今日の臨床サポート

異物(気管・食道)(救命救急)

著者: 瀬良誠 福井県立病院 救命救急センター

監修: 林寛之 福井大学医学部附属病院

著者校正/監修レビュー済:2021/02/24
患者向け説明資料

概要・推奨   

気管・消化管異物】
  1. 小児異物の40%は目撃がなく、40%はX線透過性である。また40%は初診時には無症状である。つまり疑わなければ診断できず、また40%はX線に写らないため、閾値を下げて画像検査を施行する必要がある(推奨度1)
  1. 異物の診断には病歴、身体所見、X線写真とあり、画像検査が重要であることに異論はないが、気管異物に関しては病歴が一番感度が高い(推奨度1)
  1. 落ち着いており、無症状の患者であれば外来経過観察が可能と思われるが、24時間以上の経過観察はすべきではなく、8~16時間を勧めている(推奨度1)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
瀬良誠 : 特に申告事項無し[2021年]
監修:林寛之 : 講演料(メディカ出版),原稿料(羊土社)[2021年]

改訂のポイント:
  1. AHAのガイドライン改定(G2020)に伴い、異物に伴う気道閉塞における緊急時対応について追記した。
  1. 消化管異物における内視鏡のタイミングについてESGEのガイドラインを追記した。

病態・疫学・診察

疾患(疫学・病態)  
【消化管異物】
  1. 異物誤飲の80%は子どもで、コイン、おもちゃ、クレヨン、ボールペンキャップが多い。大人では肉と骨が多く、歯のない患者や犯罪者、精神患者では意図的であることが多く、歯ブラシやスプーン、ひげ剃りの刃などの誤飲を認め、繰り返すことが特徴である。
  1. 消化管異物の80~90%は、自然に合併症なく通過する。10~20%は内視鏡的摘出が必要になる。米国では、手術適応になるのは1%未満であるものの、年間で1,500人が死亡している。
  1. 異物誤飲では、異物の性状、形状、大きさ、嵌頓部位が重要となる。
  1. 特に、ボタン電池は食道にある場合早急な対応が必要で、2~2.5時間で重篤な組織障害を生じるため緊急内視鏡の適応となる。
 
  1. 消化管異物の80~90%は自然に合併症なく通過する。10~20%は内視鏡的摘出が必要になる(推奨度1M)
  1. 米国では、手術適応になるのは1%未満だが、年間で1,500人が死亡している[3]
  1. 小児消化管異物で救急受診した125人のレトロスペクティブな解析では、9%が内視鏡あるいは経過観察のため入院となった。
  1. 16%に侵襲的な治療が必要だったが合併症は小さなものが2%、穿孔や出血、縦隔炎のような大きな合併症はなかった[4]
  1. 1996年のstudyでは542人、1,203個の異物誤飲について調べた結果、75.6%が自然通過し、4.8%に手術が必要であった。
  1. ただしこのstudyでは69.9%が受刑者であり、15~82歳であったことを考慮する必要がある[5]
  1. 異物が疑われる小児675人を調べたstudyでは、異物の部位としては胃が58.1%、小腸が32.7%、食道が9.2%であった。
  1. 結果として内視鏡を必要としたのは19.1%で、手術が必要となったのはわずか0.4%であった[6]
 
【気管異物】
  1. 小児の異物誤嚥による死亡の65%は3歳未満である。異物の種類としては玩具が約70%を占め、その中では風船が29%で最も多く注意が必要である[1]。.
  1. 誤嚥した異物の約3%は喉頭に存在する[2]
 
必読文献(推奨度1M):
  1. 以下文献は非常によくまとまっている。特に後者は大変読みやすく、フローチャートもついている。
  1. Anderson KL, Dean AJ. Foreign bodies in the gastrointestinal tract and anorectal emergencies. Emerg Med Clin North Am. 2011 May;29(2):369-400.[3]
  1. Uyemura MC. Foreign body ingestion in children. Am Fam Physician. 2005 Jul 15;72(2):287-91.[7]
  1. 以下はボタン電池についての詳細、かつ、よくまとまっており、特にフローチャートは一度みておくことをお勧めする。
  1. Litovitz T, Whitaker N, Clark L, White NC, Marsolek M. Emerging battery-ingestion hazard: clinical implications. Pediatrics. 2010 Jun;125(6):1168-77.[8]
問診・診察のポイント  
  1. 誤嚥、誤飲のエピソードははっきりしないことが多く、強く疑うことが大事である。なぜなら、約40%は目撃がなく、50%以上が無症状だからである。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

著者: F L Rimell, A Thome, S Stool, J S Reilly, G Rider, D Stool, C L Wilson
雑誌名: JAMA. 1995 Dec 13;274(22):1763-6.
Abstract/Text OBJECTIVE: To characterize the types, shapes, and sizes of objects causing choking or asphyxiation in children and to compare these characteristics to current standards.
DESIGN: To evaluate morbidity, retrospective 5-year medical record survey; to evaluate mortality, data reanalysis.
SETTINGS: Pediatric hospital and consumer product testing laboratory.
PATIENTS: All children (n = 449) who underwent endoscopy for foreign body aspiration or ingestion at Children's Hospital of Pittsburgh (Pa) between 1989 and 1993 and children (n = 449) whose deaths due to choking on man-made objects were recorded by the Consumer Product Safety Commission (CPSC) between 1972 and 1992.
MAIN OUTCOME MEASURES: Objects removed from children's aerodigestive tracts were characterized by location, procedure for removal, and type. Objects causing death were characterized by type, shape, and consistency. Three-dimensional objects that had caused asphyxiation were analyzed by computer-simulated models.
RESULTS: Of the 165 children treated by endoscopy, 69% were 3 years of age or younger. Foreign bodies most often ingested or aspirated were food (in 36 children) and coins (in 60 children). Of 449 children whose deaths after aspirating foreign bodies were reported to the CPSC, 65% were younger than 3 years. Balloons caused 29% of deaths overall. Conforming objects such as balloons caused a significantly (P < .001) higher proportion of deaths in those aged 3 years or older (60%) vs those younger than 3 years (33%). Of the 101 objects causing deaths that we could analyze, 14 met current standards for use by children of any age.
CONCLUSIONS: Balloons pose a high risk of asphyxiation to children of any age. Changes in regulations regarding products intended for children's use might have prevented up to 14 (14%) of 101 deaths in this study.

PMID 7500505  JAMA. 1995 Dec 13;274(22):1763-6.
著者: Bernard F Laya, Ricardo Restrepo, Edward Y Lee
雑誌名: Radiol Clin North Am. 2017 Jul;55(4):845-867. doi: 10.1016/j.rcl.2017.02.012.
Abstract/Text Foreign bodies (FBs) may be unintentionally ingested, inhaled, or inserted into a body cavity or tissue, or may be due to traumatic or iatrogenic injury. They are frequently detected in clinical practice and emergency rooms. Early detection and prompt management are mandatory to avoid severe and life-threatening complications. Imaging plays an important role in confirming the presence and characterization of the FB, and its relationship with any affected organs. This article reviews commonly encountered FBs with regard to incidence, risk factors, mechanisms of entry, clinical presentation, associated complications, and typical imaging appearance in children.

Copyright © 2017 Elsevier Inc. All rights reserved.
PMID 28601182  Radiol Clin North Am. 2017 Jul;55(4):845-867. doi: 10.1・・・
著者: Kenton L Anderson, Anthony J Dean
雑誌名: Emerg Med Clin North Am. 2011 May;29(2):369-400, ix. doi: 10.1016/j.emc.2011.01.009.
Abstract/Text Of all ingested foreign bodies (FBs) brought to the attention of physicians (probably a small minority of the total), 80% to 90% pass spontaneously; however, 10% to 20% require endoscopic removal, and about 1% require surgery. The article divides the GI tract into regions in which the anatomy, presentation, clinical findings, and management of FBs are distinct. The final third of this article describes the management of anorectal emergencies. An understanding of anatomy and common pathological conditions allows the emergency physician to make a diagnosis and provide relief and/or resolution in most cases.

Copyright © 2011. Published by Elsevier Inc.
PMID 21515184  Emerg Med Clin North Am. 2011 May;29(2):369-400, ix. do・・・
著者: L Binder, W A Anderson
雑誌名: Ann Emerg Med. 1984 Feb;13(2):112-7.
Abstract/Text One hundred twenty-five consecutive emergency department cases of pediatric gastrointestinal foreign body ingestions were analyzed retrospectively to tabulate data, identify high risk ingestions, and draw conclusions regarding the standard of care. Eleven patients (9%) were admitted for endoscopy or observation of high risk situations. Twenty patients (16%) were managed invasively, 19 with esophageal foreign bodies; 17 of 20 attempts at invasive management were successful. There was a 2% incidence of minor complications; no major complications (perforation, obstruction, bleeding, or mediastinal infection) or complications of invasive procedures were observed. High risk factors identified included the following: 1) the ingestion of rounded objects (esophageal impaction); 2) the presence of social, developmental, or psychiatric risk factors (29.6% incidence); and 3) esophageal disease (significantly associated with recurrent foreign bodies and frequent endoscopy or other surgical procedures). We conclude that, while asymptomatic gastric and intestinal foreign bodies can be managed with outpatient observation, hospitalization is indicated for endoscopic management and for symptom complexes suggestive of complication. Immediate endoscopy is recommended for removal of esophageal foreign bodies and for direct evaluation of the esophagus.

PMID 6691612  Ann Emerg Med. 1984 Feb;13(2):112-7.
著者: N G Velitchkov, G I Grigorov, J E Losanoff, K T Kjossev
雑誌名: World J Surg. 1996 Oct;20(8):1001-5.
Abstract/Text Ingested foreign bodies (FBs) present a common clinical problem. As the incidence of FBs requiring operative removal varies from 1% to 14%, it was decided to perform this study and compare the data with those from the world literature, as well as to outline an algorithm for management, including indications for surgery. We reviewed all patients with FB ingestion from 1973 to 1993. There were 542 patients with 1203 ingestions, aged 15 to 82 years. Among them, 69. 9% (n = 379) were jail inmates at the time of ingestion, 22.9% (n = 124) had a history of psychosis, and 7.2% (n = 39) were alcoholics or denture-wearing elderly subjects. Most foreign bodies passed spontaneously (75.6%; n = 410). Endoscopic removal was possible in 19. 5% (n = 106) and was not associated with any morbidity. Only 4.8% (n = 26) required surgery. Of the latter, 30.8% (n = 8) had long gastric FBs with no tendency for distal passage and were removed via gastrotomy; 15.4% (n = 4) had thin, sharp FBs, causing perforation; and 53.8% (n = 14) had FBs impacted in the ileocecal region, which were removed via appendicostomy. Conservative approach to FB ingestion is justified, although early endoscopic removal from the stomach is recommended. In cases of failure, surgical removal for gastric FBs longer than 7.0 cm is wise. Thin, sharp FBs require a high index of suspicion because they carry a higher risk for perforation. The ileocecal region is the most common site of impaction. Removal of the FB via appendicostomy is the safest option and should not be delayed more than 48 hours.

PMID 8798356  World J Surg. 1996 Oct;20(8):1001-5.
著者: Dimitris Antoniou, George Christopoulos-Geroulanos
雑誌名: Turk J Pediatr. 2011 Jul-Aug;53(4):381-7.
Abstract/Text Although foreign body ingestion is a common problem in children, there are no clear guidelines regarding the management of ingested foreign bodies. The aim of this study was to evaluate the effectiveness of our protocol in the work-up and management of children with ingested foreign bodies. Between September 2002 and August 2010, a total of 675 children with suspected foreign body ingestion were seen in the emergency department. At initial presentation, the majority of foreign bodies were located in the stomach (n=392, 58.1%) followed by the small intestine (n=221, 32.7%) and esophagus (n=62, 9.2%). Based on our protocol, 84 (12.4%) patients were admitted at initial presentation, and 5 after a 48-hour observation period at home; 61 (9%) required prompt endoscopic removal. Sixty-eight (10.1%) patients returned for endoscopic removal after a four-week observation period, and 3 (0.4%) patients underwent delayed surgery due to complications. The overall success rate of endoscopic retrieval was 96.1%. There were no major complications. The majority of ingested foreign bodies will pass spontaneously and most children can be safely observed at home. Selective endoscopic intervention is the preferable method for the removal of ingested foreign bodies in pediatric patients.

PMID 21980840  Turk J Pediatr. 2011 Jul-Aug;53(4):381-7.
著者: Monte C Uyemura
雑誌名: Am Fam Physician. 2005 Jul 15;72(2):287-91.
Abstract/Text Because many patients who have swallowed foreign bodies are asymptomatic, physicians must maintain a high index of suspicion. The majority of ingested foreign bodies pass spontaneously, but serious complications, such as bowel perforation and obstruction, can occur. Foreign bodies lodged in the esophagus should be removed endoscopically, but some small, blunt objects may be pulled out using a Foley catheter or pushed into the stomach using bougienage [corrected] Once they are past the esophagus, large or sharp foreign bodies should be removed if reachable by endoscope. Small, smooth objects and all objects that have passed the duodenal sweep should be managed conservatively by radiographic surveillance and inspection of stool. Endoscopic or surgical intervention is indicated if significant symptoms develop or if the object fails to progress through the gastrointestinal tract.

PMID 16050452  Am Fam Physician. 2005 Jul 15;72(2):287-91.
著者: Toby Litovitz, Nicole Whitaker, Lynn Clark, Nicole C White, Melinda Marsolek
雑誌名: Pediatrics. 2010 Jun;125(6):1168-77. doi: 10.1542/peds.2009-3037. Epub 2010 May 24.
Abstract/Text OBJECTIVES: Recent cases suggest that severe and fatal button battery ingestions are increasing and current treatment may be inadequate. The objective of this study was to identify battery ingestion outcome predictors and trends, define the urgency of intervention, and refine treatment guidelines.
METHODS: Data were analyzed from 3 sources: (1) National Poison Data System (56535 cases, 1985-2009); (2) National Battery Ingestion Hotline (8648 cases, July 1990-September 2008); and (3) medical literature and National Battery Ingestion Hotline cases (13 deaths and 73 major outcomes) involving esophageal or airway button battery lodgment.
RESULTS: All 3 data sets signal worsening outcomes, with a 6.7-fold increase in the percentage of button battery ingestions with major or fatal outcomes from 1985 to 2009 (National Poison Data System). Ingestions of 20- to 25-mm-diameter cells increased from 1% to 18% of ingested button batteries (1990-2008), paralleling the rise in lithium-cell ingestions (1.3% to 24%). Outcomes were significantly worse for large-diameter lithium cells (> or = 20 mm) and children who were younger than 4 years. The 20-mm lithium cell was implicated in most severe outcomes. Severe burns with sequelae occurred in just 2 to 2.5 hours. Most fatal (92%) or major outcome (56%) ingestions were not witnessed. At least 27% of major outcome and 54% of fatal cases were misdiagnosed, usually because of nonspecific presentations. Injuries extended after removal, with unanticipated and delayed esophageal perforations, tracheoesophageal fistulas, fistulization into major vessels, and massive hemorrhage.
CONCLUSIONS: Revised treatment guidelines promote expedited removal from the esophagus, increase vigilance for delayed complications, and identify patients who require urgent radiographs.

PMID 20498173  Pediatrics. 2010 Jun;125(6):1168-77. doi: 10.1542/peds.・・・
著者: Atalay Sahin, Fatih Meteroglu, Sevval Eren, Yusuf Celik
雑誌名: J Trauma Acute Care Surg. 2013 Feb;74(2):658-63. doi: 10.1097/TA.0b013e3182789520.
Abstract/Text BACKGROUND: Foreign body (FB) inhalation into airways of the respiratory system is a life-threatening condition and can be fatal. The purpose of this survey was to evaluate the types and characteristics of inhaled foreign bodies, the age distribution of children, and the outcome.
METHODS: We outlined a retrospective review of hospital data of patients between 1990 and 2012. FB inhalation occurring in children 0 year to 16 years was considered for inclusion. During the study period, 1,660 patients undergoing bronchoscopy with the diagnosis of FB were included. Deaths on arrival were excluded.
RESULTS: Of the patients, 53% were male, and 47% were female (p > 0.05). The mean age was 6.2 years for girls and 4.7 years for boys. In 57% of all cases, the children were younger than 3 years. An FB was found within the respiratory tract of 1,565 patients. The FBs were always extracted by using rigid bronchoscopy. Hospitalization was always required owing to an institutional requirement. The origin of the FBs were within the two main groups of food and objects. Food FBs included seeds, nuts, beans, and fruit parts. FB objects included pins, toy parts, and metal pieces. FB and subsequent treatment revealed that morbidity was present; however, mortality was rare.
CONCLUSION: Most of the inhaled FBs were found in the bronchial tree. Children younger than 3 years are more vulnerable. There seemed to be an association between the aspirated FBs and season, geographic locality, and sociocultural environment. The removal of choice is rigid bronchoscopy under general anesthesia. That most cases of FB in children occurs under the supervision of adults indicates that the incidence and severity of airway FB inhalation can be reduced by parental education and public awareness.
LEVEL OF EVIDENCE: Epidemiologic study, level III.

PMID 23354266  J Trauma Acute Care Surg. 2013 Feb;74(2):658-63. doi: 1・・・
著者: G Paul Digoy
雑誌名: Otolaryngol Clin North Am. 2008 Jun;41(3):485-96, vii-viii. doi: 10.1016/j.otc.2008.01.013.
Abstract/Text Although often listed together in review articles and case series, tracheobronchial and esophageal foreign bodies can be dissimilar. Airway foreign bodies can range widely in the severity of presentation. When to proceed with a diagnostic bronchoscopy is not always obvious and is based on three diagnostic tools: clinical history, physical examination, and radiography. Radiography plays a more central role in the diagnosis of an esophageal foreign body. In either condition, a delay in diagnosis leads to a greater complication rate. This article provides diagnostic and treatment guidelines in the management of aerodigestive foreign bodies.

PMID 18435994  Otolaryngol Clin North Am. 2008 Jun;41(3):485-96, vii-v・・・
著者: A G Linegar, U O von Oppell, S Hegemann, M de Groot, J A Odell
雑誌名: S Afr Med J. 1992 Sep;82(3):164-7.
Abstract/Text Ninety-six children with suspected tracheobronchial foreign bodies were referred to the Department of Cardiothoracic Surgery at Red Cross War Memorial Children's Hospital, Cape Town, between February 1985 and February 1990. Foreign bodies were removed by rigid bronchoscopy from 63 patients, 79% of whom were under 5 years of age. The majority of patients (59%) presented more than 24 hours after aspiration of the foreign body, and this delay in definitive management was associated with an increased incidence of complications (P = 0.01). Complications occurred in 28 patients, and there was one fatality at bronchoscopy due to overwhelming aspiration of an unanticipated release of pus, following the removal of a chronically impacted foreign body. The complete classic diagnostic triad (sudden onset of coughing, wheezing and decreased air entry) was seldom present, and we recommend diagnostic bronchoscopy in children presenting with either a history of sudden choking or a witnessed aspiration of a foreign body, an unexplained acute wheeze or cough or a chronic pulmonary infection. This report also highlights the continued need for increased awareness on the part of both parents and medical practitioners of the need for early referral if a foreign body is suspected. Furthermore, public education is needed as regards the dangers of allowing young children to eat peanuts. Peanuts were the commonest foreign bodies removed.

PMID 1519136  S Afr Med J. 1992 Sep;82(3):164-7.
著者: Arbay O Ciftci, Meltem Bingöl-Koloğlu, Mehmet E Senocak, F Cahit Tanyel, Nebil Büyükpamukçu
雑誌名: J Pediatr Surg. 2003 Aug;38(8):1170-6.
Abstract/Text PURPOSE: The aim of this study was to present the entire spectrum of pediatric bronchoscopy performed for foreign body aspiration (FBA), with emphasis on accuracy of diagnostic tools, technical aspects, and predictors of complications.
METHODS: Records of patients who underwent bronchoscopy for evaluation of FBA in our unit from 1991 to 2000, inclusive, were reviewed retrospectively. Age, sex, history of FBA, symptoms, results of radiologic studies, bronchoscopy findings, complications, and outcome were recorded and statistically analyzed to find out the most accurate diagnostic tool.
RESULTS: A total of 740 bronchoscopies were done in 663 children (402 boys, 261 girls) presenting with a mean age of 3.1 +/- 0.1 years. FBA was confirmed in 563 (85%) patients, whereas normal bronchoscopic findings, signs of pulmonary infection, and endobronchial mass were noted in 43 (6%), 54 (8%), and 3 (0.4%) patients, respectively. There was significant difference between patients with and without FBA with regard to presence of definite history (91% v 54%), normal physical examination findings (14% v 46%), and normal radiologic findings (13% v 31%). However, none of these parameters or their associations were found to be reliable to predict the presence of FBA or clinical complications. Presence of history was the most sensitive (91%), accurate (84%), and specific (46 %) diagnostic tool. Bronchoscopic removal of-foreign bodies was succeeded in 558 (99%) children. Worsening of respiratory tract infection (n = 13), cardiac arrest (n = 6), laryngeal edema (n = 5), pneumothorax (n = 5), pneumomediastinum (n = 2), tracheal laceration (n = 2), and bronchospasm (n = 2) were the life-threatening complications observed in 21 (4%) patients with FBA and 14 (14%) patients without FBA (P <.05). There were 5 (0.8%) deaths. Of these, 2 patients presented with cardiopulmonary arrest immediately after FBA. Although foreign bodies were removed as quickly as possible, cardiac arrest was irreversible. The remaining 3 patients died of complications of bronchoscopy as irreversible cardiac arrest during bronchoscopy (n = 1) and worsening of respiratory tract infection after bronchoscopy (n = 2).
CONCLUSIONS: The third year of the life carries the highest risk for FBA. There are no specific symptoms and signs to make a clear-cut differential diagnosis between FBA and respiratory tract infection. Bronchoscopy is invariably indicated on the basis of reliable history alone even when symptoms are minimal, and imaging studies are negative. Secondary bronchoscopy should be done in patients with persistent signs and symptoms to rule out overlooked organic foreign body particles or to remove persistent granulation tissue to avoid long-term complications necessitating lobectomy. The long duration of the procedure, presence of dense granulation tissue, and type of foreign body are important predictors of complications. Bronchoscopy should be regarded as an expert procedure and done with great care to avoid lethal complications. Differential diagnosis of respiratory tract infection by various diagnostic tools is of utmost important to avoid morbidity and mortality related to needless bronchoscopy.

PMID 12891487  J Pediatr Surg. 2003 Aug;38(8):1170-6.
著者: Laurence H Raney, Joseph D Losek
雑誌名: J Emerg Med. 2008 Jan;34(1):63-6. doi: 10.1016/j.jemermed.2007.03.004. Epub 2007 Jul 20.
Abstract/Text Aspirated or swallowed coins are a common phenomenon resulting in a pediatric patient presenting to the Emergency Department. The location of the coin (trachea vs. esophagus) is commonly determined by the alignment of the coin on radiographic studies. We present a child who had an esophageal coin but radiographic findings that supported a coin located in the trachea. Our case illustrates the importance of performing radiographic studies that include both anteroposterior and lateral neck/chest views in patients who aspirate or swallow coins.

PMID 17976776  J Emerg Med. 2008 Jan;34(1):63-6. doi: 10.1016/j.jemerm・・・
著者: Steve C Lee, Charles S Ebert, Lynn Fordham, Austin S Rose
雑誌名: Int J Pediatr Otorhinolaryngol. 2008 Oct;72(10):1487-91. doi: 10.1016/j.ijporl.2008.06.013. Epub 2008 Aug 8.
Abstract/Text OBJECTIVE: To determine the sensitivity and specificity of plain films in differentiating coin batteries from coins.
SETTING: Study was conducted at a tertiary referral university medical center.
METHODS: Eleven radiographs were taken of various objects and independently reviewed by 14 radiologists and otolaryngologists. Reviewers were asked to identify the object filmed as either a battery or not a battery. In addition, otolaryngologists were asked if they would immediately proceed to the operative suite for removal based on the film. Results were tabulated and analyzed using a spreadsheet.
RESULTS: Overall, plain films had a sensitivity and specificity of 80.4% and 79.1%, respectively with an overall accuracy of 79.8%. When used as a test to determine urgency of removal, sensitivity increases to 94.4% while specificity decreases to 67.1% with an overall accuracy of 83.1%.
CONCLUSIONS: Plain films are an effective method of evaluating for the possibility of batteries as esophageal foreign bodies.

PMID 18687477  Int J Pediatr Otorhinolaryngol. 2008 Oct;72(10):1487-91・・・
著者: Danielle Orsagh-Yentis, Rebecca J McAdams, Kristin J Roberts, Lara B McKenzie
雑誌名: Pediatrics. 2019 May;143(5). doi: 10.1542/peds.2018-1988. Epub 2019 Apr 12.
Abstract/Text OBJECTIVES: To describe the epidemiology of foreign-body ingestions (FBIs) of children <6 years of age who were treated in US emergency departments from 1995 to 2015.
METHODS: We performed a retrospective analysis using data from the National Electronic Injury Surveillance System for children <6 years of age who were treated because of concern of FBI from 1995 to 2015. National estimates were generated from the 29 893 actual cases reviewed.
RESULTS: On the basis of those cases, 759 074 children <6 years of age were estimated to have been evaluated for FBIs in emergency departments over the study period. The annual rate of FBI per 10 000 children increased by 91.5% from 9.5 in 1995 to 18 in 2015 (R2 = 0.90; P < .001). Overall, boys more frequently ingested foreign bodies (52.9%), as did children 1 year of age (21.3%). Most children were able to be discharged after their suspected ingestion (89.7%). Among the types of objects ingested, coins were the most frequent (61.7%). Toys (10.3%), jewelry (7.0%), and batteries (6.8%) followed thereafter. The rates of ingestions of those products also increased significantly over the 21-year period. Across all age groups, the most frequently ingested coin was a penny (65.9%). Button batteries were the most common batteries ingested (85.9%).
CONCLUSIONS: FBIs remain common in children <6 years of age, and their rate of ingestions has increased over time. The frequency of ingestions noted in this study underscores the need for more research to determine how best to prevent these injuries.

Copyright © 2019 by the American Academy of Pediatrics.
PMID 30979810  Pediatrics. 2019 May;143(5). doi: 10.1542/peds.2018-198・・・
著者: Angelo Montana, Monica Salerno, Alessandro Feola, Alessio Asmundo, Nunzio Di Nunno, Filomena Casella, Emilpaolo Manno, Federica Colosimo, Raffaele Serra, Giulio Di Mizio
雑誌名: Int J Environ Res Public Health. 2020 Jun 30;17(13). doi: 10.3390/ijerph17134700. Epub 2020 Jun 30.
Abstract/Text (1) Background: Foreign body aspiration (FBA) is a significant public health concern among the pediatric population, and fatalities are dramatic for families. It typically involves organic foreign bodies (mainly food) aspirated by children under three years old, usually at home or school. This review aimed to focus on the preventive measures around four actual cases of fatal foreign body aspiration, emphasizing the correct execution of the Heimlich maneuver and cardiopulmonary resuscitation, supervised mealtimes, and high-risk foods. (2) Methods: Four fatal cases of foreign body aspiration in children are presented here. The children were in a free environment, such as school, home, and the countryside, and were in the presence of teachers, parents, and a grandmother who did not supervise the children adequately. A literature review was performed via the MEDLINE database using the key terms: "foreign body aspiration," "infant choking, 1.5 to 3 years," "food and foreign body aspiration," "common household," "prevention of foreign body aspiration," "guidelines," "recommendations," "training of caregivers (parents, educators)," "resuscitation," "Heimlich maneuver," and "disengagement of the upper airways." We focused on the prevention of foreign body aspiration. (3) Results: a complete postmortem examination was performed. In three cases, the foreign bodies were food (mozzarella cheese, pear, or raw bean), while in one case, the foreign body was a pebble. (4) Conclusions: This review aimed to discuss recent scientific literature and provide a perspective on the benefits of a dedicated approach to the management of fatal foreign body aspiration in children by caregivers who usually have no experience with the best ways of supervising children in a safe environment, especially regarding the correct execution of resuscitation maneuvers, such as the Heimlich maneuver. Recommendation updates could improve healthcare quality in a pediatric setting and reduce medico-legal implications.

PMID 32629891  Int J Environ Res Public Health. 2020 Jun 30;17(13). do・・・
著者: Zhao-Shen Li, Zhen-Xing Sun, Duo-Wu Zou, Guo-Ming Xu, Ren-Pei Wu, Zhuan Liao
雑誌名: Gastrointest Endosc. 2006 Oct;64(4):485-92. doi: 10.1016/j.gie.2006.01.059. Epub 2006 Aug 22.
Abstract/Text BACKGROUND: Reports on endoscopic management of ingested foreign bodies of the upper-GI tract in China are scarce.
OBJECTIVE: To report our experience and outcome in the management of ingestion of foreign bodies in Chinese patients.
SETTING AND PATIENTS: Between January 1980 and January 2005, a total of 1088 patients (685 men and 403 women; age range, 1 day to 96 years old) with suspected foreign bodies were admitted to our endoscopy center.
INTERVENTIONS: All patients underwent endoscopic procedure after admission.
MAIN OUTCOME MEASUREMENTS: Demographic and endoscopic data, including age, sex, and referral sources of patients, types, number and location of foreign bodies, associated upper-GI diseases, endoscopic methods, and accessory devices for removal of foreign bodies were collected and analyzed.
RESULTS: A total of 1090 foreign bodies were found in 988 (90.8%) patients. The types of foreign bodies varied greatly: mainly food boluses, coins, fish bones, dental prostheses, or chicken bones. The foreign bodies were located in the pharynx (n = 12), the esophagus (n = 577), the stomach (n = 441), the duodenum (n = 50), and the surgical anastomosis (n = 10). The associated GI diseases (n = 88) included esophageal carcinoma (33.0%), stricture (23.9%), diverticulum (15.9%), postgastrectomy (11.4%), hiatal hernia (10.2%), and achalasia (5.7%). A rat-tooth forceps and a snare were the most frequently used accessory devices. The success rate for foreign-body removal was 94.1% (930/988).
CONCLUSIONS: Ingestion of foreign bodies is a common clinic problem in China. Endoscopy procedures are frequently performed, and a high proportion of patients with foreign bodies require endoscopic intervention.

PMID 16996336  Gastrointest Endosc. 2006 Oct;64(4):485-92. doi: 10.101・・・
著者: Pilar Anton-Martin, Pallav Bhattarai, Peter Rycus, Lakshmi Raman, Renee Potera
雑誌名: J Emerg Med. 2019 May;56(5):523-529. doi: 10.1016/j.jemermed.2019.01.036. Epub 2019 Mar 14.
Abstract/Text BACKGROUND: Foreign body aspiration (FBA) is a common cause of morbidity and mortality in children < 3 years of age. Guidelines recommend performing a bronchoscopy in any suspected or confirmed FBA. Extracorporeal membrane oxygenation (ECMO) can be used as a rescue mode of support in children with life-threatening FBA for stabilization before, during, and after removal.
CASE REPORT: We present a series of children with life-threatening FBA who were placed on ECMO for stabilization before or after FB removal and a review of the literature and the Extracorporeal Life Support Organization database. Foreign bodies were removed without complications, and all patients survived ECMO support and were promptly discharged home. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: ECMO can be safely used in the stabilization of children with life-threatening FBA before, during, and after bronchoscopic removal. ECMO should be considered in the stabilization of children presenting with FBA to facilitate removal.

Copyright © 2019. Published by Elsevier Inc.
PMID 30879854  J Emerg Med. 2019 May;56(5):523-529. doi: 10.1016/j.jem・・・
著者: T E Zimmers, S B Chan, P L Kouchoukos, H Mirande, Y Noy, B VanLeuven
雑誌名: Ann Emerg Med. 1988 Jul;17(7):693-5.
Abstract/Text Twenty-six patients were treated with a gas-forming mixture of tartaric acid and sodium bicarbonate to relieve esophageal food impactions. A success rate of 65% was achieved, with one patient suffering a mucosal tear of the esophagus. Recommendations are made to limit the use of such gas-forming agents to impactions less than six hours old and in patients without chest pain.

PMID 2837929  Ann Emerg Med. 1988 Jul;17(7):693-5.
著者: M I Robbins, M J Shortsleeve
雑誌名: AJR Am J Roentgenol. 1994 Feb;162(2):325-8. doi: 10.2214/ajr.162.2.8310919.
Abstract/Text OBJECTIVE: In 1990, we described a combination therapy that uses glucagon, an effervescent agent, and water to relieve acute esophageal food impaction. The initial trial showed relief of the obstruction in 12 of 16 cases without complication, so we continued the series to determine the safety and effectiveness of this technique.
SUBJECTS AND METHODS: Between July 1987 and August 1993, a prospective trial consisting of 43 patients with 48 episodes of acute (less than 24-hr duration) food impaction in the distal two thirds of the esophagus were identified with either a barium or water-soluble contrast agent swallow. Subsequently, we attempted to relieve the obstruction by using 1 mg of IV glucagon, an effervescent agent, and water. A water-soluble esophagogram was obtained immediately in all cases to determine the response to the therapeutic intervention and to look for any complication such as perforation.
RESULTS: The combination therapy resulted in the clearance of food obstruction in 33 (69%) of 48 attempts. One complication, a minor mucosal laceration, occurred after two unsuccessful treatments. A lower esophageal ring was the single most common abnormality identified (n = 24). The average width of rings in the successful cases was 15.4 mm and the average in the unsuccessful cases was 13 mm. Other underlying causes of obstruction were esophagitis and stricture.
CONCLUSION: Our experience with the use of glucagon, an effervescent agent, and water to relieve acute esophageal food impaction indicates that the technique is highly successful and that serious complications are rare.

PMID 8310919  AJR Am J Roentgenol. 1994 Feb;162(2):325-8. doi: 10.221・・・
著者: Anette Mortensen, Nikolaj Friis Hansen, Ole Mikael Schiødt
雑誌名: Am J Emerg Med. 2010 Oct;28(8):984.e5-6. doi: 10.1016/j.ajem.2010.01.007. Epub 2010 Apr 2.
Abstract/Text
PMID 20825843  Am J Emerg Med. 2010 Oct;28(8):984.e5-6. doi: 10.1016/j・・・
著者: Howard I Pryor, Patricia A Lange, Ali Bader, James Gilbert, Kurt Newman
雑誌名: J Am Coll Surg. 2007 Jul;205(1):182-6. doi: 10.1016/j.jamcollsurg.2007.01.060.
Abstract/Text
PMID 17617348  J Am Coll Surg. 2007 Jul;205(1):182-6. doi: 10.1016/j.j・・・

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