EM@3AM: Beverage Tab Ingestion

A 12-year-old boy with no past medical history accidentally ingested a soda can tab 2.5 hours prior to arrival. He is asymptomatic at present and feels well. He is able to tolerate secretions without difficulty. On exam, the patient is comfortable, alert, acyanotic, and non-stridulous. Breath sounds are clear to auscultation bilaterally, and his abdomen is nontender.

What evaluation is necessary, and what is the appropriate management?

Answer: X-rays, +/- CT imaging or metal detector use, likely endoscopy or bronchoscopy

A History: Evolution of the “Stay Tab”

• The church key – required this device to puncture the top of a can = laceration hazard (Image 1).
• The pull tab, est. 1959-1962, completely disconnected from the top of the can. Often ended up either in the environment or in the respiratory/GI tract of individuals (Image 2).
• The push tab – posed a risk of finger laceration as individuals had to push part of the can inside, leaving their fingers exposed to the can’s sharp aluminum edges (Image 3).
• The familiar “stay tab” (est. 1970s) used on beverages today (Image 4).
• Case reports of ingestion or inhalation have been reported as early as 1975.^1,2

History

• The patient may or may not recall inhaling or swallowing the tab.
• If the patient does remember the ingestion, it is important to know how long it occurred before presentation and whether the patient has been able to or tried to ingest any solids or liquids since then.
• Common scenarios to evaluate for: upper airway symptoms in young children, alcohol ingestion surrounding the episode, consuming a beverage that prior to had the tab popped off and into the can.^1-4
• Questions about symptoms can help delineate where the tab is located. Symptoms to ask about include:
  • Globus sensation, sore throat, stridulous breathing, changes in voice, ability to tolerate secretions
  • Cough, hemoptysis, dyspnea, chest pain
  • Abdominal pain, vomiting, melena, or hematochezia
• Patients may be asymptomatic.

Exam

• The physical exam should be directed toward symptoms.
• A thorough exam includes the oropharynx, neck, cardiopulmonary systems, and abdomen.
  • Oropharynx – have the patient open their mouth, use a light to evaluate the oral cavity for signs of foreign bodies or trauma. Note if the patient is drooling.
  • Neck – evaluate for free air, stridor.
  • Cardiopulmonary – examine for tachycardia, equal breath sounds, rhonchi, free air along the precordium.
  • Abdominal – looking for tympany, abdominal distension, tenderness, guarding, rectal bleeding (if indicated by history).
• If asymptomatic or if the patient is unable to relate their symptoms (young child, cognitive delay), it is reasonable to focus on areas the beverage tab could be if either aspirated or ingested.

Diagnosis

• Keep both inhalation and ingestion of the tab on the differential – there are case reports of patients who reported drinking a beverage with the tab inside the can later found to have aspirated rather than ingested the tab.¹
• Historically, the ability to see aluminum (the principal metal in beverage tabs) on x-ray has been difficult as the atomic numbers between soft tissue and aluminum are similar (7.5 and 13, respectively).³ Some studies have sited only 21% of known aluminum tab ingestions as being able to be detected on x-ray,⁴ though one study in cadavers found the sensitivity and specificity on AP and lateral x-rays to approach 80-90% and 90-100%, respectively.⁵Given this sensitivity, one cannot fully rule out their presence, especially in patients unable to give a clear history (i.e. altered mental status, intoxication, very young children).
• In one small, single-center retrospective chart review, of 19 ingestions that presented over a 16-year period only 4 were apparent on x-ray and all of those were located in the stomach.⁴
• X-rays are still recommended first line: typically with neck, chest, and abdominal x-rays suggested.
• If negative x-ray series, further workup is recommended if clinical suspicion is moderate to high that the ingestion occurred. Stay tabs have a significant likelihood for life-threatening injury given their sharp edges.
• In some low resource settings or when location of the foreign body is in question, handheld metal detectors can be used to identify the location of the tab. A suggested method for performing this examination includes:⁶
  • Separate all removable metal objects from the patient (glasses, piercings, etc.).
  • Place the patient in a hospital gown.
  • Have the patient stand in the middle of an area without surrounding metal (i.e. away from stretcher railings, hospital machinery).
  • Extend their hands overhead with their neck held in extension.
  • Test the metal detector on a known metal object to confirm feedback.
  • Pass the detector from the nasopharynx caudally to the pubic symphysis performing both on dorsal and ventral aspects of the patient.
• In one paper comparing detection of “metallic foreign bodies” in the gastrointestinal tract using a metal detector compared to radiographs, sensitivity of the detector was 88.6% and specificity was 100%.⁷ To our knowledge there are no published papers regarding the efficacy of this intervention specifically with aluminum beverage tabs.
• CT has also been used for identifying tab location, particularly in patients with negative radiographs, where location could be varied based on prolonged time to presentation or unclear history, or who have suspected complications such as perforation, fistula, phlegmon, or abscess.⁸ Largely, successfulness of CT imaging in identifying an aspirated or ingested aluminum beverage tab has been demonstrated in case reports without primary studies evaluating its efficacy. ^9,15 While the efficacy of this modality has yet to be determined with aluminum tabs, studies on esophageal foreign bodies have shown sensitivity and specificity of 100% and 70.6%, respectively when using CT imaging for diagnosis.⁹

Management

• If the tab is suspected in the upper airway, use your airway foreign body management algorithm of choice, such as the one detailed in this article:
  • http://www.emdocs.net/upper-airway-foreign-bodies-emergency-department-presentation-evaluation-and-management/
• Most patients will need either endoscopy or bronchoscopy for retrieval of the foreign body, though some cases report presumed successful passage of an ingested tab.¹
• Maintain a low threshold for consulting gastroenterology or pulmonology for retrieval of the tab via endoscopy or bronchoscopy. Consider consulting general surgery, otolaryngology, or cardiothoracic surgery, particularly if you are concerned for gastrointestinal, tracheal, or bronchial perforation, respectively (unstable vital signs, free air in the neck or precordium, tympanic/distended abdomen).

Potential Complications

• Several complications have been reported in the literature.
  • If aspirated: lodging of the tab in or laceration of the trachea, upper airway obstruction, chronic cough/pulmonary infiltrates, inflammatory changes to bronchi/bronchioles with narrowing and compensatory hyperinflation with air-trapping of the affected lung, and development of significant granulation tissue requiring thoracotomy for surgical removal.^1,11-13
  • If ingested: esophageal stenosis, bolus obstruction, abscess and perforation, tracheoesophageal fistula, and small bowel stenosis with recurrent obstruction have all been reported.^2,11,13-15
• Sometimes ingestion or aspiration can produce chronic symptoms (cough, dyspnea, halitosis, dysgeusia, chest pain, abdominal pain) with retrieval of the foreign body being diagnostic several years later.^1,9,11,14,15

Pearls

• Beverage tab ingestions/aspirations have a high risk for life-threatening complications and will often need to be removed via endoscopy, bronchoscopy, or surgical
• Aluminum tabs often will not appear on x-rays (higher likelihood if in the stomach), thus absence should not falsely reassure the clinician.
• CT imaging or metal detectors can be used as adjuncts to determine location of the foreign body.

Further Reading (Historical):

• 1974 New York Times article: “Swallowed Cans on Tabs a Danger”: https://www.nytimes.com/1974/09/15/archives/swallowed-tabs-on-cans-a-danger-numbers-unknown.html
• Washington Post: “The Inventor Who Pulled Back the Tab and Found Millions”: https://www.washingtonpost.com/archive/lifestyle/2005/02/06/the-inventor-who-pulled-back-the-tab-and-found-millions/bbafa67f-e2a3-449b-ad4b-5caa76f5d076/
• “From Church Key to Pop Top, a Look Back at Canned Beer”: https://www.eater.com/drinks/2015/7/15/8942369/dirt-cheap-week-canned-beer

FOAMed

• Children’s Hospital of Philadelphia (CHOP) Pathway for the Evaluation/Treatment of the Child with Foreign Body Ingestion – Ingestion of Radiopaque or Suspected Radiotranslucent Sharp Object: https://www.chop.edu/clinical-pathway/foreign-body-ingestion-ingestion-radiopaque-or-suspected-radiotranslucent-sharp
• EM@3AM: Esophageal Foreign Bodies: http://www.emdocs.net/em3am-esophageal-foreign-bodies/
• Aspirated Foreign Bodies: https://pedemmorsels.com/aspirated-foreign-body/
• Upper Airway Foreign Bodies: Emergency Department Presentation, Evaluation and Management: http://www.emdocs.net/upper-airway-foreign-bodies-emergency-department-presentation-evaluation-and-management/
• Ingested Lead Foreign Bodies: Not a Typical FB: https://pedemmorsels.com/ingested-lead-foreign-bodies/

References

1. Rogers LF, Igini JP. Beverage can pull-tabs: inadvertent ingestion or aspiration. JAMA. 1975;233(4):345–348.
2. Keating JP, Weldon CS, Connors JP, McAlister WH. The “pop-top” tab. A cause of esophageal stenosis. J Pediatr.1975;86(1):111-112.
3. Stewart GD, Lakshmi MV, Jackson A. Aluminum ring pulls: an invisible foreign body. J Accid Emerg Med. 1994;11(3):201– 203.
4. Donnelly LF. Beverage can stay-tabs: still a source for inadvertently ingested foreign bodies in children. Pediatr Radiol. 2010;40(9):1485-1489.
5. Valente JH, Lemke T, Ritalin M, et al. Aluminum foreign bodies: do they show up on x-ray? Emerg Radiol. 2005;12:30-33.
6. Ramlakhan SL, Burke DP, Gilchrist J. Things that go beep: experience with an ED guideline for use of a handheld metal detector in the management of ingested non-hazardous metallic foreign bodies. Emerg Med J. 2006;23:456-460.
7. Saz EU, Arikan C, Ozgenc F, et al. The utility of handheld metal detector in confirming metallic foreign body ingestion in the pediatric emergency department. Turk J Gastroenterol. 2010;21(2):135-139.
8. Tseng HJ, Hanna TN, Shuaib W, et al. Imaging Foreign Bodies: Ingested, Aspirated, and Inserted. Ann Emerg Med.2015;66:570-582.
9. Kotsenas AL, Campeau NG, Oeckler RA, et al. Evaluation of Suspected Aspirated Beverage Can Pull Tab: Radiographs May Not Be Enough. Case Rep Radiol. 2014;2014:196960.
10. Loh WS, Eu DKC, Loh SRH, et al. Efficacy of computed tomographic scans in the evaluation of patients with esophageal foreign bodies. Ann Otol Rhinol Laryngol. 2012;121(10):678-681.
11. Elghouche AN, Lobo BC, Ting JY. Aspiration of Aluminum Beverage Can Tab: Case Report and Literature Review. Case Rep Otolaryngol. 2017;2017:1010975.
12. Limper AH, Prakash UBS. Tracheobronchial foreign bodies in adults. Annals of Internal Medicine. 1990;112(8):604–609.
13. Burrington JD. Aluminum “Pop Tops”: A Hazard to Child Health. JAMA. 1976;235(24):2614–2617.
14. Eggli KD, Potter BM, et al. Delayed diagnosis of esophageal perforation by aluminum foreign bodies. Pediatr Radiol. 1986;​16(6):511-513.
15. Ogrydziak CE, Kirkland JW, Falta EM. The aluminum beverage tab and a soldier with chronic abdominal pain. Radiol Case Rep. 2020 Nov 1;16(1):51-54.