Foreign body - Oesophageal and Ingested


These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

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To guide PCH Emergency Department (ED) staff with the assessment and management of oesophageal and ingested foreign bodies in children.


  • Most foreign bodies pass harmlessly through the gastrointestinal tract.
  • Once they are in the stomach, most objects will usually pass through the pylorus and the ileocaecal valve and are unlikely to cause complications.
  • Ingested button batteries are potentially an emergency and can have serious (even fatal) complications.

Key points1

  • The commonest age of presentation is 6 months to 4 years.
  • The usual presentation for children is the witnessed ingestion of a foreign body.
  • Less commonly the child presents with a complication of unwitnessed foreign body ingestion.
  • Complications due to food ingestion are uncommon in children.
  • Oesophageal impaction with a foreign body may occur at any of 3 typical locations:
    • 70% occur at the cricopharyngeus sling at the thoracic inlet (between the clavicles on chest X-ray).
    • 15% occur in the mid-oesophagus (at junction of aortic arch and carina on chest X-ray).
    • 15% occur at the lower oesophageal sphincter.
  • Impaction at other sites in the oesophagus suggests an underlying oesophageal abnormality.
  • A foreign body may rarely impact in a Meckel’s diverticulum.
  • Special consideration is needed for sharp, very large (too long > 6cm, or too wide > 2cm) or toxic foreign bodies (e.g. button batteries).
  • Children with pre-existing gastro-intestinal tract (GIT) abnormalities (including repaired tracheo-oesophageal fistula or eosinophilic oesophagitis) are at increased risk for complications from foreign body ingestion.
  • Impaction of button batteries in the GIT may lead to local inflammation with pain, bleeding, scarring or erosion through the GIT (mediastinitis, aortoenteric fistula, peritonitis).


Symptoms of an oesophageal foreign body include:

  • Dysphagia
  • Food refusal, drooling
  • Chest pain
  • Vomiting, hematemesis
  • Throat pain
  • Unexplained fever
  • Altered mental state.

Symptoms of an impacted foreign body in the stomach or lower GIT include:

  • Abdominal pain, abdominal distension
  • Vomiting, haematemesis
  • Haematochezia
  • Malaena
  • Unexplained fever.



  • Most foreign bodies are radiopaque and a single frontal X-ray including the lower neck, chest and abdomen is usually sufficient to locate the object
  • An additional lateral X-ray may confirm if the foreign body is in the oesophagus
  • Repeat X-rays are not generally necessary if the object is below the diaphragm
  • Radiolucent objects may be located by looking for their effects (such as compression) seen on plain X-rays, but may require direct visualisation under oesophagoscopy or specialist radiographic techniques after discussion with a Paediatric ENT Surgeon.


  • Under a general anaesthetic, this may be diagnostic and therapeutic
  • The patient should be fasted and pre-procedure X-rays taken to verify that the foreign body has not passed spontaneously
  • Management of children with known GIT abnormalities should be discussed with the Paediatric Gastroenterology team.

Blood tests

  • These are generally only indicated for specific complications (e.g. infection), or for heavy metal toxicity if the patient is symptomatic of defragmented ingested button battery.


Initial management

  • The drooling child may require suction
  • Spontaneous passage of a foreign body lodged at the lower oesophageal sphincter may occur after several hours, and the stable patient with normal anatomy may be observed in hospital, allowed to eat and re-X-rayed at 12-24 hours.
  • Contact Toxicology or WA Poisons Information Centre on 13 11 26 for toxic ingestions (e.g. heavy metals, cigarettes)

Further management

Special circumstances


  • A single frontal X-ray of the lower neck, chest and abdomen will verify the presence and location of the coin
  • Once in the stomach, most coins will pass uneventfully and patients can be discharged home, with advice to return if they develop abdominal pain or vomiting
  • Parental examination of the stools and serial X-rays are unnecessary
  • Admission is warranted for patients with oesophageal impaction who are symptomatic; however many lodged at the lower oesophageal junction will spontaneously pass within a few hours. If not, referral to gastroenterology for endoscopic removal is indicated.
  • Upper oesophageal coins require endoscopic removal by ENT.

Button (Disk) Batteries2,3

Oesophageal Button Batteries

  • A button battery lodged in the oesophagus is a medical emergency and can cause serious complications and even death.
  • All children with suspected button battery ingestion should be X-rayed to verify position and size. 
    • On X-ray a button battery is a rounded with a double density rounded edge (halo sign). 
  • Button batteries located in the oesophagus should be removed immediately to avoid liquefaction necrosis and perforation of the oesophagus. Contact ENT immediately once button battery is identified.
  • If there will be a delay for definitive removal, honey has been shown to reduce mucosal injury4:
    • Give 10 mL (2 teaspoons) honey every 10 minutes for up to 6 doses if child >12 months (risk of botulism in younger infants)
    • Only give honey if readily available, is tolerated by child and it does not delay definitive transfer or care

Ingested Button Batteries which have passed oesophagus

  • Most button batteries are less than 15mm in diameter.
  • Older children will usually successfully pass batteries up to 21-23 mm in diameter, and batteries that have traversed the oesophagus are unlikely to lodge elsewhere.
  • If the battery is located in the stomach it will usually pass through the remainder of the GIT. 
  • A button battery ≥ 15mm diameter swallowed by a child < 6 years is unlikely to be passed from the stomach if it has not done so by 48hours.  Endoscopic removal (by gastroenterology) should be considered
  • Children who have ingested button batteries should have their stools monitored for passage of the battery, and regular weekly X-rays considered.
  • Discharged patients should be advised to return immediately if symptoms of abdominal pain or distension, tarry or bloody stools, persistent vomiting or fever.
  • Heavy metal toxicity is a rare complication.
  • Serum lithium and mercury levels should be considered if there is repeated vomiting or central nervous system disturbance (altered mental state, ataxia), especially if X-ray shows defragmentation of the battery.
  • Rarely, nickel sensitivity may cause a rash.

Sharp Objects

  • Fish or chicken bones are most common.
  • The patient may be able to accurately localise the foreign body in the pharynx or the upper third of the oesophagus.
  • Acute symptoms range from minor discomfort, pain, dysphagia, drooling, gagging, airway compromise or delayed symptoms of poor feeding, fever, stridor or respiratory symptoms, abdominal pain or vomiting.
  • Fish bones in the pharynx may be radio-opaque, depending on the size of the bone and the type of fish.
  • A foreign body in the oropharynx may be removed in the ED under direct vision after application of local anaesthetic spray, by the ED Doctor or ENT Surgeon.
  • Abrasions to the oropharynx can also create a foreign body sensation. Children with minor symptoms in whom there has been failure to directly visualise a foreign body and in whom the X-ray is negative, may be discharged home and reviewed at 24 hours, or earlier if symptoms increase.
  • Endoscopy is required immediately for airway compromise, or for sharp foreign bodies > 6cm (including toothpicks, chicken bones which have a high risk of perforation) that are in the oesophagus or the stomach. Such foreign bodies which have passed beyond the pyloric sphincter into the small intestine don’t necessarily need to be removed, but should be referred to the General Surgical team for an opinion.
  • Metal screws will generally pass through the GIT with the blunt end leading.
  • Aluminium can tabs have a high risk of entrapment in the oesophagus, so endoscopy should be considered early. They are radio-opaque and thus easily seen on X-ray (particularly on lateral view).


  • If more than one magnet has been ingested, damage can be caused when bowel wall is trapped between two magnets when they are attracted to each other.
  • If multiple magnets in the stomach, discuss with the Paediatric Gastroenterology team to consider endoscopy.
  • If they are in the small or large intestine, discuss with the General Surgical team.


  • Patients need to be monitored for signs of complications arising from foreign body ingestion.
  • Inform treating doctor immediately if haematemesis, respiratory symptoms (stridor or wheeze), altered mental state or signs of shock.
  • Full set of observations - temperature, respiratory rate, heart rate, blood pressure, oxygen saturations and pain score.


  1. Gilger MA & Jain AK (2022) Foreign bodies of the esophagus and gastrointestinal trract in children. UpToDate. Accessed at
  2. Litovitz T, Whitaker N, Clark L, White NC, Marsolek M (2010) Emerging battery ingestion hazard: clinical implications, Paediatrics, 125:6, p1168-1177
  3. Jatana KR, Litovitz T, Reilly JS, Koltai PJ, Rider G, Jacobs IN (2013) Paediatric button battery injuries: 2013 task force update, International Journal of Paediatric Otorhinolaryngology, 77, p1392-1399
  4. Anfang RR, Jatana KR, Linn RL, Rhoades K, Fry J, Jacobs IN. “pH-neutralizing esophageal irrigations as a novel mitigation strategy for button battery injury,” The Laryngoscope 2019 Jan;129(1):49-57.

Endorsed by:  Co-director, Surgical Services  Date:  Oct 2023

 Review date:   Oct 2026

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