IMAGE OF THE WEEK

WEEK 44

CHYLOTHORAX

Ingested foreign bodies (FBs) are common among children and less common in adults. It has been reported that up to four percent of children have ever ingested a FB. The incidence is highest in children aged between 6 months to 4 years, the age when children are more likely put things into their mouths. In teenagers or adults, concomitant psychiatric problems and mental disturbances need to be suspected. In these cases, there is often recurrent history or the number of ingested FBs are often multiple. In other instances, FBs ingestion is intentional and is associated with risk taking behaviours or illegal activities such as ‘body packing’.

The most commonly reported FBs are coins. Other FBs include small parts of toys, button batteries, pins and screws in children and fish bones in regions where fish is a major dietary staple. Other FBs include nails, hairs, cutleries, jewelries and packaged drugs in rubber containers such as condoms (drugs).

Most ingested foreign bodies pass through the gastrointestinal tract without causing any complications. There are several locations where FBs are more likely to get impacted or retained due to anatomical narrowing such as sphincter, external compressions or valves. Any pathological states causing narrowing (previous surgeries, strictures or tumours) of the gastrointestinal lumen will lead to higher risk of retention. The size and shape of FBs are also important determinant of being retained, impacted or to cause perforations. There anatomical locations in the gastrointestinal tract where FBs may get retained or impacted are as follow:

Pointed FBs (i.e. thumbtacks, fishbones, pins and screws) may become impaled and, therefore, lodged anywhere part of the gastrointestinal tract. Pointed FBs can also lead to perforations resulting in mediastinitis (oesophagus), peritonitis (abdomen) or abscesses (stomach adjacent to the liver). Small objects, such as pills and smaller button batteries, may adhere to the slightly moist and cause local complications. Ingestion of more than one magnet can lead to serious complications obstruction or necrosis of the intervening tissues. In body-packers, if there is rupture of the condom package, it can lead to serious acute fatal consequence of drug overdose (cocaine or heroin).

FB in the oesophagus should be removed if there are symptoms. Otherwise, they can be monitored for movement into the stomach. Once a FB reaches the stomach, it is much less likely to lead to complications. Exceptions include pointed or toxic FBs or FBs that are long (>6 cm) or too wide (>2 cm) to pass through the pyloric sphincter. Larger objects that are unlikely to pass spontaneously or are causing complications should be removed. Endoscopy can be considered for small objects (Figures 1 and 2). Surgery is the preferred options for larger FBs.

Image and text contributed and prepared by

Dr Vui Heng Chong, Department of Internal Medicine, RIPAS Hospital, Brunei Darussalam.

All images are copyrighted and property of RIPAS Hospital.