exacerbated by eating coughing and sneezing her she appeared a mild distress but her vital signs were stable and her tenderness was localized to and to the right upper

quadrant with palpation and percussion so the x-ray shows a your object 13 millimeters in length adjacent to the large bowel and liver she was transferred to the emergency department where her pain continued to

intensify they got a CT the IDI doc dug for some more history this goes just you know history history is important keep digging you know as long as you don't know what's going on keep digging and then

finally when talking about food and anything that she could have eaten different they did figure out they had just gotten the grill out about a week ago and the dad had cleaned it real good and they'd been eating barbecue so they

suspected a wire ingestion from the cleaning brush for the grill surgery was consulted there was no signs or symptoms of sepsis or peritonitis so she was admitted for observation this is the CT so you well it's got a narrow good so

you can see and then down here she got to the floor they decided on bowel rest pain control and antibiotics however the pain continued to intensify again feels like a needle poking me she was very specific about the pain where

it was how it felt so surgical removal was recommended and here you see the wire brush or bristle that they removed post-op uneventful discharged after two days with no complications she did continue to be treated for her IBS again

this really just highlights a really common outpatient IDI complaint with a really uncommon diagnosis keep in mind you know we've talked about unwitnessed and kids that you know don't want to tell well this was really you know a

whole different story it was an unknown ingestion take-homes in the last decade there has been a huge increase in reported incidence of this type with wire bristle detailed history preceding the onset of acute and focal

symptoms should prompt physicians to consider unintentional foreign body ingestion and continue digging for that history and

then real quick just mercury ingestion again they're not selling the mercury

the liquid mercury thermometers anymore but there's still a lot of them out there and we do still occasionally in the DDC some of these come in the mercury is a dense silver white odorless heavy metal it can penetrate cell

membranes and accumulate in several organs and become toxic in several systems including the urinary CNS endocrine and Gi it's unusual to cause toxicity if the integrity of the mucosa is intact

and it does not enter further into the system if ingested from like a single thermometer 500 to 700 milligrams of Elemental mercury it's virtually non-toxic other sources are barometers batteries and sigma m-- fig manometers

you think after 30 years in nursing I could say that better so this is a two-year-old and the mother noted the broken thermometer with no evidence of mercury so he didn't have any symptoms that he wasn't complaining of pain he

wasn't coughing no breathing or swallowing but the mom brought him in anyway because it was mercury and she knew that it could be toxic he was stable vital signs stable no oral cuts abrasions glass particles but this

is what his x-ray looked like so it's just multiple scattered round densities throughout they did admit him for observation they repeated the x-ray in a serial course on day two he had complete clearance of the densities and was

discharged without complications so again our take homes usually it is with small amounts of mercury that have not gotten further into the system it's rarely toxic so you need to know the dose and the

the level of exposure the really important thing here is do not induce emesis or administer activated charcoal and do not use glass mercury containing thermometers in the home that's it and

we're gonna move on I have Nancy for the

final piece good morning everybody so I'm going to start with attraction the attraction of magnets that children seem to have so you can see here on the right that the incidence of these types of ingestion is relatively low but what you

need to know is that there's been a major increase in the number of times that we see this because there's so many toys and other objects that contain magnets in them and the magnets that are in there are extremely high-powered so

just because it's a small magnet doesn't mean that it's less of a problem so as you can see there are packaged warning labels on them but a lot of people still don't really actually I think believe that ingesting a magnet can be fatal but

there have been several fatalities and children from magnet ingestions and this is just really cool-looking puzzle I would be attracted to it if I was a child but this contains over 200 magnetic balls in there so I like x-men

so I'm calling this the case of magneto so this is a ten year old boy with a one-day history of recurrent vomiting who basically had some abdominal pain which is you've heard multiple times this is a very common presentation and

he had some abdominal tenderness so they started treatment for gastroenteritis which seemed totally appropriate but then his pain got worse and he started to have rebound tenderness so of course they're thinking

maybe appendicitis they did in a abdominal ultrasound and then they got the x-ray and then they got the x-ray there we go any guesses on what this is like a bracelet right like a little small brace

that's what I thought when I saw this so when you see that what type of material do you think this could be if you're thinking it's a bracelet yeah like a hard plastic right so obviously we're talking about magnets so here you go

foreshadowing not really it's a magnet but when you would first look at it I think you would think maybe hard plastic or some sort of jewelry some sort of that type of metal so they took him to the operating room and this is the

segment that they took out he had one of those rainbow magnet puzzles that I showed you at the beginning so when they removed it they found 16 separate little magnet balls so what people don't understand about the magnets is when

they travel through the GI system they continue to attract each other so in this situation you can see here that there is a fistula that's developed and that's because two magnets were on the opposite side of bowel and so they

attract each other and they pressed together this can cause perforations this can cause fistula x' and this can cause necrosis of those parts of the intestine and so in this case he had seven

fistulas several perforations and they had to actually remove part of his ileum because he had so many of them and then just because this poor child he's never gonna or he or she he will never do this again he had a wound

infection afterwards so this became a very complicated thing so he's in the hospital for quite a while but was able to be discharged successfully so the question comes up about well if the problem is that there are two magnets

that attract each other and that's what causes a problem then if there's a single magnet then in theory that shouldn't be an issue it should be able to pass so when you look at some of the algorithms for treatment of magnets

it'll say that if you believe that it's a single magnet that we should attempt to let it pass so that's sort of the conventional wisdom for it

so on to case number two so this is a three-year-old child and you can see

very clearly he comes to the IDI and he said 24 hours of pain vomiting he's a febrile doesn't look like he's ill at all and in this case the mother recognizes this this is a little stick magnetic stick from a construction type

of toy so so it's one single piece so he's admitted for eight hours of observation just to be conservative they give him IV fluids he begins to improve he's not vomiting he's not having any pain anymore he sent home with

instructions letting them know that this should pass eventually through his stool and two days post-op on follow-up he's back at baseline as far as playing he's eating normally and everything seems fine then on day three he started to

have abdominal pain again and you can see his white blood Khaled cell count went up he's now has a rigid abdomen he's guarding and he's having a lot of pain so they decide to do a surgical consult

okay so now we see this same object right it's moved which is what should happen but there's all this free air now all around it which is different so they begin to do some IV fluid resuscitation and he's emergently taken to the or so

he had two perforations in the jejunum and what had happened was those pieces of magnet were actually covered by this outside covering and that piece that looked like it was one piece was actually five individual magnets so

inside of the GI system the whole covering basically II rotate and then these little magnets some of them stuck together but they started moving and you can see how small they are and so that's why he had those major

complications so this is one situation where we thought that there was just one magnet but in reality they were multiple so in a sense you know this has come up as an issue there's not a lot of big Studies on this because it doesn't

happen that frequently but there was one good review that was done and this was done a few years ago where looked at 80 some odd cases and they used to children's hospitals and they just tried to find out so you know what happens in

terms of the progression of the the ingestion so again 56 percent were males not a surprise that that happened and I want you to note the age so about eight years old you know you kind of start thinking maybe they would know better

but I guess not so the age I never really think too much about age as much I had some really bad ingestions with people that were developmentally normal that were 14 and 15 years old and then the other thing you need to note 67% had

multiple magnets or they had a magnet and also ingested another metallic object so there's a CO ingestion there and those definitely were the situations where they were more likely to have to have some surgical type of procedure

because there were difficulties so 39 not many presented with symptoms and the most common one was abdominal pain and that could be just about anything and so 53% initially did not have operative management and of those 38 of them 37

percent failed it and then they've 47% had an endoscopy or they would have endoscopy and surgery combination so the take home the ingestion think about magnet ingestion a lot of people don't just because the magnets are hidden in a

lot of different toys and it is definitely a problem and that could become emergent so based on that study there's now an algorithm that basically has you be somewhat watchful but to go ahead and basically unless you're a

hundred percent certain assume that there's more than one magnet there and they're more likely to actually take them to have a procedure to remove it another thing to think about there's a few articles about

this about using handheld metal detectors not just for magnets but for other metallic objects and this it can be used in the emergency department so this is just a commercial type of handheld detector and this could be

maybe the parent is refusing to have an x-ray or the child is you know really difficult to get you know any sort of cooperation to do it or it's gonna take a really long time to get this x-ray so a few places have used this to be able

to just do a quick identification and localization of whether or not there's a metal object so I don't know if any of your places are using this but if you do some things to know first of all it is not fda-approved for this purpose but

they are medical grade because they're the same ones that are approved to be used when you go through TSA so it's not going to be harmful so you want to put the child in the center of the room away from metal objects they can't have any

zippers or clasp or anything like that and you want to ask them to put their hands up in this way and then we're wandering from the top all the way down to the pubis looking for any type of sounds okay it's bizarro or bizarro

so these are collections of indigestion material that can get stuck in the GI tract and they're usually either plant material or it can also be hair and the ones that I've seen the most are hair the most common one for the plant one is

actually rhubarb I don't know who's eating rhubarb but apparently there's some really bad things that can happen from it there's several cases of that but I'm going to talk about trickle but B sores which are hair balls so it's

pretty rare but it is more common in girls and it's secondary to the ingestion of hair this is a hairy tale so there are hair balls and that's because the surface of the hair is so smooth it can be difficult for it to be

digested and move through the intestinal tract it'll get caught in the gastric mucosa and then food and mucus will also accumulate in there and they can become quite large and this will be over time so it's like an impact

that can occur there is something called Rapunzel syndrome not that common but that's where this hairball can actually extend into the jejunum into the lower parts and parts of it could break off and actually obstruct the intestine so

not a lot of symptoms we do look for some psychiatric comorbidity so the child that is pulling their hair or Piko or other kinds of things can be indicators some complications as this enlarges there's been episodes where

there's been obstructive where there's perforations and ulcerations so in this case this was a nine year old female who had no chronic abdominal pain just vomiting and weight loss she had no alopecia so that's something if you see

somebody and you want to know whom where's that hair going if they're pulling it out but she had a big palpable mass and you can see it right there she did have a history of a psychiatric comorbidity and they tried

to do an endoscopy it was unsuccessful and that you see why so you can see the size of what they removed from her stomach look I purposely left the image there of the hand so that you could see this and this is what Rapunzel's sink

syndrome is so you can see how long this can be and how it could be very obstructive so these are rare they're difficult to recognize consider this in children with pica or other psychiatric illnesses consider alopecia without a

medical cause as a possibly on assessment and then remember that they need a referral for psychiatric follow-up so in conclusion detailed assessment and history are very critical and identifying potential

presence of foreign bodies radiological imaging is helpful but you need to know that it is not a hundred percent accurate all the time and then just think about some evidence-based practices and what I wanted to leave

with you and this is here BMJ hopefully you can see the website this is actually a very nice algorithm that helps in deciding what to do depending on where the object is and what types of objects could possibly be coming through thank

you very much

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