naspghan foreign body guidelines naspghan foreign body guidelines

In addition, close inspection of the image is necessary to identify a double ring or halo sign (Fig. In 100 patients (57%), the foreign body was visualized. Finally, it is of great importance to develop different prevention strategies along with the industry and regulatory agencies. Anfang R, Jatana K, Linn R, et al. Epub 2015 Apr 8. 13 The foreign body reaction at the site of impaction causes a local inflammatory response with bowel wall thickening. The European Society for Paediatric Gastroenterology Hepatology and Nutrition task force for button battery ingestions aims to prevent morbidity and mortality because of button battery injuries. It is not a substitute for care by a trained medical provider. sharing sensitive information, make sure youre on a federal In some cases, a CT scan should even be done before endoscopy or endoscopic removal of the battery (see below). Journal of Pediatric Gastroenterology and Nutrition - Volume 66, Number 1, January 2018. Finally, prevention strategies are discussed in this paper. Most ingestions by children are accidental, and the amounts ingested tend to be small. Button battery ingestions pose a huge health risk for the pediatric population potentially leading to severe morbidity and even mortality. sharing sensitive information, make sure youre on a federal An expert panel of pediatric endoscopists was convened and produced the present article that outlines practical clinical approaches to the pediatric patient with a variety of foreign body ingestions. Established by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN), Clinical Guidelines & Position Statements, Journal of Pediatric Gastroenterology and Nutrition - Volume 74, Issue S1, March 2022, Journal of Pediatric Gastroenterology and Nutrition - Volume 66, Issue 3, March 2018, Journal of Pediatric Gastroenterology and Nutrition - Volume 64, Number 6, June 2017, Journal of Pediatric Gastroenterology and Nutrition - Volume 64, Number 2, February 2017, Journal of Pediatric Gastroenterology and Nutrition - Volume 64, Number 1, January 2017, Journal of Pediatric Gastroenterology and Nutrition - Volume 63, Number 5, November 2016, Journal of Pediatric Gastroenterology and Nutrition - Volume 58, Number 2, February 2014, Journal of Pediatric Gastroenterology and Nutrition - Volume 56, Supplement 1, January 2013, Journal of Pediatric Gastroenterology and Nutrition - Volume 54, Number 6, June 2012, Journal of Pediatric Gastroenterology and Nutrition - Volume 40, Number 1, January 2005, (For primary care physicians/pediatricians), Journal of Pediatric Gastroenterology and Nutrition - Volume 76, Number 1, January 2023, Journal of Pediatric Gastroenterology and Nutrition - Volume 74, Number 5, May 2022, Journal of Pediatric Gastroenterology and Nutrition - Volume 74, Number 1, January 2022, Journal of Pediatric Gastroenterology and Nutrition - Volume 72, Number 3, March 2021, Journal of Pediatric Gastroenterology and Nutrition - Volume 72, Number 2, February 2021, Journal of Pediatric Gastroenterology and Nutrition - Volume 72, Number 1, January 2021, Journal of Pediatric Gastroenterology and Nutrition - Volume 71, Number 4, October 2020, Journal of Pediatric Gastroenterology and Nutrition - Volume 71, Number 3, September 2020, Journal of Pediatric Gastroenterology and Nutrition - Volume 71, Number 2, August 2020, Journal of Pediatric Gastroenterology and Nutrition - Volume 71, Number 1, July 2020, Journal of Pediatric Gastroenterology and Nutrition - Volume 70, Number 6, June 2020, Journal of Pediatric Gastroenterology and Nutrition - Volume 70, Number 5, May 2020, Journal of Pediatric Gastroenterology and Nutrition, Volume 70, Number 3, March 2020, Journal of Pediatric Gastroenterology and Nutrition, Volume 69, Number 4, October 2019. Emesis/hematemesis. Medical decision making, however, remains a complex process requiring integration of clinical data beyond the scope of these guidelines. Unfortunately, severe damage can occur within 2 hours after becoming lodged in the tissue (1,2). See Foreign body . Journal of Pediatric Gastroenteology and Nutrition - Volume 65, Number 4, October 2017. For example, 80-90% of ingested foreign bodies are able to pass without intervention, 10-20% must be removed endoscopically, and only approximately 1% require surgery [].However, intentional ingestion results in intervention rates as high as 76% [], and surgical intervention is performed in as many as 28% . The battery gets stuck in the esophagus where after both poles are in close contact with the mucosa. Again, it is important to note that this recommendation is based on a study in piglet esophagus preparations and a very small study in children (n = 6) (33,35). Epub 2023 Jan 10. Delayed endoscopic removal of sharp foreign body in the esophagus - LWW This can be done with 50 to 150 mL 0.25% sterile acetic acid and should only be considered if signs of perforation are absent (21,3236). Caustic ingestion in children: is endoscopy always indicated?. Foreign Body Ingestion Clinical Pathway Emergency Department, ICU Part of the strategy is also developing the first European clinical algorithm for the diagnosis and management of BB ingestions, which we do in this article. 1) (1417). During Black History Month, NASPGHAN 50th Anniversary History Project. Journal of Pediatric Gastroenterology and Nutrition73(1):129-136, July 2021. According to the NASPGHAN guideline, removal is, therefore, advised if a BB is still in the stomach after 2 to 4 days (30). Gastroenterology Guidelines | BSPGHAN Study documents, essay examples, research papers, course notes and The Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) has also endorsed the project since many adult endoscopists usually manage children with these conditions. Foreign body ingestion is a potentially serious problem that peaks in children aged six months to three years. 2023 Jan;26(1):1-14. doi: 10.5223/pghn.2023.26.1.1. 24. . Lerner D, Brumbaugh D, Lightdale J. Mitigating risk of swallowed button batteries: new strategies before and after removal. Perforations are usually diagnosed within 2 days (rarely in the first 12 hours) but fistulas can present up to 4 weeks postremoval. Ingestion of foreign bodies and caustic substances in children. Diagnosis, Management, and Prevention of Button Battery - PubMed 8:00 AM - 4:00 PM. 14days, which is different from previous guidelines where repeat X-ray and removal is recommended after 2-4days and is also based on age. Only if the battery still has not passed the stomach by 7 to 14 days, endoscopic removal is necessary as by then the chance that it will pass spontaneously is expected to be minimal. A Single-Center Experience. to maintaining your privacy and will not share your personal information without In complicated cases, this period should be extended until the patient is stabilized. Eisen G, Baron T, Dominitz J, et al. ESPGHAN Guidelines Clinical Presentation and Outcome of Multiple Rare Earth Magnet Ingestions in Children of Qatar. Severe esophageal injuries caused by accidental button battery ingestion in children. There are several reasons why timely removal of the battery may not be possible. Ruhl D, Cable B, Rieth K. Emergent treatment of button batteries in the oesophagus: evolution of management and need for close second look esophagoscopy. Therefore, based on this evidence, we recommend that once the BB has passed the esophagus, asymptomatic cases should be followed-up after 7 to 14 days with an X-ray to confirm passage unless the battery has been noticed in the stools by the parents (parents should be instructed to check all stools) (3,24). Management of Ingested Foreign Bodies in Children - LWW E.M. received grant or research support from Nestle Italy and Nutricia Italy, served as a member of the advisory board for Abbvie, and received payment/honoraria from Ferring. The clinical relevance of this, however, seems low as data show that arrested battery progression did not lead to adverse outcomes (24,29). NASPGHAN - Publications 2013 Oct;60(5):1221-39. doi: 10.1016/j.pcl.2013.06.007. 11267794: Benzothia(di)azepine compounds and their use as bile acid mo If evidence of coughing, choking, respiratory distress consider inhalation. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Endoscopy Committee. HHS Vulnerability Disclosure, Help An algorithm for the diagnosis and management of BB ingestions is presented and compared to previous guidelines (NASPGHAN, National Poison Center). Bethesda, MD 20894, Web Policies Address correspondence and reprint requests to Lissy de Ridder, Department of Pediatric Gastroenterology, Erasmus Medical Center-Sophia Children's Hospital, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands (e-mail: [emailprotected]). Possible complications after battery ingestions are listed in Table 1. 1 Children 5 years of age and younger are responsible for 75% of all foreign-body ingestions (FBIs), 2 and 20% of children 1 to 3 years of age have ingested some kind of foreign body. Esophageal battery impaction has the highest risk of complications, especially in children <6 years of age and in batteries >20 mm in diameter. An increasing number of button battery (BB) ingestions has been described worldwide, mainly because of the wide abundance of batteries in consumer electronics (1,2). By having such a task force in Europe, we will be able to do so more effectively as we will be able to use a more localized approach. Litovitz T. Battery ingestions: product accessibility and clinical course. Foreign Body and Caustic Substance Ingestion in Childhood In fact, fatalities in children where the battery was initially discovered in the stomach have been reported (21). Gastrointest Endosc Clin N Am. Management of Ingested Foreign Bodies in Children: A - ResearchGate Takagaki K, Perito E, Jose F, et al. Paediatric Gastrointestinal Endoscopy: European Society for - LWW In these cases, a joint approach with (cardiothoracic) surgeons and a cardiac catheter lab may be necessary. impaction, foreign body ingestion, magnet, superabsorbent (JPGN 2015;60: 562-574) I n 2000 the American Association of Poison Control Centers documented that 75% of the >116,000 ingestions reported were in children 5 years of age or younger (1). 2015 Apr;60(4):562-74. doi: 10.1097/MPG.0000000000000729. . 5. The European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) is a multi-professional organisation whose aim is to promote the health of children with special attention to the gastrointestinal tract, liver and nutritional status, through knowledge creation, the dissemination of science based information, the promotion of best practice in the delivery of . If still present in the esophagus or located in the stomach in a symptomatic patient, immediate endoscopic removal is necessary. Other complications, such as esophageal strictures, spondylodiscitis or recurrent laryngeal nerve injury may take weeks or even months to develop (1). Batteries passing the esophagus usually pass the remaining gastrointestinal tract successfully: only 7% and 1.3% of overall complications occur in the stomach and small bowel, respectively (3). 18. Jun 04, 2022. Avoidance of the risk of mucosal injury in case of a battery ingestion, for example, changes in battery design and technology. Lead Poisoning from a Toy Necklace, Study Authors Advise Giving Honey to Children who Swallow Button Batteries, Esophageal, nasal or airway Button Battery, Cluster notification to ENT, GI, Gen Surgery and OR to prepare for patient, Sharp longer objects in stomach with no symptoms, 2022 The Childrens Hospital of Philadelphia. Endoscopic removal of the foreign body in the cardiac catheterization laboratory operation room with fluoroscopic guidance and arteriogram of the aorta allows direct visualization of the BB and its proximity to the aorta. 0 comments. Use of this site is subject to theTerms of Use. Most battery ingestions occur in children <6 years of age with a peak at 1 year of age, which is also the age with the highest risk of complications (1,3). 2023 by Children's Hospital of Philadelphia, all rights reserved. ESGPHAN DISCLAIMER: ESPGHAN is not responsible for the practices of physicians and provides guidelines and position papers as indicators. Before Unable to load your collection due to an error, Unable to load your delegates due to an error. Serious complications after button battery ingestion in children. Pediatr Gastroenterol Hepatol Nutr. government site. A systematic search of the literature was performed to identify publications relevant to the aims of this position paper. Tringali A, Thomson M, Dumonceau JM, et al. Thursday, October 13, 2022. NASPGHAN - NASPGHAN Timeline The .gov means its official. The Association of Pediatric Gastroenterology and Nutrition Nurses, Help & Hope for Children with Digestive Disorders, Journal of Pediatric Gastroenterology and Nutrition, Digestive Health for Life Partners Program, Conflict of Interest, Ethics, and Policy Statements, Council for Pediatric Nutrition Professionals, Clinical Guidelines & Position Statements, COVID-19 Resources for Healthcare Providers, 2023 Medical Student Mentored Summer Research Program, NASPGHAN Celebrates Tanisha Richards, N.P. English Espaol Portugus Franais Italiano Svenska Deutsch M.T., C.T. Note that MRI scans should never be performed before removal of a battery. Foreign body and caustic ingestions in children: A clinical practice Worldwide initiatives have been set up in order to prevent and also timely diagnose and manage BB ingestions. 2023. Caregivers may well choose a course of action outside of those represented in these guidelines because of specific patient circumstances. Please try after some time. PDF Paediatric Clinical Practice Guideline Ingestion of foreign bodies (FB) On the basis of the available data, the ESPGHAN task force for BB ingestions concludes that: The ESPGHAN task force for BB ingestions recommends further research on: Children with BB ingestion commonly present in the emergency department. Epub 2022 Dec 21. Federal government websites often end in .gov or .mil. Use of acid blockade to minimize the impact of acid reflux on the esophageal injury has not been studied but seems well justified in cases of mucosal injury. 2009 Oct;21(5):651-4. doi: 10.1097/MOP.0b013e32832e2764. NASPGHAN - Clinical Guidelines & Position Statements Krom H, Elshout G, Hellingman CA, et al. Qatar Med J. Although mucosal damage can occur within 2 hours after lodgement, development of complications mostly takes longer. Foreign body sensation. Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Childrens Hospital of Philadelphia (CHOP), its physicians and the individual patients in question. Buttazzoni E, Gregori D, Paoli B, et al. Foreign body and caustic ingestions in children: A clinical practice guideline. Thus, these guidelines may be revised as needed to account for new data, changes in clinical practice, or availability of new technology. 2011;53(4):381-387. Journal of Pediatric Gastroenterology and Nutrition Pediatric Foreign Body Ingestion - Medscape For advice about a disease, please consult a physician. Jatana K, Litovitz T, Reilly J, et al. It is important to keep in mind that delayed diagnosis or removal may be associated with more life-threatening complications. Nevertheless, it should be noted that the presence of a BB in the stomach or beyond does not exclude esophageal injury, especially in unwitnessed ingestions when the total time of BB exposure is unknown. National Capital Poison Center. The site is secure. Established by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN). NASPGHAN - Reflux & GERD In addition, the imprecise nature of the histories often leaves the clinician to question the timing and nature of the ingestion. Journal of Pediatric Gastroenterology and Nutrition - Volume 54, Number 2, February 2012, Journal of Pediatric Gastroenterology and Nutrition - Volume 53, Number 1, July 2011, Journal of Pediatric Gastroenterology and Nutrition - Volume 54, Number 1, January 2011, Journal of Pediatric Gastroenterology and Nutrition - Volume 47, Number 5, November 2008, Journal of Pediatric Gastroenterology and Nutrition - Volume 47, Number 3, September 2008, Journal of Pediatric Gastroenterology and Nutrition - Volume 44, Number 5, May 2007, Journal of Pediatric Gastroenterology and Nutrition - Volume 43, Number 4, October 2006, Journal of Pediatric Gastroenterology and Nutrition - Volume 43, Number 1, July 2006, Journal of Pediatric Gastroenterology and Nutrition - Volume 40, Number 4, April 2005, Journal of Pediatric Gastroenterology and Nutrition - Volume 40, Number 3, March 2005, The Association of Pediatric Gastroenterology and Nutrition Nurses, Help & Hope for Children with Digestive Disorders, Journal of Pediatric Gastroenterology and Nutrition, Digestive Health for Life Partners Program, Conflict of Interest, Ethics, and Policy Statements, Council for Pediatric Nutrition Professionals, COVID-19 Resources for Healthcare Providers. The NASPGHAN Foundation is pleased to provide these resources to medical professionals treating pediatric Reflux and GERD. In case of delayed diagnosis (first confirmation of the BB on X-ray >12 hours after ingestion or time point of removal >12 hours after ingestion) and esophageal impaction the guideline suggests to perform a CT scan in order to evaluate for vascular injury before removing the battery. The imprecise clinical history frequently leaves clinicians uncertain about timing and nature of the ingestion. It is, however, the electrolysis that seems to be the most significant mechanism. Litovitz T, Whitaker N, Clark L, et al. Management of oesophageal foreign bodies in children: a 10-year retrospective analysis from a tertiary care center. 1. PDF Foreign Body Ingestion in Children: Epidemiological, Clinical Features In agreement with earlier guidelines, immediate localization of the BB is important and in case of esophageal impaction, the BB should be removed instantly (preferably <2 hours). If you have questions about any of the clinical pathways or about the process of creating a clinical pathway pleasecontact us. Epub 2013 Sep 5. This leads to hydroxide ion formation at the negative pole, which in turn rapidly leads to pH rise causing tissue liquefaction and necrosis, comparable with damage occurring in the esophagus after alkaline liquid ingestion (1012). Basic mechanism of button battry ingestion injuries and novel mitigation strategies after diagnosis and removal. Phrase With The Word Secret In It; Victorian House Color Schemes Exterior . Would you like email updates of new search results? NASPGHAN Clinical Practice Guideline for the Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease in Children: Recommendations from the Expert Committee on NAFLD (ECON) and the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) Journal of Pediatric Gastroenterology and Nutrition - Volume 64, Number . BJA Educ. Foreign bodies, bezoars, and caustic ingestion. Ibrahim A, Andijani A, Abdulshakour M, et al. 0 Analysis of complications after button battery ingestion in children. 2022 Nov;18(11):715-724. doi: 10.1007/s12519-022-00584-8. Honda S, Shinkai M, Usui Y, et al. Foreign-Body Ingestions of Young Children Treated in US Emergency Diaconescu S, Gimiga N, Sarbu I, et al. Among patients whose foreign body was radiographically viewed, 83 (83%) were asymptomatic and 19 (19%) had symptoms. During Black History Month, NASPGHAN 50th Anniversary History Project. Journal of Pediatric Gastroenterology and Nutrition - Volume 63, Number 2, August 2016. Several theories have been hypothesized regarding the mechanism of injury in BB ingestions. Removal of gastric BB is necessary in symptomatic cases, in case of co-ingestion with a magnet or in delayed diagnosis. The goal of our study is to describe. 9. Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee. Few clinical guidelines regarding management of these ingestions in children have been published, none of which from the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP). Mubarak, Amani; Benninga, Marc A.; Broekaert, Ilse; Dolinsek, Jernej; Homan, Matja||; Mas, Emmanuel; Miele, Erasmo#; Pienar, Corina; Thapar, Nikhil,; Thomson, Mike; Tzivinikos, Christos||||; de Ridder, Lissy, Department of Pediatric Gastroenterology, University Medical Center Utrecht, Utrecht, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands, Department of Paediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany, Paediatric Gastroenterology, Hepatology and Nutrition Unit, Department of Paediatrics, UMC Maribor, ||Department of Gastroenterology, Hepatology, and Nutrition, Faculty of Medicine, University Children's Hospital, University of Ljubljana, Ljubljana, Slovenia, Unit de Gastroentrologie, Hpatologie, Nutrition et Maladies Hrditaires du Mtabolisme, Hpital des Enfants, CHU de Toulouse, F-31300, France et IRSD, Universit de Toulouse, INSERM, INRA, ENVT, UPS, Toulouse, France, #Department of Translational Medical Science, Section of Paediatrics, University of Naples Federico II, Naples, Italy, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania, Department of Paediatric Gastroenterology, Great Ormond Street Hospital, London, United Kingdom, Department of Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia, Centre for Paediatric Gastroenterology and International Academy of Paediatric Endoscopy Training, Sheffield Children's Hospital, Sheffield, United Kingdom, ||||Department of Pediatric Gastroenterology, Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates. Introduction: Rare earth magnets are powerful magnets that can have several negative effects if ingested. Such cases are considered highly emergent as mucosal damage can occur within 2 hours if the battery is impacted in the esophagus necessitating urgent endoscopic removal. Moreover, because of the anatomical position and close contact with the respiratory tract and the major vessels, fistulization of the esophagus can be fatal (Fig. 1994 .. ESPGHAN-NASPGHAN Guidelines for the Evaluation and Treatment of Gastrointestinal and . It is not a substitute for care by a trained medical provider. The https:// ensures that you are connecting to the 2013 Oct;60(5):1221-39. doi: 10.1016/j.pcl.2013.06.007. %%EOF 1. HHS Vulnerability Disclosure, Help According to the CPSC's own estimates, thousands of otherwise preventable injuries have occurred in children due to these high-powered magnet sets. Endoscopic removal of the foreign body in the cardiac catheterization laboratory operation room with fluoroscopic guidance and arteriogram of the aorta allows direct visualization of the BB and . Severe gastric damage caused by button battery ingestion in a 3-month-old infant. In other cases, a BB in the stomach should be removed (30). We included randomized controlled trials, cohort studies, cross-sectional studies, clinical trials, epidemiological studies, systematic reviews, meta-analyses, and consensus statements/guidelines published in English up to May 2020. If the ingested battery is located in the airway or in the gastrointestinal tract above the clavicles, an Ear, Nose and Throat (ENT) doctor should be consulted to remove objects from the (upper) airways or upper part of the esophagus by rigid endoscopy (16). Long-term follow-up after removal depends on the presence and extent of esophageal injury. Journal of Pediatric Gastroenterology and Nutrition - Volume 63, Number 1, July 2016. [PDF] Management of ingested foreign bodies in children: a clinical (PDF) Dysphagia in the Elderly Patient | Aaliya Shaikh - Academia.edu Flow of electricity then leads to electrolysis. Management of these conditions often requires different levels of expertise and competence. Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee. Button Battery Ingestion Triage and Treatment Guideline ; National Battery Ingestion Hotline: 800-498-8666; IMAGING AP single view (chest, neck, abdomen) . 37. A Clinical Report of the NASPGHAN Endoscopy . The https:// ensures that you are connecting to the Determining the indications and timing for intervention requires assessment of patient size, type of object ingested, location, clinical symptoms, time since ingestion, and myriad other factors. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. 15. your express consent. Jatana K, Rhoades K, Milkovich S, et al. endstream endobj startxref In the respiratory tract, complications in the nasal cavity are the most common and account for almost 16% of the complications (3). 3 In 2016, FBIs were the fourth most common reason for calls to American poison . eCollection 2022 Nov. Xu G, Chen YC, Chen J, Jia DS, Wu ZB, Li L. BMC Emerg Med. The Journal of Pediatric Gastroenterology and Nutrition (JPGN) provides a forum for original papers and reviews dealing with pediatric gastroenterology and nutrition, including normal and abnormal functions of the alimentary tract and its associated organs, including the salivary glands, pancreas, gallbladder, and liver. To raise public awareness, involvement of the industry, media, schools, family doctors, and pediatricians (through National Pediatric Societies) is also very important. 25. Management of Gastrointestinal Foreign Bodies with Brief Review of the Guidelines. Journal of Pediatric Gastroenterology and Nutrition - Volume 64, Number 4, April 2017. Best Pract Res Clin Gastroenterol. A European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) task force for BB ingestions has been founded, which aimed to contribute to reducing the health risks related to this event. 352 0 obj <> endobj Foreign Body Ingestion. Number 2, February 2018. PDF Diagnosis,Management,andPreventionofButtonBattery Ingestion in Postgraduate Course. naspghan foreign body guidelines. Esophageal perforation is less likely in the first 12 hours after ingestion but this period does contain the peak of electrolysis activity and battery damage (32). The esophagogram can be performed 1 to 2 days after removal (21). Updates in pediatric gastrointestinal foreign bodies. Transmural esophageal wall damage may occur leading to fistulization of both the esophageal wall and surrounding tissues (such as trachea, aorta or subclavian artery) leading to several life-threatening complications. About ESPGHAN. 16. An algorithm for the diagnosis and management of BB ingestions is presented and compared to previous guidelines (NASPGHAN, National Poison Center). Often the easiest and least anxiety-producing decision is the one to proceed to endoscopic removal, instead of observation alone. Caustic injury of the anterior wall of the esophagus prompts greater concern for vascular and tracheal injury, whereas posteriorly oriented inflammation has been associated with the development of spondylodiscitis (18).