1. Mahsa Akhavan, MD Pediatric Emergency Medicine Fellow Cohen Children’s Medical Center March 16, 2011

2.  Frequent reason for pediatric ED visits  More than 125,000 ingestions of foreign bodies by <19 years old reported to American Poison Control Centers in 2007  Common entrapment sites:  Proximal esophagus at thoracic inlet (skeletal to smooth muscle change)  Mid-esophagus: Level of carina and aortic arch  Lower Esophageal Sphincter

3.  Common foreign bodies:  Coins  Food  Small metallic and plastic toys  Buttons  Bones  Batteries  Most gastric objects pass without complication  70% of esophageal objects remain entrapped, especially upper/ mid-esophagus

4.  XRay  Consider Warning Signs  Require immediate removal?  Endoscopy  Wait for passage

5.  Induces immediate, short-lived relaxation of enteric smooth muscle  Alters motility  Reduces LES resting pressure  0.5mg or 1mg IV often used in cases of FBI or food impaction in adults  0.1mg/kg, max 1mg in children  Most common side effect: Vomiting

6.  Nonrandomized small trials reported 37-75% success rates in relieving esophageal foreign bodies with glucagon  Newer, small but double-blind, placebo controlled studies failed to show difference from placebo

7.  Mostly adult literature  Mostly for food impaction  One article on coin dislodgement in children

8.  Mehta, Acad Emerg Med, Feb 2001  Prospective, double blind, placebo controlled  Children 1-8yo presenting to Peds ER with XRay confirmed single coin impaction  Exclusion: those with warning signs  1mg IV glucagon versus placebo  Repeat XRay in 30-60min

9.  42 pts presented, 18 enrolled  17 didn’t qualify, 4 weren’t invited, 3 didn’t consent  14 patients completed  1 excluded due to vomiting and chest pain  Additional pts not pursued due to inefficacy  9 in glucagon group, 5 in placebo  Two groups similar in age, coin position, time to presentation, time to repeat XRay

10.  15% in glucagon group passed coin to stomach  60% passes coin to stomach in placebo group  Conclusion:  Glucagon does not seem to be effective in dislodgement of esophageal coins in children  Limitation: Small sample size but well designed

11.  Tibbling, Dysphagia, 1995  Multicenter, placebo controlled, double blind study  Glucagon plus diazepam versus placebo  43 pts enrolled, 24 to treatment group, 19 to placebo

12.  Disimpaction noted in:  38% of treatment group  32% of placebo group  Difference not statistically significant  Limitations:  Small sample size  Treatment group received glucagon PLUS diazepam ▪ Clouds effect of glucagon alone

13.  Al-Haddad, Dig Dis Sci, 2006.  Retrospective case series, adult population  92 patients with EFBI, all by food  Glucagon given to all patients  33% had complete resolution of symptoms  62% went for endoscopy

14.  Difficult to make conclusions  Limitations:  Retrospective with selection bias  Unknown number of pts who went home without glucagon treatment and why the enrolled received glucagon  No placebo group for comparison  Uncontrolled design - other patient meds?

15.  Sodemon, Dysphagia, 2004  All patients with acute food impactions from 1975-2000 from Mayo database  222 cases identified  106 received glucagon (48%), average 1mg

16.  Data collected on  Age  Sex  BMI  PMH  Food type ingested  Duration of symptoms at presentation  Dose of glucagon

17.  Findings:  Meat less likely responsive to glucagon (70% versus 90%)  No significant difference in terms of age, sex, BMI, and PMH  0.5mg versus 1mg of glucagon did not make a difference  Success rate: ▪ Glucagon group - 9.4% ▪ Control group - 17.2%

18.  Limitations:  Retrospective ▪ May have lead to higher success rate in control group  Conclusions:  Glucagon less likely to work in meat impaction  Unclear benefit compared to control or spontaneous resolution

19.  No good evidence supporting use of glucagon  All studies either small or not well designed  Well designed studies show no difference from placebo/ control and thus spontaneous resolution  Risk of use is minimal, vomiting primarily, so may try  May not be worth extra delay in discharge from ED/ admission/ EGD

20.  Al-Haddad M, Ward EM, Scolapio JS, Ferguson DD, Raimondo M. Glucagon for the relief of esophageal food impaction does it really work?. Dig Dis Sci. Nov 2006;51(11):1930-3.  Arana A, Hauser B, Hachimi-Idrissi S, Vandenplas Y. Management of ingested foreign bodies in childhood and review of the literature. Eur J Pediatr. 2001;160:468–72.  Chen MK, Beierle EA. Gastrointestinal foreign bodies. Pediatr Ann. 2001;30:736–42.  Metha D, Attia M, Cronan K. Glucagon for esophageal coin dislodgement in children: a prospective, double-blind, placebo-controlled study. Acad Emerg Med. Feb 2001;8(2):200-3.  Sodeman TC, Harewood GC, Baron TH. Assessment of the predictors of response to glucagon in the setting of acute esophageal food bolus impaction. Dysphagia 2004;19:18-21.  Tibbling L, Bjorkhoel A, Jansson E, et al. Effect of spasmolytic drugs on esophageal foreign bodies. Dysphagia 1995;10:126-7.