Foreign Bodies and Bezoars PDF - Nelson Textbook of Pediatrics

Chapter 360 ◆ Foreign Bodies and Bezoars 1967 Chapter 360 Foreign Bodies and Bezoars 360.1 Foreign Bodies in the Stomach and Intestine Asim Maqbool and Chris A. Liacouras Once in the stomach, 95% of all ingested objects pass without difficulty through the rema...

Chapter 360 ◆ Foreign Bodies and Bezoars 1967 Chapter 360 Foreign Bodies and Bezoars 360.1 Foreign Bodies in the Stomach and Intestine Asim Maqbool and Chris A. Liacouras Once in the stomach, 95% of all ingested objects pass without difficulty through the remainder of the gastrointestinal tract. Perforation after ingestion of a foreign body is estimated to be 6 cm in length fail to to continue a regular diet and to observe the stools for the appearance negotiate the pylorus or duodenal sweep and should also be removed. of the ingested object. Cathartics should be avoided. Exceptionally long In infants and toddlers, objects >3 cm in length or >20 mm in diameter or sharp objects are usually monitored radiologically. Parents or patients do not usually pass through the pylorus and should be removed. An should be instructed to report abdominal pain, vomiting, persistent open safety pin presents a major problem and requires urgent endoscopic fever, and hematemesis or melena immediately to their physicians. removal if within reach. Razor blades can be managed with a rigid Failure of the object to progress within 3-4 wk seldom implies an endoscope by pulling the blade into instrument. The endoscopist can impeding perforation but may be associated with a congenital malforma- alternatively use a rubber hood on the head of the endoscope to protect tion or acquired bowel abnormality. the esophagus. Other sharp objects (needles, bones, pins) usually pass Certain objects pose more risk than others. In cases of sharp foreign the stomach, but complications may be as high as 35%; if possible, they bodies, such as straight pins, weekly assessments are required. Surgical should be removed by endoscope if in the stomach or proximal duo- removal is necessary if the patient develops symptoms or signs of denum. If sharp objects are not able to be removed but no progress is obstruction or perforation or if the foreign body fails to progress for observed in location during 3 days, surgical removal is indicated. Drugs several weeks. Small magnets used to secure earrings or parts of toys (aggregated iron pills, cocaine) may have to be surgically removed; are associated with bowel perforation. Whereas a single magnet in the initial management can include oral polyethylene glycol lavage. Drug stomach may not require intervention in an asymptomatic child, a body packing (heroin, cocaine) is usually seen on kidneys-ureters-bladder magnet in the esophagus requires immediate removal. When the multiple or CT imaging and often passes without incident. Endoscopic procedures magnets disperse after ingestion, they may be attracted to each other may rupture the material, causing severe toxicity. Surgery is indicated across bowel walls, leading to pressure necrosis and perforation (Fig. if toxicity develops, if the packages fail to progress, or if there are signs 360.1). Inexpensive toy medallions containing lead can lead to lead of obstruction. toxicity. Newer coins can also decompose when subjected to prolonged Ingestion of magnets poses a danger to children. The number of acid exposure. Unless multiple coins are ingested, the metals released magnets is thought to be critical. If a single magnet is ingested, there are unlikely to pose a clinical risk. is the least likelihood of complications. If 2 or more magnets are ingested, Ingestion of batteries rarely leads to problems, but symptoms can the magnetic poles are attracted to each other and create the risk of arise from leakage of alkali or heavy metal (mercury) from battery obstruction, fistula development, and perforation. Endoscopic retrieval degradation in the gastrointestinal tract. Batteries can also generate is emergent after films are taken when multiple magnets are ingested. electrical current and thereby cause low-voltage electrical burns to the Abdominal pain or peritoneal signs require urgent surgical intervention. intestine. If patients experience symptoms such as vomiting or abdominal If all magnets are located in the stomach, immediate endoscopic removal pain, if a large-diameter battery (>20 mm in diameter) remains in the is indicated. If the ingestion occurred greater than 12 hr prior to evalu- stomach for longer than 48 hr, or if a lithium battery is ingested, the ation, or if the magnets are beyond the stomach and the patient is battery should be removed. Batteries larger than 15 mm that do not symptomatic, general surgery should be consulted. If the patient is pass the pylorus within 48 hr are less likely to pass spontaneously and asymptomatic, endoscopic or colonoscopic removal may be considered, generally require removal. In children younger than 6 yr of age, batteries along with a surgical evaluation. larger than 15 mm are not likely to pass spontaneously and should be Lead-based foreign bodies can cause symptoms from lead intoxication. removed endoscopically. If the patient develops peritoneal signs, surgical Early endoscopic removal is indicated of an object suspected to contain removal is required. Batteries beyond the duodenum pass per rectum lead. A lead level should be obtained. in 85% within 72 hr. The battery should be identified by size and imprint Water-absorbing polymer balls (beads) can expand to approximately code or by evaluation of a duplicate measurement of the battery compart- 400 times their starting size and if ingested may produce intestinal ment. The National Button Battery Ingestion Hotline (202-625-3333) obstruction. Initially of a small diameter, they pass the pylorus only to can be called for help in identification. The Poison Control Center rapidly enlarge in the small intestine. Surgical removal is indicated. (800-222-1222) can be called as well for ingestion of batteries and caustic Children occasionally place objects in their rectum. Small blunt objects usually pass spontaneously, but large or sharp objects typically need to be retrieved. Adequate sedation is essential to relax the anal sphincter before attempting endoscopic or speculum removal. If the object is proximal to the rectum, observation for 12-24 hr usually allows the object to descend into the rectum. Bibliography is available at Expert Consult. 360.2 Bezoars Asim Maqbool and Chris A. Liacouras A bezoar is an accumulation of exogenous matter in the stomach or intestine. They are predominantly composed of food or fiber. Most bezoars have been found in females with underlying personality problems or in neurologically impaired persons. Patients who have undergone Fig. 360.1 Abdominal radiograph of a boy aged 3 yr, noting three attached magnets that resulted in volvulus (i.e., twisting of the bowel) abdominal surgery are at higher risk for the development of bezoars. and multiple bowel perforations. (Courtesy U.S. Consumer Product The peak age at onset of symptoms is the 2nd decade of life. Safety Commission. From Centers for Disease Control and Prevention: Bezoars are classified on the basis of their composition. Trichobezoars Gastrointestinal injuries from magnet ingestion in children—United States, are composed of the patient’s own hair. It is most frequently a complica- 2003–2006. MMWR Morb Mortal Wkly Rep 55:1296–1300, 2006.) tion of the psychiatric disorder trichotillomania, and the most severe  Chapter 360 ◆ Foreign Bodies and Bezoars 1968.e1 Bibliography Litovitz T, Whitaker N, Marsolek M, et al: Emerging battery-ingestion hazard: clinical ASGE Standards of Practice Committee: Management of ingested foreign bodies and implications, Pediatrics 125:1168, 2010. food impactions, Gastrointest Endosc 73:1085–1091, 2011. Mallon PT, White JS, Thompson RL: Systemic absorption of lithium following ingestion Centers for Disease Control and Prevention (CDC): Injuries from batteries among of a lithium button battery, Hum Exp Toxicol 23:193–195, 2004. children aged 35 kg 500 mg twice a day Metronidazole 15-24 kg 250 mg twice a day 14 days 25-34 kg 500 mg in AM, 250 mg in PM >35 kg 500 mg twice a day Depending on previous antibiotic use history, recommended combinations are Amoxicillin + Clarithromycin + PPI OR Amoxicillin + Metronidazole + PPI OR Clarithromycin + Metronidazole + PPI. (Modified from Jones NL, Koletzko S, Goodman K, et al: Joint ESPGHAN/NASPGHAN Guidelines for the Management of Helicobacter pylori in Children and Adolescents, J Pediatr Gastroenterol Nutr 64(6):991–1003, 2017.) Table 361.3 Antisecretory Therapy With Pediatric Dosages MEDICATION PEDIATRIC DOSE HOW SUPPLIED H2 RECEPTOR ANTAGONISTS Ranitidine 4-10 mg/kg/day Syrup: 75 mg/5 mL Divided 2 or 3 × a day Tablets: 75, 150, 300 mg Famotidine 1-2 mg/kg/day Syrup: 40 mg/5 mL Divided twice a day Tablets: 20, 40 mg Nizatidine 5-10 mg/kg/day divided twice a day Solution: 15 mg/mL Older than 12 yr: 150 mg twice a day Capsule 150, 300 Tablet: 75 mg PROTON PUMP INHIBITORS Omeprazole 1.0-3.3 mg/kg/day weigh < 20 kg: 10 mg/day weigh > 20 kg: Capsules: 10, 20, 40 mg 20 mg/day Approved for use in those older than 2 yr Lansoprazole 0.8-4 mg/kg/day weigh < 30 kg: 15 mg/day weigh > 30 kg: Capsules: 15, 30 mg 30 mg/day Powder packet: 15, 30 mg Approved for use in those older than 1 yr SoluTab: 15, 30 mg Rabeprazole 1-11 yr (weigh < 15 kg): 5 mg/day Delayed release capsule: 5, 10 mg 1-11 yr (weigh > 15 kg): 10 mg/day Delayed release tablet: 20 mg >12 yr: 20 mg tablet Pantoprazole 1-5 yr: 0.3-1.2 mg/kg/day (limited data) Tablet: 20, 40 mg >5 yr of age: Powder pack: 40 mg weigh > 15 kg to < 40 kg: 20 mg/day weigh > 40 kg: 40 mg/day Esomeprazole 1 mo - < 1 yr old Capsules: 20, 40 weigh 3 kg to 5 kg: 2.5 mg Delayed release single dose packs: 2.5, 5, weigh > 5 kg to 7.5 kg: 5 mg 10, 20 mg weigh > 7.5 kg to 12 kg: 10 mg 1-11 yr old weigh < 20 kg: 10 mg weigh > 20 kg: 20 mg Approved for use 1 mo and older Dexlansoprazole 12-17 yr: 30-60 mg Capsules: 30, 60 Approved for use in 12-17 yr Omeprazole sodium bicarbonate Not approved for use < 18 yr at time of publication Capsules: 20, 40 Powder for oral suspension: 20 mg, 40 mg CYTOPROTECTIVE AGENTS Sucralfate 40-80 mg/kg/day Suspension: 1,000 mg/5 mL Tablet: 1,000 mg after stopping antibiotics and at least 2 wk after stopping PPI therapy. Idiopathic Ulcers Eradication can be tested with the 13C-urea breath (13C-UBT) test or H. pylori–negative peptic ulcers in children who have no history stool antigen test. If there is an eradication failure, the patient should of taking NSAIDs represent 15–20% of pediatric peptic ulcers. The receive rescue therapy (Fig. 361.3). Because of a significant incidence pathogenesis of idiopathic ulcer remains uncertain. These patients do of H. pylori resistance to clarithromycin, other treatment options not have nodularity in the gastric antrum or histologic evidence of are recommended if the community resistance rate is >15% or if it gastritis. In idiopathic ulcers, acid suppression alone is the preferred is unknown. effective treatment. Either PPIs or H2 receptor antagonists may be 1972 Part XVII ◆ The Digestive System RESCUE THERAPIES FAILED TREATMENT RESCUE TREATMENT Triple therapy with amoxicillin Triple therapy with amoxicillin and clarithromycin and metronidazole Triple therapy with amoxicillin Triple therapy with amoxicillin and metronidazole and clarithromycin PPI-metronidazole — high dos Sequential therapy eamoxicillin or bismuth based* Triple therapy with metronidazole PPI-metronidazole — high dose and clarithromycin amoxicillin or bismuth based* Fig. 361.3 Rescue therapy for failed eradication of H. pylori. *Bismuth-based therapy with tetracycline instead of amoxicillin if patients >8 yr. Bismuth dose is 262 mg four times a day for patients 8–10 yr and 524 mg four times a day for those >10 yr. (See Tables 361.2 and 361.3.) In adolescents, levofloxacin or tetracycline can be considered. High-dose amoxicillin ranges from 750 mg twice a day for body weight 15–24 kg, 1000 mg twice a day for 25–34 kg, and 1500 mg twice a day for >35 kg. (Adapted from Jones NL, Koletzko S, Goodman K, et al: Joint ESPGHAN/ NASPGHAN guidelines for the management of Helicobacter pylori in children and adolescents, J Pediatr Gastroenterol Nutr 64:991–1003, 2017.) used. Idiopathic ulcers have a high recurrence rate after discontinu- matched, and a large-bore catheter should be placed for fluid or blood ing antisecretory therapy. These children should be followed closely, replacement. A nasogastric tube should be placed to determine if the and if symptoms recur, antisecretory therapy should be restarted. bleeding has stopped. Significant anemia can occur after fluid resuscitation It is also important to consider uncommon but possible conditions as a consequence of equilibration or continued blood loss (which can like Crohn disease, cytomegalovirus (CMV), and Zollinger-Ellison also cause shock). In adults, a conservative threshold for transfusion syndrome. (35% chance of acquiring the disorder. Relatives of a patient with ulcerative colitis have a greater risk of acquiring ulcerative colitis than Crohn disease, whereas relatives of a patient with Crohn disease have a greater risk of acquiring this disorder; the 2 diseases can occur in the same family. The risk of occurrence of IBD among relatives of patients with Crohn disease is somewhat greater than for patients with ulcerative colitis. The importance of genetic factors in the development of IBD is noted by a higher chance that both twins will be affected if they are monozygotic rather than dizygotic. The concordance rate in twins is higher in Crohn disease (36%) than in ulcerative colitis (16%). Genetic disorders that have been associated with IBD include Turner syndrome, the Hermansky-Pudlak syndrome, glycogen storage disease type Ib, and various immunodeficiency disorders. In 2001, the first IBD gene, NOD2, was identified through association mapping. A few months later, the IBD 5 risk haplotype was identified. These early successes were followed by a long period without notable risk factor discovery. Since 2006, the year of the first published genome-wide array study on IBD, there has been an exponential growth in the set of validated genetic risk factors for IBD (Table 362.1). A perinuclear antineutrophil cytoplasmic antibody is found in approximately 70% of patients with ulcerative colitis compared with