Esophageal Symptoms

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Removal of esophageal foreign bodies is recommended regardless of type, though the urgency depends on symptoms, object type, and how long it has been impacted. Emergent endoscopy (within 2-6 hours) should be performed for high-risk objects such as button batteries, sharp/pointed objects, and objects causing complete obstruction leading to significant symptoms and inability to swallow oral secretions.

For objects that are not high-risk but are located in the esophagus, removal should be accomplished within 24 hours. A case-control study of 273 patients by Loh et al found that esophageal foreign bodies left untreated for more than 24 hours are strongly associated with complications.$^{84}$ If the object is small (<2.5 cm), blunt, and the patient has no symptoms, endoscopy does not have to be accomplished immediately, but should be arranged within 24 hours of ingestion.

Many authors recommend a period of observation in the asymptomatic patient, because many low-risk objects will spontaneously pass into the stomach.$^{85}$ A high-quality randomized clinical trial by Waltzman et al evaluated management strategies for asymptomatic esophageal coins.$^{86}$ Pediatric patients were randomized to either endoscopy or admission for observation. Spontaneous passage rates varied, depending on location in the esophagus. Coins in the proximal esophagus passed spontaneously 14% of the time; in the middle esophagus, 43%; and distal esophageal coins, 67%. There were no complications in the observation group, and for patients whose ingestion spontaneously resolved, passage occurred within 19 hours.$^{86}$ Other studies have found that this period of observation can occur safely at home if patients are asymptomatic.$^{87}$ A reasonable approach for an asymptomatic patient with a low-risk esophageal foreign body is next-day follow-up for repeat evaluation and endoscopy.