# Pediatric Endoscopy, Update 2020
## 4 Esophago-Gastro-Duodenoscopy
### Intervention
#### 4.6.2 Foreign Body Ingestion  
Foreign bodies often get stuck in anatomical areas with a relatively smaller diameter in the gastrointestinal tract. These areas are the three constrictions of the esophagus, the pyloric region, and the ileococcal valve. In the esophagus, the most common constriction is in the middle of the organ. The immediate risk to the patient ranges from negligible to life-threatening, depending on the ingested substance, its location, patient fitness, and time to appropriate therapy [71]. If there is a chance that a spontaneous passage of the foreign body might occur, endoscopy should be withheld. However, batteries and magnets should be removed as soon as possible. Already after a short time, complications like fistulas, ulcerations, and perforations can occur (up to 13%) [72; 42; 73; 74; 75]. Battery ingestion, particularly in the pediatric population, has become more common since the development of button batteries. Larger cylindrical battery ingestion is less common [76].  
For the removal procedure, a variety of endoscopic equipment comes into play. A very useful tool seems to be a polyp recovery net. The net structure secures nearly every shape of a foreign body and can even protect the mucosa from sharp ends. Other tools like an alligator forceps or a single tooth forceps can be very helpful. In round and hard to pick up objects, a Dormia basket is recommendable. For soft objects, single wired snares are possibly the best removal tools. The physician should act with a great deal of inventiveness because no situation is equal to the next one. For instance, some objects with a small hole can be removed by insertion of a forceps through the hole and open the forceps behind. Simple and inexpensive devices such as Foley catheters and magnet-attached tubes can be used in emergencies [77]. The success rates for rigid esophagoscopy (100%) and flexible endoscopy (96.2%) were not significantly different (\(p>0.05\)). Overall, rigid esophagoscopy had a higher complication rate than flexible endoscopy (10% versus 5.1%, \(p>0.05\)), but this trend did not reach statistical significance [78]. An accurate history is of paramount importance to establish if the ingested body is an acid or a base. In case of acid or base inges, the indication to arrange an endoscopy is based on the symptoms. However, the impact of an early gastroscopy is not quite clear [17]. Every acid and base ingestion should be graded according to the mucosal defect because the grade of injury has a prognostic value (Table 4). The grades 1 and 2 have a relative good prognosis whereas grade 2b and 3 may lead to complications.  
\begin{table}
\begin{tabular}{l l} \hline \hline
**Grade** & **Description** \\ \hline Grade 0 & normal \\ Grade 1 & mucosal irritation, edema, and hyperemia \\ Grade 2a & trans mucosal (bleeding, ensudation, erosion, blisters, ulcerations) \\ Grade 2b & like grade 2a but with transural ulcerations \\ Grade 3 & deep ulcerations with necrosis and with or without perforation \\ \hline \hline \end{tabular}
\end{table}
Table 4: Grading of injury after acid and base ingestion.  
\begin{table}
\begin{tabular}{l} \hline \hline
**Additional Medication in Variecal bleeding** \\ \hline \hline Octreeotide: 1 mg/kg as flush injection (max. 50 mg), followed by 1 mg/kg/h \\ Somatostatin increase of dosage every 8 h possible to 4 mg/kg (max 250 mg within 8 h) \\ After successful stopping of the bleed, doses reduction of 50% in 8 h \\ \hline \hline \end{tabular}
\end{table}
Table 3: Additional medication in variecal bleeding.  
Since the ingestion in children is usually incidental and not with intended self-harm as often in adults, immediate complications like aspiration and obstruction of the airways, which are more frequent in the adult, are rare in the children. Late complications like strictures are more frequent in children.