The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–3, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
Letters to the Editor , INVISIBLE INGESTED FOREIGN BODY: ALUMINUM CAN TOP
of a handheld metal detector were found to be 88.6% (95% confidence interval [CI] 72.1–96.5%), 100% (95% CI 61.8–100%), 100% (95% CI 85.8–100%), and 55.5% (95% CI 34.3–84.6%), respectively. Finally, we have suggested that a handheld metal detector is an accurate, inexpensive, and radiation-free screening tool and should be used for evaluation of patients suspected of ingesting MFBs. We would like to report this case of a boy who ingested a tab pulled from a soda can in which radiographs failed
, To the Editor: We have reported our series of patients, in whom ingested metallic foreign bodies (MFBs) were detected with a handheld metal detector, in the Turkish Journal of Gastroenterology, 2010 (1). The sensitivity, specificity, and positive and negative predictive values (PPV, NPV)
Figure 1. Radiographs were negative for metallic foreign body.
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2
Letters to the Editor
Figure 2. Endoscopic visualization of metallic foreign body.
Figure 3. Removed metallic foreign body.
to demonstrate the foreign body. We want to emphasize not only the PPV and sensitivity of a handheld metal detector, but also the ability of this tool in detecting thin, metallic, and aluminum objects that are invisible by standard radiographs. A 12-year-old boy presented to our Emergency Department with odynophagia after ingesting a tab pulled from a soda can. The ingestion of the tab was not witnessed. He was not taking any medications. Although on physical examination there was no focal tenderness or evidence of drooling, the patient described that he felt the tab in his esophagus. Radiographs (anteroposterior and lateral) of the neck, chest, and abdomen were obtained and considered normal (Figure 1). The patient was scanned by a metal detector, and both a visual signal and audible alarm indicated the presence of metal at the level of the sternal notch. Endoscopic removal of the tab from the middle portion of the esophagus was performed uneventfully, and the patient was discharged (Figures 2, 3). Tabs of aluminum beverage cans are unusual foreign bodies, yet they have been reported in both pediatric and adult populations (2,3). Esophageal impaction may be suspected clinically in the setting of difficulty swallowing and retrosternal discomfort (4). Management of this clinical condition should include inspection of the
oropharynx and radiography of the neck and chest if the foreign body is thought to be radiopaque. Aluminum has a low radiodensity, but this fact is not widely known. Previous reports demonstrate that radiographs of the neck, chest, and abdomen should not be considered adequate to exclude esophageal impaction of an aluminum foreign body (5). The minimal thickness of steel detectable in vivo is 0–12 mm, and aluminum is 10 times less absorptive. The average thickness of an aluminum tab is 3.5 mm. Aluminum foreign bodies may be easily missed on a superficial reading of the images. If symptoms persist but no foreign body has been identified, the metal detector should be used as a preliminary scan prior to endoscopic intervention. Our previous report showed that a metal detector could be used safely and reliably in children suspected of having ingested MFBs. Because the metal detector has several advantages (easy to use, inexpensive [$200 USD] and radiation-free), it should be the first screening test with children who ingested an MFB (Figure 4). Moreover, metal objects are usually radiopaque, and radiological detection of ingested MFBs is usually an easy task for the emergency physician. Physicians must be aware of the low radiodensity of aluminum, because superficial assessment of radiographs may result in missed aluminum foreign bodies. In this case, metal detector screening should be a mandatory part of the investigation.
The Journal of Emergency Medicine
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¨ mu¨r Ecevit, MD C ¸ igdem O ¨ zgenc¸, MD Funda O Division of Gastroenterology Department of Pediatrics Ege University School of Medicine Bornova, Izmir Turkey http://dx.doi.org/10.1016/j.jemermed.2013.11.083
REFERENCES Figure 4. The Hand Held Metal Detector.
Eylem Ulas Saz, MD ¨ zen, MD Selime O Emergency Medicine Department of Pediatrics Division of Emergency Medicine Ege University School of Medicine Bornova, Izmir Turkey
1. Saz EU, Arikan C, Ozgenc¸ F, Duyu M, Ozananar Y. The utility of handheld metal detector in confirming metallic foreign body ingestion in the pediatric emergency department. Turk J Gastroenterol 2010;21:135–9. 2. Bradbum DM, Carr HF, Renwick I. Radiographs and aluminium: a pitfall for the unwary. BMJ 1994;308:1226. 3. Burrington JD. Aluminum “pop tops”. A hazard to child health. JAMA 1976;235:2614–7. 4. Obiako MN. Tracheoesophageal fistula. A complication of foreign body. Ann Otol Rhinol Laryngol 1982;91:325–7. 5. Bartalena T, Rinaldi MF, Rinaldi G, et al. Ingested aluminium foreign body. Eur J Radiol Extra 2009;71:e23–4.
Letters to the Editor , INVISIBLE INGESTED FOREIGN BODY: ALUMINUM CAN TOP
of a handheld metal detector were found to be 88.6% (95% confidence interval [CI] 72.1–96.5%), 100% (95% CI 61.8–100%), 100% (95% CI 85.8–100%), and 55.5% (95% CI 34.3–84.6%), respectively. Finally, we have suggested that a handheld metal detector is an accurate, inexpensive, and radiation-free screening tool and should be used for evaluation of patients suspected of ingesting MFBs. We would like to report this case of a boy who ingested a tab pulled from a soda can in which radiographs failed
, To the Editor: We have reported our series of patients, in whom ingested metallic foreign bodies (MFBs) were detected with a handheld metal detector, in the Turkish Journal of Gastroenterology, 2010 (1). The sensitivity, specificity, and positive and negative predictive values (PPV, NPV)
Figure 1. Radiographs were negative for metallic foreign body.
1
2
Letters to the Editor
Figure 2. Endoscopic visualization of metallic foreign body.
Figure 3. Removed metallic foreign body.
to demonstrate the foreign body. We want to emphasize not only the PPV and sensitivity of a handheld metal detector, but also the ability of this tool in detecting thin, metallic, and aluminum objects that are invisible by standard radiographs. A 12-year-old boy presented to our Emergency Department with odynophagia after ingesting a tab pulled from a soda can. The ingestion of the tab was not witnessed. He was not taking any medications. Although on physical examination there was no focal tenderness or evidence of drooling, the patient described that he felt the tab in his esophagus. Radiographs (anteroposterior and lateral) of the neck, chest, and abdomen were obtained and considered normal (Figure 1). The patient was scanned by a metal detector, and both a visual signal and audible alarm indicated the presence of metal at the level of the sternal notch. Endoscopic removal of the tab from the middle portion of the esophagus was performed uneventfully, and the patient was discharged (Figures 2, 3). Tabs of aluminum beverage cans are unusual foreign bodies, yet they have been reported in both pediatric and adult populations (2,3). Esophageal impaction may be suspected clinically in the setting of difficulty swallowing and retrosternal discomfort (4). Management of this clinical condition should include inspection of the
oropharynx and radiography of the neck and chest if the foreign body is thought to be radiopaque. Aluminum has a low radiodensity, but this fact is not widely known. Previous reports demonstrate that radiographs of the neck, chest, and abdomen should not be considered adequate to exclude esophageal impaction of an aluminum foreign body (5). The minimal thickness of steel detectable in vivo is 0–12 mm, and aluminum is 10 times less absorptive. The average thickness of an aluminum tab is 3.5 mm. Aluminum foreign bodies may be easily missed on a superficial reading of the images. If symptoms persist but no foreign body has been identified, the metal detector should be used as a preliminary scan prior to endoscopic intervention. Our previous report showed that a metal detector could be used safely and reliably in children suspected of having ingested MFBs. Because the metal detector has several advantages (easy to use, inexpensive [$200 USD] and radiation-free), it should be the first screening test with children who ingested an MFB (Figure 4). Moreover, metal objects are usually radiopaque, and radiological detection of ingested MFBs is usually an easy task for the emergency physician. Physicians must be aware of the low radiodensity of aluminum, because superficial assessment of radiographs may result in missed aluminum foreign bodies. In this case, metal detector screening should be a mandatory part of the investigation.
The Journal of Emergency Medicine
3
¨ mu¨r Ecevit, MD C ¸ igdem O ¨ zgenc¸, MD Funda O Division of Gastroenterology Department of Pediatrics Ege University School of Medicine Bornova, Izmir Turkey http://dx.doi.org/10.1016/j.jemermed.2013.11.083
REFERENCES Figure 4. The Hand Held Metal Detector.
Eylem Ulas Saz, MD ¨ zen, MD Selime O Emergency Medicine Department of Pediatrics Division of Emergency Medicine Ege University School of Medicine Bornova, Izmir Turkey
1. Saz EU, Arikan C, Ozgenc¸ F, Duyu M, Ozananar Y. The utility of handheld metal detector in confirming metallic foreign body ingestion in the pediatric emergency department. Turk J Gastroenterol 2010;21:135–9. 2. Bradbum DM, Carr HF, Renwick I. Radiographs and aluminium: a pitfall for the unwary. BMJ 1994;308:1226. 3. Burrington JD. Aluminum “pop tops”. A hazard to child health. JAMA 1976;235:2614–7. 4. Obiako MN. Tracheoesophageal fistula. A complication of foreign body. Ann Otol Rhinol Laryngol 1982;91:325–7. 5. Bartalena T, Rinaldi MF, Rinaldi G, et al. Ingested aluminium foreign body. Eur J Radiol Extra 2009;71:e23–4.
