TUGAS MAKALAH Corpus Alienum Diajukan dalam rangka memenuhi persyaratan co-assisten SMF Radiologi RSUP Dr. Sardjito Fakultas Kedokteran Universitas adjah Mada
Disusun oleh:
Fauzi Syahrul Ramadhan 0!"#"$%!KU!$&"'&
()*D+D+KA* (R,F)S+ K)D,KT)RA* SMF RAD+,L,G+ RSU( Dr- SARD.+T, U*+/)RS+TAS GAD.AH MADA "0$' 1
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&.) *#!KR(U'D # corpus alienum 67oreign 8ody9 english translation: is any o8ject originating outside the 8ody. $hese 7oreign 8odies can propulse into natural 8ody ori7ices to various hollo; organs in human 8ody. Foreign 8odies can 8e inert or irritating. $he irritation due to 7oreign 8odies ;ill cause in7lammation and su8seic to the 8ody 6Munter9 +?)1:. !hildren and adults can e>perience pro8lems due to 7oreign materials enter their 8odies. /oung children are o7ten naturally curious and may intentionally put shiny o8jects9 such as coins or 8utton 8atteries9 into their mouths9 ears and their noses. (8jects that have passed the esophagus9 once they reach the stomach9 do not cause symptoms unless complications occur. $hey are usually eliminated spontaneously ;ith normal 8o;el movements. $here7ore9 one can imagine that a lot o7 ingested 7oreign o8jects are passed daily ;ithout notice 8ecause the child has never complained 6'guyen9 +??@:. Prior to the )@0?s9 the mortality associated ;ith F*s ;as very high. !urrently9 it is a8out )A+B. &n recent years9 the develop ment o7 modern instruments and etremely su8tle.
&.+ #&M $he purpose o7 ;riting this document is to gain more kno;ledge regarding the de7inition9 classi7ication9 sign and symptoms9 radiological 7inding a8out corpus alienum9 and the managements.
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Figure 1 Anatomy of the respiratory tract
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$he term respiration has three meaningsC 6): ventilation o7 the lungs9 6+: the e>change o7 gases 8et;een air and 8lood and 8et;een 8lood and tissue 7luid9 and 60: the use o7 o>ygen in cellular meta8olism. $he principal organs o7 the respiratory system are the nose9 pharyn>9 laryn>9 trachea9 8ronchi9 and lungs 6Saladin9 +?)+:. $hese organs serve to receive 7resh air9 e>change gases ;ith the 8lood9 and e>pel the modi7ied air. ithin the lungs9 air 7lo;s along a dead-end path;ay consisting essentially o7 8ronchi 8ronchioles alveoli. &ncoming air stops in the alveoli 6millions o7 thin-;alled9 microscopic air sacs in the lungs:9 e>changes gases ;ith the 8loodstream across the alveolar ;all9 and then 7lo;s 8ack out. $he conducting division o7 the respiratory system consists o7 those passages that serve only 7or air7lo;9 essentially 7rom the nostrils through the 8ronchioles. $he respiratory division consists o7 the alveoli and other distal gas-e>change regions 6Saladin9 +?)+:. $he air;ay 7rom the nose through the laryn> is o7ten called the upper respiratory tract9 and the regions 7rom the trachea through the lungs compose the lo;er respiratory tract.
Figure 2 Anatomy of the digestive tract
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$he digestive system has t;o anatomical su8divisions9 the digestive tract and the accessory organs. $he digestive tract is a tu8e e>tending 7rom mouth to anus9 measuring a8out @ m 60? 7t: long in the cadaver 6Saladin9 +?)+: . &t is also kno;n as the alimentary + canal. &t includes the oral cavity9 pharyn>9 esophagus9 stomach9 small intestine9 and large intestine. Part o7 this9 the stomach and intestines9 constitute the gastrointestinal 6&: tract. $he accessory organs are the teeth9 tongue9 salivary glands9 liver9 gall8ladder9 and pancreas. $he digestive tract is open to the environment at 8oth ends. Most o7 the material in it has not entered any 8ody tissues and is considered to 8e e>ternal to the 8ody until it is a8sor8ed 8y epithelial cells o7 the alimentary canal. &n the strict sense9 de7ecated 7ood residue ;as never in the 8ody.
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#spiration o7 7oreign 8odies9 such as peanuts9 carrots or plastic toy pieces9 occurs most o7ten in children under the age o7 1 years. $he ;orst case is complete air;ay o8struction ;ith total occlusion o7 the trachea a8ove the carina. Partial o8struction occurs9 ;hen the trachea is partially occluded or ;hen the 7oreign 8ody o8structs 8ronchi distal the carina. $he majority o7 7oreign 8odies lodge in the main 8ronchi ;ith almost eternal o8ject9 introduced voluntarily or accidentally into the digestive system. Foreign 8odies may 8e ingested9 inserted into a 8ody cavity9 or deposited into the 8ody 8y a traumatic or iatrogenic injury. &n general9 7oreign 8odies in the air and 7ood passages are the si>th most common cause o7 accidental death in the United States 6Mukherjee E Paul9 +?)):. $he ingestion o7 a F* is a relatively common & emergency that causes signi7icant mor8idity. Fortunately9 the vast majority o7 all s;allo;ed o8jects pass through the & tract ;ithout a pro8lem. (nly )B o7 involuntary and generally unconsciously ingested F* ;ill per7orate the 8o;el and constitute a8dominal emergencies ;hose diagnosis represents a challenge. $hose that cause per7oration are usually sharp9 pointed9 or elongated. $hey are usually 7ish 8ones9 toothpicks9 6
and chicken 8ones.
Foreign 8ody ingestions are common in children and mentally
handicapped adults. #lthough e>act 7igures are unavaila8le9 7oreign 8ody ingestion is very common among children. &n the pediatric population9 toddlers aged +A0 years are most commonly a77ected 8ecause children in this age group are am8ulatory and more orally e>plorative. hile children younger than 3 months are rarely a8le to get a 7oreign o8ject into the oropharyn>9 in7ants can ingest 7oreign 8odies ;ith the assistance o7 a si8ling. #ny child can s;allo; a 7oreign 8ody most incidents result in minor annoyance9 8ut a 7e; can lead to major catastrophe
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F* aspiration in the air;ays is the cause o7 )3? annual deaths in children younger than )1 years old in the United States. $he +??) #nnual Report o7 the #merican #ssociation o7 Poison !ontrol !enters noted ))290+? cases o7 ingestion o7 a 7oreign 8ody 8y children younger than +? years. More than 5?B o7 these c hildren are younger than 3 years. Food items such as peanuts9 grains9 seeds or pieces o7 meat compose 2?AG?B o7 F*s removed 8y endoscopy 7rom childrenHs aero-digestive tract. &n +??)9 the US !enter 7or Diseases !ontrol 6!D!: reported an estimated 3?B o7 choking episodes treated in %mergency Department ;ere due to 7ood items such as peanuts9 seeds9 candy9 gum9 pieces o7 7ruit9 vegeta8les and hot dogs. #nother 0?B ;ere due to non 7ood su8stances o7 ;hich coins accounted 7or a signi7i cant portion. (ther non 7ood items areC plastic pieces9 scre;s9 pins and 8utton 8atteries. Si>ty eight percent o7 the deaths in children younger than )1 years reported to the !onsumer Product Sa7ety !ommission ;ere due to non 7ood su8stances 6*aert9 +??G:. $he remaining 0+B o7 deaths ;ere caused 8y household items. $he majority o7 deaths occurred in children aged 0 years and older. $he diagnosis o7 a 7oreign 8ody in the aero-digestive tract may 8e challenging 8ecause o7 the di77iculty in o8taining a relia8le history 7rom children9 especially ;hen they are very young. &n clinical practice9 most children 6G?B: had 8een ;itnessed to choke on an identi7i a8le o8ject 8ut only 2+B o7 events o7 air;ay F* ;ere diagnosed early. #n estimated 1?B o7 7oreign 8ody ingestions are not ;itnessed9 and in many cases9 the child never develops symptoms. &n a retrospective revie;9 only 2?B o7 children ;ith con7i rmed 7oreign 8ody ingestion ;ere symptomatic. 7
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!hildren can put just a8out anything they can grasp into their mouths or their noses and then s;allo; it or aspirate it. Foreign 8odies 6F*: o7 the aero-digestive tract9 ;hether they are aspirated9 inserted or ingested are potentially dangerous. &7 they are not diagnosed early and removed they can result in numerous complications9 such as per7oration9 o8struction o7 the gastro-intestinal tract9 tissue necrosis9 7istula 7ormation9 ulcerations9 massive 8leeding9 air;ay and lung in7ections.
1. P#$"(P"/S&(,(/ Food particles or organic materials may a8sor8 ;ater 7rom 8ronchial secretions and tend to increase in si=e. (il9 salt and vegeta8le proteins irritate the mucosa9 leading to oedema and 7ormation o7 granulation tissue ;ith su8se is ;ell-innervated9 and patients can typically locali=e oropharyngeal 7oreign 8odies. Scratches or a8rasions to the mucosal sur7ace o7 the oropharyn> can create a 7oreign 8ody sensation. !hronic 7oreign 8odies or per7orations can cause in7ections in surrounding so7t tissues o7 the throat and neck. Patients can usually locali=e 7oreign 8odies in the upper esophagus 8ut locali=e them poorly in the lo;er t;o-thirds o7 the structure. $he esophagus has three areas o7 narro;ingC the upper esophageal sphincter 6U%S:9 ;hich consists o7 the cricopharyngeus muscle the crossover o7 $he aortaandthelo;eresophagealsphincter6,%S:.$hese areas are ;here most esophageal 7oreign 8odies 8ecome entrapped 6Romano9 +?)+:. Structural a8normalities o7 the esophagus9 including strictures9 ;e8s9 diverticula9 and malignancies9 increase the risk o7 7oreign 8ody entrapment9 as do motor distur8ances such as scleroderma9 di77use esophageal spasm9 or achalasia.
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Most 7oreign o8jects ;ill pass through the pylorus9 although on occasion9 some o8jects may remain in the stomach 7or a long period. (nce 8eyond the pyloric canal most o8jects9 even sharply edged 7oreign 8odies such as pieces o7 glass or nails9 ;ill pass ;ithout harm until the terminal ileum ;hich is again a predilection site 7or o8struction. &ngested o8jects may occasionally remain 7i>ed in the cecum9 ascending colon9 or sigmoid. Foreign 8odies detected in the rectum have in most instances 8een introduced transanally.
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!hildren ;ith 7oreign 8ody aspiration usually present ;ith the classical triad o7 choking9 coughing and ;hee=ing. (ther symptoms are stridor9 dyspnoea9 haemoptysis or rarely pneumothora>. !rackles9 decreased 8reath sounds in the a77ected lung and unepansion may 8e 7ound on physical e>amination9 8ut also normal 7indings are common. *esides acute symptoms o7 respiratory distress9 recurrent pneumonia is o8served as late sepectantly unless there are indications 7or a more aggressive approach. ,arge 7oreign
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8odies are not generally encountered in the small 8o;el in that rarely pass 8eyond the pylorus or the duodenojejunal 7le>ure. # per7oration o7 the peritoneal cavity can cause peritonitis ;hereas a retroperitoneal per7oration9 at the duodenojejunal 7le>ure 7or e>ample9 can lead to the involvement o7 the psoas and the 7ormation o7 an a8scess. 'onetheless9 the per7oration o7 jejunal or ileal loop is a rare event 6I)B o7 cases: and is usually caused 8ye>tremely pointed o8jects9 such as 7ish 8ones9 chicken 8ones9 and toothpicks. Patients ;ith a rectal 7oreign 8ody may present ;ith a8dominal or rectal pain9 pruritus9 or 8leeding.
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Major 7indings include ne; a8normal air;ay sounds9 such as ;hee=ing9 stridor9 or decreased 8reath sounds. $hese sounds are o7ten9 8ut not al;ays9 unilateral. Sounds are inspiratory i7 the material is in the e>trathoracic trachea. &7 the lesion is in the intrathoracic trachea9 noises are symmetric 8ut sound more prominent in the central air;ays. $hese sounds are a coarse ;hee=e 6sometimes re7erred to as e>piratory stridor: heard ;ith the same intensity all over the chest. (nce the 7oreign 8ody passes the carina9 the 8reath sounds are usually asymmetric. "o;ever9 remem8er that the young chest transmits sounds very ;ell9 and the stethoscope head is o7ten 8igger than the lo8es. # lack o7 asymmetry should not dissuade the o8server 7rom considering the diagnosis. Similarly9 a lack o7 7indings upon physical e>amination does not preclude the possi8ility o7 an air;ay 7oreign 8ody.
$he physical e>amination typically is not help7ul9 8ut the oropharyn>9 neck9 chest9 lungs9 heart9 and a8domen should 8e care7ully e>amined. (ccasionally9 a 7oreign 8ody in the oropharyn> can 8e visuali=ed and removed. &n cooperative patients9 indirect laryngoscopy or 7i8eroptic nasopharyngoscopy provides 8etter in7ormation than a direct e>amination. &n children9 tracheal compression and stridor suggest a large 7oreign 8ody at the U%S. !omplete o8structions can cause drooling and the ina8ility to s;allo;. Delayed presentations may 8e accompanied 8y signs o7 in7ection9 including peritonitis.
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5. $"%R#P/ Foreign 8odies lodged in the esophagus9 i7 not detected ea rly can cause complications. Depending on the nature o7 the o8ject and the duration o7 its presence9 these include *utton 8atteries ;hich can cause esophageal 8urn9 stricture9 per7oration aortoesophageal 7istula9 tracheoesophageal 7istula9 retropharyngeal a8scess sharp o8jects ;hich can cause per7oration9 a8scess9 retropharyngeal a8scess mediastinitis9 stricture9 esophagitis. Foreign 8odies in the esophagus should 8e removed promptly. $hree main technitraction 8y using Foley catheter9 *ougienage9 %ndoscopic retrieval 6Munter9 +?)1:. $he 7irst t;o technicellent9 up to @3B. $his technipectation that they ;ill then 8e eliminated spontaneously 6up to @2B:. *ougienage ;ill 8e attempted in a selected group o7 patients9 a single coin or impacted meat ingested less than +1 h since the ingestion9 no esophageal a8normalities9 no respiratory distress. Done under general anesthesia9 endoscopic retrieval is the most thorough techni
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!"#P$%R &&& D&S!USS&(' !hest radiography is usually the 7irst imaging technipiratory chest 4-rays9 lateral decu8itus radiographs or ;ith the use o7 7luoroscopy is o7ten necessary additionally to plain chest radiographs. &n some instances !$ may provide additional in7ormation9 8ecause o7 its high sensitivity in demonstrating radiolucent 7oreign 8odies. ,o;-dose MD!$ and virtual 8ronchoscopy has sho;n good results in identi7 ying the e>act location o7 a 7oreign 8ody 8e7ore 8ronchoscopy and in ruling out a 7oreign 8ody in patients ;ith a lo; level o7 suspicion and normal or non-speci7ic 7indings on chest radiography. MR& has 8een used 7or the diagnosis o7 peanut inhalation9 ho;ever the high cost and the need 7or sedation prevents routine use o7 MR& in children ;ith 7oreign 8ody aspiration.
Figure 3 Radiograph showing ingested beads (left), and coin in esophagus (right)
$he relative di77iculty in identi7ying a 7oreign 8ody varies according to the type o7 o8ject ingested and its radio-opacity. Metal o8jects ;ith a relatively high atomic ;eight are 12
readily visi8le ;ith plain 7ilm radiography in that they are intensely radiopacept aluminum: most animal 8ones and some 7ish 8ones some 7oods some soil 7ragments9 sand9 gravel9 and mineral 7ragments some medications and poisons 6!"&P%SC chloral hydrate9 heavy metals9 iodides9 phenothia=ines9 enteric coated pills9 solvents:. 'onradiopa9 esophagus9stomach9small and large intestine.Radiopacept in delaying endoscopy or computed tomography 6!$: scanning. &n small children9 a mouth-to-anus radiograph !an 8e o8tained.&n older children and adults9 plain 7ilms o7 the neck9 chest9 and a8domen should 8e o8tained. # posteroanterior6P#:and lateral chest radiographs provide 8etter locali=ation 7or 7oreign 8odies ;ithin the lumen o7 the esophagus. $he progress in the 8o;el9 i7 needed9 can 8e checked periodically ;ith radiographs. &7 the tip o7 a sharp-edged 7oreign 8ody has per7orated the ;all9 it may project outside the air-containing lumen. "o;ever9 some 7oreign 8odies such as small 7ish 8ones or pieces o7 plastic and ;ood are only 7aintly radiopa
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Figure Radiograph showing !shbone stuc"
*atman study may 8e indicated in cases o7 ingestion o7 nonopaclude per7oration and can then 8e completed ;ith a 8arium e>amination. $he contrast medium may impregnate the sur7ace o7 the 7oreign 8ody and render it more conspicuous. Recent technical developments have led !$ to 8e used more 7re9 esophagus9 stomach9 small intestine9 and large intestine. !$scanning is highly relia8le in locali=ing 7oreign 8odies in the esophagus. "o;ever9 the application is pro8a8ly un;arranted in every case o7 acute 8one dysphagia9 as 14
only a minority o7 patients ;ho sense 7oreign 8odies a7ter eating chicken or 7ish have a 8one present. Per7oration o7 intestinal structures 8y ingested 7oreign 8odies is a challenging diagnosis that should al;ays 8e invocated in cases o7 acute a8dominal symptoms. $he de7inite diagnosis is 8ased on the demonstration o7 the responsi8le 7oreign 8ody that is optimally achieved 8y !$. &t is also superior to other imaging modalities in demonstration o7 o8struction caused 8y a 7oreign 8ody. %specially9 the recent developments in !$ 6multidetector !$: technology made high-traluminal gas98ut its per7ormance is impaired 8y a limited spatial resolution9 the discontinuity o7 the sections9 and the very poor
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Foreign 8ody aspiration in the air;ay remain the cause o7 annual deaths in children and in7ants9 causing as many as )3? death per year in children younger than )1 years old in the US#. Predominated mainly 8y 7ood items such as peanuts9 grains9 seeds9 and meat. 'on 7ood items such as coin9 or paperclip may also o8struct aerodigestive tract causing many e77ect in children. $he main etiology o7 7oreign 8ody aspiration is the ha8it o7 children to aspirate and s;allo; everything in their o;n grasping hand. Foreign 8ody entrance to the aero-digestive tract remains a serious threat leading to dangerous complications in children(rganic and nonorganic material tend to o8struct and irritate the aerodigestive tract that leads to in7ection9 in7lammation and su8se9 recurrent pneumonia also can 8e 7ound as a late seamination may reveal a8normal air;ay sounds such as ;hee=ing9 stridor9 decreased 8reath sounds9 o7ten 8ilateral.$he physical e>amination typically is not help7ul9 8ut the oropharyn>9 neck9 chest9 lungs9 heart9 and a8domen should 8e care7ully e>amined. (ccasionally9 a 7oreign 8ody in the oropharyn> can 8e visuali=ed indirect laryngoscopy or 7i8eroptic nasopharyngoscopy and removed. $here are three main technitraction 8y using Foley catheter9 *ougienage9 %ndoscopic retrieval. $he 7irst t;o techni
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Baert, A. L. (2008). #ncyclopedia of $iagnostic %maging& Berlin: Springer Berlin Heidelerg. !"tta, #. #., $ %&'"d&"r, B. (2008). An "n""al *'reign 'd in t&e na'p&arn+. %ndian 'ournal of tolaryngology and ead and *ec" +urgery , 266267. -"&er/ee, -., $ a"l, . (2011). 'reign B'd Apirati'n: !e'grap&i rend and 'reign B'die 'ing a i. %ndian 'ournal of tolaryngology and ead *ec" +urgery , 313316 . -"nter, !. . (2014, April 21). -astrointestinal Foreign .odies. !iail eali dari ediine -edape: &ttp:eediine.edape.'artile776566'erie;a0101 #g"en, L. . (2009). /ediatric +urgery& -'ntreal: Springer Berlin Heidelerg. 'an', L. (2012). #rrors in Radiology& -ilan: Springer -ilan. Saladin, <. S. (2012). Anatomy /hysiology, 0he nity of Form and Function& &iladelp&ia: &e -=ra&ill %'pan.
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