TUGAS MAKALAH

Corpus 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

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 12%. 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.

CHAPTER II
LITERATURE REVIEW

II.1 DIGESTIVE AND RESPIRATORY TRACT ANATOMY

Figure 1 Anatomy of the respiratory tract

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

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 23 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 5080% of FBs removed by
endoscopy from childrens 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. Nonorganic 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.

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 23 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. Thoracotomy will

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be required to retrieve FBs in the mediastinum and to treat complications such as aortoesophageal 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 CTs ability to accurately discriminate between those
patients with a normal or abnormal abdomen, and to further characterize the etiology of the
patients 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

BAB IV

CONCLUSION
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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 nonorganic 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

REFERENCE

16

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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