Mahsa Akhavan, MDPediatric Emergency Medicine Fellow

Cohen Children’s Medical CenterMarch 16, 2011

Frequent reason for pediatric ED visits

More than 125,000 ingestions of foreign bodies by <19 years old reported to American Poison Control Centers in 2007

Common entrapment sites: Proximal esophagus at thoracic inlet (skeletal to

smooth muscle change) Mid-esophagus: Level of carina and aortic arch Lower Esophageal Sphincter

Common foreign bodies: Coins Food Small metallic and plastic toys Buttons Bones Batteries

Most gastric objects pass without complication

70% of esophageal objects remain entrapped, especially upper/ mid-esophagus

XRay

Consider Warning Signs Require immediate removal?

Endoscopy

Wait for passage

Induces immediate, short-lived relaxation of enteric smooth muscle

Alters motility

Reduces LES resting pressure

0.5mg or 1mg IV often used in cases of FBI or food impaction in adults

0.1mg/kg, max 1mg in children

Most common side effect: Vomiting

Nonrandomized small trials reported 37-75% success rates in relieving esophageal foreign bodies with glucagon

Newer, small but double-blind, placebo controlled studies failed to show difference from placebo

Mostly adult literature

Mostly for food impaction

One article on coin dislodgement in children

Mehta, Acad Emerg Med, Feb 2001

Prospective, double blind, placebo controlled

Children 1-8yo presenting to Peds ER with XRay confirmed single coin impaction

Exclusion: those with warning signs

1mg IV glucagon versus placebo

Repeat XRay in 30-60min

42 pts presented, 18 enrolled 17 didn’t qualify, 4 weren’t invited, 3 didn’t

consent

14 patients completed 1 excluded due to vomiting and chest pain Additional pts not pursued due to inefficacy

9 in glucagon group, 5 in placebo

Two groups similar in age, coin position, time to presentation, time to repeat XRay

15% in glucagon group passed coin to stomach

60% passes coin to stomach in placebo group

Conclusion: Glucagon does not seem to be effective in

dislodgement of esophageal coins in children

Limitation: Small sample size but well designed

Tibbling, Dysphagia, 1995

Multicenter, placebo controlled, double blind study

Glucagon plus diazepam versus placebo

43 pts enrolled, 24 to treatment group, 19 to placebo

Disimpaction noted in: 38% of treatment group 32% of placebo group

Difference not statistically significant

Limitations: Small sample size Treatment group received glucagon PLUS

diazepam▪ Clouds effect of glucagon alone

Al-Haddad, Dig Dis Sci, 2006.

Retrospective case series, adult population

92 patients with EFBI, all by food

Glucagon given to all patients

33% had complete resolution of symptoms

62% went for endoscopy

Difficult to make conclusions

Limitations: Retrospective with selection bias Unknown number of pts who went home

without glucagon treatment and why the enrolled received glucagon

No placebo group for comparison Uncontrolled design - other patient meds?

Sodemon, Dysphagia, 2004

All patients with acute food impactions from 1975-2000 from Mayo database

222 cases identified

106 received glucagon (48%), average 1mg

Data collected on Age Sex BMI PMH Food type ingested Duration of symptoms at presentation Dose of glucagon

Findings: Meat less likely responsive to glucagon (70%

versus 90%)

No significant difference in terms of age, sex, BMI, and PMH

0.5mg versus 1mg of glucagon did not make a difference

Success rate:▪ Glucagon group - 9.4%▪ Control group - 17.2%

Limitations: Retrospective▪ May have lead to higher success rate in

control group

Conclusions: Glucagon less likely to work in meat

impaction

Unclear benefit compared to control or spontaneous resolution

No good evidence supporting use of glucagon

All studies either small or not well designed

Well designed studies show no difference from placebo/ control and thus spontaneous resolution

Risk of use is minimal, vomiting primarily, so may try

May not be worth extra delay in discharge from

ED/ admission/ EGD

Al-Haddad M, Ward EM, Scolapio JS, Ferguson DD, Raimondo M. Glucagon for the relief of esophageal food impaction does it really work?. Dig Dis Sci. Nov 2006;51(11):1930-3.

Arana  A, Hauser  B, Hachimi-Idrissi  S, Vandenplas  Y.  Management of ingested foreign bodies in childhood and review of the literature.  Eur J Pediatr.  2001;160:468–72.

Chen  MK, Beierle  EA.  Gastrointestinal foreign bodies.  Pediatr Ann.  2001;30:736–42.

Metha D, Attia M, Cronan K. Glucagon for esophageal coin dislodgement in children: a prospective, double-blind, placebo-controlled study. Acad Emerg Med. Feb 2001;8(2):200-3.

Sodeman TC, Harewood GC, Baron TH. Assessment of the predictors of response to glucagon in the setting of acute esophageal food bolus impaction. Dysphagia 2004;19:18-21.

  Tibbling L, Bjorkhoel A, Jansson E, et al. Effect of spasmolytic

drugs on esophageal foreign bodies. Dysphagia 1995;10:126-7.