Referat Radiology - Corpus Alienum

TUGAS MAKALAHCorpus Alienum

Diajukan dalam rangka memenuhi persyaratan co-assisten

SMF Radiologi RSUP Dr. Sardjito Fakultas Kedokteran Universitas Gadjah Mada

Disusun oleh:

Fauzi Syahrul Ramadhan

09/282169/KU/13243

PENDIDIKAN PROFESI KEDOKTERAN

SMF RADIOLOGI

RSUP Dr. SARDJITO

UNIVERSITAS GADJAH MADA

2014

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CONTENTS

CHAPTER I INTRODUCTION

I.1 BACKGROUND...........................................................................................3

I.2 AIM................................................................................................................3

CHAPTER II LITERATURE REVIEW

II.1 DIGESTIVE AND RESPIRATORY TRACT ANATOMY.........................4

II.2 CORPUS ALIENUM...................................................................................6

1. DEFINITION................................................................................................6

2. EPIDEMIOLOGY.........................................................................................7

3. ETIOLOGY..................................................................................................8

4. PATHOPHYSIOLOGY................................................................................8

5. CLINICAL MANIFESTATION...................................................................9

6. PHYSICAL EXAMINATION....................................................................10

7. THERAPY..................................................................................................11

CHAPTER III DISCUSSION

CHAPTER IV CONCLUSION

REFERENCE....................................................................................................17

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CHAPTER I

INTRODUCTION

I.1 BACKGROUND

A  corpus alienum (foreign body, english translation) is any object originating outside

the body. These foreign bodies can propulse into natural body orifices to various hollow

organs in human body. Foreign bodies can be inert or irritating. The irritation due to foreign

bodies will cause inflammation and subsequently scarring. They can also cause infection

acquiring infectious agents. They can obstruct passageways either by the size or by their

effects on human hollow viscous tract. Some of the foreign bodies are toxic to the body

(Munter, 2014).

Children and adults can experience problems due to foreign materials enter their

bodies. Young children are often naturally curious and may intentionally put shiny objects,

such as coins or button batteries, into their mouths, ears and their noses. Objects that have

passed the esophagus, once they reach the stomach, do not cause symptoms unless

complications occur. They are usually eliminated spontaneously with normal bowel

movements. Therefore, one can imagine that a lot of ingested foreign objects are passed daily

without notice because the child has never complained (Nguyen, 2009).

Prior to the 1930s, the mortality associated with FBs was very high. Currently, it is

about 1–2%. In recent years, the develop ment of modern instruments and equipments has

dramatically improved the techniques for the removal of foreign bodies, even in the small

child. During the same period, the ability to make a better diagnosis of foreign body ingestion

or aspiration and their complications has improved, reducing the mortality and morbidity in

these children. Patients with foreign bodies in the gastrointestinal (GI) tract commonly

present to the ED. Foreign bodies in the upper GI tract are usually swallowed, purposefully or

accidentally. The presentation is usually straightforward but on occasion can be extremely

subtle. 

I.2 AIM

The purpose of writing this document is to gain more knowledge regarding the definition, classification, sign and symptoms, radiological finding about corpus alienum, and the managements.

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CHAPTER II

LITERATURE REVIEW

II.1 DIGESTIVE AND RESPIRATORY TRACT ANATOMY

Figure 1 Anatomy of the respiratory tract

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The term respiration has three meanings: (1) ventilation of the lungs, (2) the exchange of

gases between air and blood and between blood and tissue fluid, and (3) the use of oxygen in

cellular metabolism. The principal organs of the respiratory system are the nose, pharynx,

larynx, trachea, bronchi, and lungs (Saladin, 2012). These organs serve to receive fresh air,

exchange gases with the blood, and expel the modified air. Within the lungs, air flows along a

dead-end pathway consisting essentially of bronchi → bronchioles → alveoli. Incoming air

stops in the alveoli (millions of thin-walled, microscopic air sacs in the lungs), exchanges

gases with the bloodstream across the alveolar wall, and then flows back out.

The conducting division of the respiratory system consists of those passages that serve

only for airflow, essentially from the nostrils through the bronchioles. The respiratory

division consists of the alveoli and other distal gas-exchange regions (Saladin, 2012). The

airway from the nose through the larynx is often called the upper respiratory tract, and the

regions from the trachea through the lungs compose the lower respiratory tract.

Figure 2 Anatomy of the digestive tract

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The digestive system has two anatomical subdivisions, the digestive tract and the

accessory organs. The digestive tract is a tube extending from mouth to anus, measuring

about 9 m (30 ft) long in the cadaver (Saladin, 2012). It is also known as the alimentary 2

canal. It includes the oral cavity, pharynx, esophagus, stomach, small intestine, and large

intestine. Part of this, the stomach and intestines, constitute the gastrointestinal (GI) tract. The

accessory organs are the teeth, tongue, salivary glands, liver, gallbladder, and pancreas. The

digestive tract is open to the environment at both ends. Most of the material in it has not

entered any body tissues and is considered to be external to the body until it is absorbed by

epithelial cells of the alimentary canal. In the strict sense, defecated food residue was never in

the body.

II.2 CORPUS ALIENUM

1. DEFINITION

Aspiration of foreign bodies, such as peanuts, carrots or plastic toy pieces, occurs

most often in children under the age of 4 years. The worst case is complete airway

obstruction with total occlusion of the trachea above the carina. Partial obstruction occurs,

when the trachea is partially occluded or when the foreign body obstructs bronchi distal the

carina. The majority of foreign bodies lodge in the main bronchi with almost equal incidence

on the right and left side.

Foreign bodies of the gastrointestinal tract are defined as any external object,

introduced voluntarily or accidentally into the digestive system. Foreign bodies may be

ingested, inserted into a body cavity, or deposited into the body by a traumatic or iatrogenic

injury. In general, foreign bodies in the air and food passages are the sixth most common

cause of accidental death in the United States (Mukherjee & Paul, 2011). The ingestion of a

FB is a relatively common GI emergency that causes significant morbidity. Fortunately, the

vast majority of all swallowed objects pass through the GI tract without a problem. Only 1%

of involuntary and generally unconsciously ingested FB will perforate the bowel and

constitute abdominal emergencies whose diagnosis represents a challenge. Those that cause

perforation are usually sharp, pointed, or elongated. They are usually fish bones, toothpicks,

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and chicken bones. Foreign body ingestions are common in children and mentally

handicapped adults. Although exact figures are unavailable, foreign body ingestion is very

common among children. In the pediatric population, toddlers aged 2–3 years are most

commonly affected because children in this age group are ambulatory and more orally

explorative. While children younger than 6 months are rarely able to get a foreign object into

the oropharynx, infants can ingest foreign bodies with the assistance of a sibling. Any child

can swallow a foreign body; most incidents result in minor annoyance, but a few can lead to

major catastrophe

2. EPIDEMIOLOGY

FB aspiration in the airways is the cause of 160 annual deaths in children younger

than 14 years old in the United States. The 2001 Annual Report of the American Association

of Poison Control Centers noted 115,320 cases of ingestion of a foreign body by children

younger than 20 years. More than 70% of these children are younger than 6 years. Food items

such as peanuts, grains, seeds or pieces of meat compose 50–80% of FBs removed by

endoscopy from children’s aero-digestive tract. In 2001, the US Center for Diseases Control

(CDC) reported an estimated 60% of choking episodes treated in Emergency Department

were due to food items such as peanuts, seeds, candy, gum, pieces of fruit, vegetables and hot

dogs. Another 30% were due to non food substances of which coins accounted for a signifi

cant portion. Other non food items are: plastic pieces, screws, pins and button batteries. Sixty

eight percent of the deaths in children younger than 14 years reported to the Consumer

Product Safety Commission were due to non food substances (Baert, 2008). The remaining

32% of deaths were caused by household items. The majority of deaths occurred in children

aged 3 years and older. The diagnosis of a foreign body in the aero-digestive tract may be

challenging because of the difficulty in obtaining a reliable history from children, especially

when they are very young. In clinical practice, most children (80%) had been witnessed to

choke on an identifi able object but only 52% of events of airway FB were diagnosed early.

An estimated 40% of foreign body ingestions are not witnessed, and in many cases, the child

never develops symptoms. In a retrospective review, only 50% of children with confi rmed

foreign body ingestion were symptomatic.

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3. ETIOLOGY

Children can put just about anything they can grasp into their mouths or their noses

and then swallow it or aspirate it. Foreign bodies (FB) of the aero-digestive tract, whether

they are aspirated, inserted or ingested are potentially dangerous. If they are not diagnosed

early and removed they can result in numerous complications, such as perforation,

obstruction of the gastro-intestinal tract, tissue necrosis, fistula formation, ulcerations,

massive bleeding, airway and lung infections.

4. PATHOPHYSIOLOGY

Food particles or organic materials may absorb water from bronchial secretions and

tend to increase in size. Oil, salt and vegetable proteins irritate the mucosa, leading to oedema

and formation of granulation tissue with subsequent narrowing of the bronchial lumen. Non-

organic materials are usually inert to the bronchial mucosa, unless they remain in the

tracheobronchial tree for a longer time and induce chronic inflammatory changes, such as

ulcerations or epithelialisation.

The oropharynx is well-innervated, and patients can typically localize oropharyngeal

foreign bodies. Scratches or abrasions to the mucosal surface of the oropharynx can create a

foreign body sensation. Chronic foreign bodies or perforations can cause infections in

surrounding soft tissues of the throat and neck.

Patients can usually localize foreign bodies in the upper esophagus but localize them

poorly in the lower two-thirds of the structure. The esophagus has three areas of narrowing:

the upper esophageal sphincter (UES), which consists of the cricopharyngeus muscle; the

crossover of The aorta;andtheloweresophagealsphincter(LES).These areas are where most

esophageal foreign bodies become entrapped (Romano, 2012). Structural abnormalities of the

esophagus, including strictures, webs, diverticula, and malignancies, increase the risk of

foreign body entrapment, as do motor disturbances such as scleroderma, diffuse esophageal

spasm, or achalasia.

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Most foreign objects will pass through the pylorus, although on occasion, some

objects may remain in the stomach for a long period. Once beyond the pyloric canal most

objects, even sharply edged foreign bodies such as pieces of glass or nails, will pass without

harm until the terminal ileum which is again a predilection site for obstruction. Ingested

objects may occasionally remain fixed in the cecum, ascending colon, or sigmoid. Foreign

bodies detected in the rectum have in most instances been introduced transanally.

5. CLINICAL MANIFESTATION

Children with foreign body aspiration usually present with the classical triad of

choking, coughing and wheezing. Other symptoms are stridor, dyspnoea, haemoptysis or

rarely pneumothorax. Crackles, decreased breath sounds in the affected lung and unequal

chest expansion may be found on physical examination, but also normal findings are

common. Besides acute symptoms of respiratory distress, recurrent pneumonia is observed as

late sequelae, especially in patients who aspirated organic material.

Nearly one-third of pediatric patients with esophageal foreign bodies are

asymptomatic. Symptoms depend on the size, shape, and nature of the FB ingested. Large FB

may cause obstruction whereas small and sharp objects may present with symptoms of

esophageal irritation. Symptoms related to esophageal foreign bodies are choking, gagging,

coughing, wheezing, dysphagia, dyspnea, fever, hematochezia, or neck, chest, or abdominal

pain. Children with chronic esophageal foreign bodies may also present with poor feeding,

irritability, fever, or stridor. Most children who have ingested a disk battery remain

asymptomatic. Children with a battery lodged in the esophagus typically present with the

above mentioned symptoms. Rashes following disk battery ingestion have also been reported

and may be a manifestation of nickel hypersensitivity (Dutta & Choudhury, 2008). It is clear

that thin, sharp objects carry a higher risk of perforation; and a safe policy is to treat the

patient expectantly unless there are indications for a more aggressive approach. Large foreign

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bodies are not generally encountered in the small bowel in that rarely pass beyond the pylorus

or the duodenojejunal flexure. A perforation of the peritoneal cavity can cause peritonitis

whereas a retroperitoneal perforation, at the duodenojejunal flexure for example, can lead to

the involvement of the psoas and the formation of an abscess. Nonetheless, the perforation of

jejunal or ileal loop is a rare event (<1% of cases) and is usually caused byextremely pointed

objects, such as fish bones, chicken bones, and toothpicks. Patients with a rectal foreign body

may present with abdominal or rectal pain, pruritus, or bleeding.

6. PHYSICAL EXAMINATION

Major findings include new abnormal airway sounds, such as wheezing, stridor, or

decreased breath sounds. These sounds are often, but not always, unilateral. Sounds are

inspiratory if the material is in the extrathoracic trachea. If the lesion is in the intrathoracic

trachea, noises are symmetric but sound more prominent in the central airways. These sounds

are a coarse wheeze (sometimes referred to as expiratory stridor) heard with the same

intensity all over the chest. Once the foreign body passes the carina, the breath sounds are

usually asymmetric. However, remember that the young chest transmits sounds very well,

and the stethoscope head is often bigger than the lobes. A lack of asymmetry should not

dissuade the observer from considering the diagnosis. Similarly, a lack of findings upon

physical examination does not preclude the possibility of an airway foreign body.

The physical examination typically is not helpful, but the oropharynx, neck, chest,

lungs, heart, and abdomen should be carefully examined. Occasionally, a foreign body in the

oropharynx can be visualized and removed. In cooperative patients, indirect laryngoscopy or

fiberoptic nasopharyngoscopy provides better information than a direct examination. In

children, tracheal compression and stridor suggest a large foreign body at the UES. Complete

obstructions can cause drooling and the inability to swallow. Delayed presentations may be

accompanied by signs of infection, including peritonitis.

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7. THERAPY

Foreign bodies lodged in the esophagus, if not detected early can cause complications.

Depending on the nature of the object and the duration of its presence, these include Button

batteries which can cause esophageal burn, stricture, perforation aortoesophageal fistula,

tracheoesophageal fistula, retropharyngeal abscess; sharp objects which can cause

perforation, abscess, retropharyngeal abscess mediastinitis, stricture, esophagitis. Foreign

bodies in the esophagus should be removed promptly. Three main techniques have been

described for removal of FBs in the esophagus, Extraction by using Foley catheter,

Bougienage, Endoscopic retrieval (Munter, 2014). The first two techniques are limited to

smooth objects such as coins. The choice between the three techniques depends on factors

such as, size and shape of the FB, History of esophageal abnormalities, how long the FB has

been lodged in the esophagus, preference of treating physician

Foley catheter retrieval is generally successful for removing smooth objects like coins

located in the upper two thirds of the esophagus. It can be performed in an outpatient setting

with or without fluoroscopic guidance. Full resuscitation equipments should be available

during the procedure. With the patient lying down in lateral decubitus and Trendelenburg, the

Foley catheter is inserted into the esophagus through the mouth. Under fluoroscopy, the tip is

passed further down, beyond the location of the FB. The balloon is infl ated and carefully

pulled back to bring the FB back into the mouth so it can be retrieved. Success rate reported

was excellent, up to 96%. This technique is not applicable for a coin that has been lodged in

the esophagus for more than 2–3 days because it may be impacted.

Bougienage is a simple method for pushing smooth objects into the stomach with the

expectation that they will then be eliminated spontaneously (up to 95%). Bougienage will be

attempted in a selected group of patients, a single coin or impacted meat ingested less than 24

h since the ingestion, no esophageal abnormalities, no respiratory distress. Done under

general anesthesia, endoscopic retrieval is the most thorough technique for safe removal of

sharp or impacted objects in the esophagus with a success rate approaching 100%. At the

time of the retrieval, the esophagus and its mucosa can be carefully inspected. Any

esophageal stenosis can be dilated in the same setting. For FBs that are present in the

esophagus for an unknown duration, endoscopic removal is the only acceptable procedure.

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Thoracotomy will be required to retrieve FBs in the mediastinum and to treat complications

such as aorto-esophageal fistula, tracheo-esophageal fistula, mediastinitis.

CHAPTER III

DISCUSSION

Chest radiography is usually the first imaging technique performed in children with

suspected foreign body aspiration. Because most aspirated foreign bodies are radiolucent, the

diagnosis is commonly based on indirect signs, such as obstructive emphysema, shifting of

the mediastinum and unequal movement of the hemidiaphragms. Assessment by inspiratory

and expiratory chest X-rays, lateral decubitus radiographs or with the use of fluoroscopy is

often necessary additionally to plain chest radiographs. In some instances CT may provide

additional information, because of its high sensitivity in demonstrating radiolucent foreign

bodies. Low-dose MDCT and virtual bronchoscopy has shown good results in identifying the

exact location of a foreign body before bronchoscopy and in ruling out a foreign body in

patients with a low level of suspicion and normal or non-specific findings on chest

radiography. MRI has been used for the diagnosis of peanut inhalation, however the high cost

and the need for sedation prevents routine use of MRI in children with foreign body

aspiration.

Figure 3 Radiograph showing ingested beads (left), and coin in esophagus (right)

The relative difficulty in identifying a foreign body varies according to the type of

object ingested and its radio-opacity. Metal objects with a relatively high atomic weight are

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readily visible with plain film radiography in that they are intensely radiopaque regardless of

their volume. Radiopaque materials are glass of all types; most metallic objects (except

aluminum); most animal bones and some fish bones; some foods; some soil fragments, sand,

gravel, and mineral fragments; some medications and poisons (CHIPES: chloral hydrate,

heavy metals, iodides, phenothiazines, enteric coated pills, solvents).

Nonradiopaque materials at times may not be identifiable as they are composed of

material with a relatively low atomic weight and therefore have intrinsically low radiopacity.

Nonradiopaque materials are most foods and medicines; most fish bones; most wood,

splinters, thorns of all types; most plastics; most aluminum objects.

Plain radiographs are indicated for every patient with a known or suspected foreign

body in the oropharynx, esophagus,stomach,small and large intestine.Radiopaque objects are

easily seen and localized on the radiograph. In cases of nonradiopaque foreign bodies,

imaging studies rarely have any influence on management, except in delaying endoscopy or

computed tomography (CT) scanning. In small children, a mouth-to-anus radiograph Can be

obtained.In older children and adults, plain films of the neck, chest, and abdomen should be

obtained. A posteroanterior(PA)and lateral chest radiographs provide better localization for

foreign bodies within the lumen of the esophagus. The progress in the bowel, if needed, can

be checked periodically with radiographs. If the tip of a sharp-edged foreign body has

perforated the wall, it may project outside the air-containing lumen. However, some foreign

bodies such as small fish bones or pieces of plastic and wood are only faintly radiopaque and

their detection may require CT. Indirect signs, visible on the plain radiograph are soft tissue

swelling or air due to edema or hematoma.

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Figure 4 Radiograph showing fishbone stuck

Batman study may be indicated in cases of ingestion of nonopaque foreign bodies,

such as toothpicks or aluminum soda can tabs, although CT scanning is a much better

imaging modality. A barium or gastrografin study, without cotton balls, can sometimes

outline the foreign body, but, again, the yield is very low. Barium swallow can be used for

food impactions; however, most authorities believe that it adds nothing to the evaluation and

delays definitive treatment. Contrast studies are not useful in detecting foreign bodies in the

stomach or small intestine. Barium is contraindicated in cases in which esophageal

perforation is suspected. Gastrografin may be used if a study is needed. Esophagography

should first be performed with hydrosoluble contrast medium to exclude perforation and can

then be completed with a barium examination. The contrast medium may impregnate the

surface of the foreign body and render it more conspicuous.

Recent technical developments have led CT to be used more frequently in emergency

departments and have greatly enhanced CT’s ability to accurately discriminate between those

patients with a normal or abnormal abdomen, and to further characterize the etiology of the

patient’s abdominal pain. CT scanning is superior to plain radiographs for localization and

identification of foreign bodies. It is now considered the imaging modality of choice to locate

nonradiopaque foreign objects in the oropharynx, esophagus, stomach, small intestine, and

large intestine. CTscanning is highly reliable in localizing foreign bodies in the esophagus.

However, the application is probably unwarranted in every case of acute bone dysphagia, as

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only a minority of patients who sense foreign bodies after eating chicken or fish have a bone

present. Perforation of intestinal structures by ingested foreign bodies is a challenging

diagnosis that should always be invocated in cases of acute abdominal symptoms. The

definite diagnosis is based on the demonstration of the responsible foreign body that is

optimally achieved by CT.

It is also superior to other imaging modalities in demonstration of obstruction caused

by a foreign body. Especially, the recent developments in CT (multidetector CT) technology

made high-quality multiplanar reconstructions possible. Conventional CT is able to detect the

calcified content of ingested foreign body and the presence of very small quantities of

extraluminal gas,but its performance is impaired by a limited spatial resolution, the

discontinuity of the sections, and the very poor quality of multiplanar reconstructions

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BAB IV

CONCLUSION

Foreign body aspiration in the airway remain the cause of annual deaths in children

and infants, causing as many as 160 death per year in children younger than 14 years old in

the USA. Predominated mainly by food items such as peanuts, grains, seeds, and meat. Non

food items such as coin, or paperclip may also obstruct aerodigestive tract causing many

effect in children.

The main etiology of foreign body aspiration is the habit of children to aspirate and

swallow everything in their own grasping hand. Foreign body entrance to the aero-digestive

tract remains a serious threat leading to dangerous complications in childrenOrganic and non-

organic material tend to obstruct and irritate the aerodigestive tract that leads to infection,

inflammation and subsequent narrowing of the lumen.Children with foreign body aspiration

usually present with the classical triad of choking, coughing and wheezing. Other symptoms

are stridor, dyspnoea, haemoptysis or rarely pneumothorax, recurrent pneumonia also can be

found as a late sequelae.

One-third of patients with esophageal foreign bodies are asymptomatic. Large FB

may cause obstruction. Small and sharp objects may present with symptoms of esophageal

irritation. Symptoms related to esophageal foreign bodies are choking, gagging, coughing,

wheezing, dysphagia, dyspnea, fever, hematochezia, or neck, chest, abdominal pain, poor

feeding, irritability, fever, and stridor.Physical examination may reveal abnormal airway

sounds such as wheezing, stridor, decreased breath sounds, often bilateral.The physical

examination typically is not helpful, but the oropharynx, neck, chest, lungs, heart, and

abdomen should be carefully examined. Occasionally, a foreign body in the oropharynx can

be visualized indirect laryngoscopy or fiberoptic nasopharyngoscopy and removed. There are

three main techniques to remove foreign body from aero-digestive tract. Extraction by using

Foley catheter, Bougienage, Endoscopic retrieval. The first two techniques are limited to

smooth objects such as coins. The choice between the three techniques depends on factors

such as, size and shape of the FB, History of esophageal abnormalities, how long the FB has

been lodged in the esophagus, preference of treating physician

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REFERENCE

Baert, A. L. (2008). Encyclopedia of Diagnostic Imaging. Berlin: Springer Berlin Heidelberg.

Dutta, N. N., & Choudhury, B. (2008). An unusual foreign body in the nasopharynx. Indian Journal of Otolaryngology and Head and Neck Surgery, 266-267.

Mukherjee, M., & Paul, R. (2011). Foreign Body Aspiration: Demographic Trends and Foreign Bodies Posing a Risk. Indian Journal of Otolaryngology and Head & Neck Surgery, 313-316 .

Munter, D. W. (2014, April 21). Gastrointestinal Foreign Bodies. Diambil kembali dari Emedicine Medscape: http://emedicine.medscape.com/article/776566-overview#a0101

Nguyen, L. T. (2009). Pediatric Surgery. Montreal: Springer Berlin Heidelberg.

Romano, L. (2012). Errors in Radiology. Milan: Springer Milan.

Saladin, K. S. (2012). Anatomy & Physiology, The Unity of Form and Function. Philadelphia: The Mc-Grawhill Company.

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