Foreign Body Ingestion of a Beverage Can Tab

Author:
Otto Louis-Jacques, MD
Pediatric Specialists of Virginia, Fairfax, Virginia

Citation:
Louis-Jacques O. Foreign body ingestion of a beverage can tab. Consultant. 2018;58(2):92-94.

A 14-year-old boy presented to an outside urgent care facility after having accidentally swallowed part of the metallic opening mechanism of an aluminum beverage can. The patient was in the habit of separating the 2 parts of the metallic opener from the can, namely the pull-tab and the flat, circular, scored part of the lid that folds inside the can as one lifts the tab. After doing so, he had placed the pull-tab inside his mouth and had placed the circular part around his lower lip.

As he laughed, he had accidentally choked on the pieces of the soda can tab. He had been able to cough up the pull-tab but felt the other part go down his throat. He subsequently had felt pain in the throat and a persistent foreign body sensation, and he had been taken to the urgent care facility.

While there, he had eaten part of a sandwich, after which the pain in his throat and the foreign body sensation had resolved. He had no vomiting, hematemesis, difficulty breathing, or cough, and he denied having abdominal pain. His vital signs and physical examination findings were normal. Radiographs of the neck, chest, and abdomen were obtained at the urgent care facility and did not show any foreign body (Figure 1).

The clinicians at the urgent care facility consulted with a pediatric gastroenterologist at our facility. Because the patient’s history was clearly indicative of foreign body ingestion, and because aluminum soda can tabs are not always visible on plain radiographs because of their low density, we advised that the patient be transferred to our institution.

An abdominal radiography series was performed at our institution 5 hours after the initial radiographs had been taken at the urgent care facility. The new films showed a 2.5-cm linear metallic density projecting over the left aspect of the L3 vertebral body, suspicious for a foreign body (Figure 2). Because of the potential for injury to the gastrointestinal tract mucosa from the sharp edges of the soda can tab, the patient underwent urgent endoscopy, and the metallic object was found in the proximal part of the stomach (Figure 3). It was removed uneventfully via endoscopy, and the patient subsequently was discharged home.

NEXT: Discussion

Discussion. Ingestion of foreign bodies is a frequent occurrence among children, with coins being the most common in the United States and Europe. More than 127,000 foreign body ingestions are reported annually in the United States in individuals of all ages.¹ Most of these pass spontaneously without complications. However, sharp pointed objects, which usually are radiopaque, may cause injury, and endoscopic removal is recommended if the foreign body can be reached with an endoscope.^2,3 No specific recommendations exist for metallic objects, such as soda can tabs, that have a sharp edge but that are not pointed. Radiographs are recommended prior to endoscopy to confirm the exact location of a swallowed foreign body and to determine whether endoscopic removal is possible.

A handful of reports have illustrated the risks related to the ingestion of soda can tabs. A case report from 1975 was the first to highlight the risks of inadvertent ingestion or aspiration of these tabs, which initially had been designed to detach and fall into the can in order to minimize pollution.⁴ One patient required endoscopy for the removal an ingested tab; another patient required an open thoracotomy for removal of the tab, which had migrated into a bronchus.⁴ Eggli and colleagues reported 2 cases of esophageal perforation and tracheoesophageal fistula formation resulting from delayed recognition of the ingestion of aluminum pop-tops.⁵

In order to decrease the risk of accidental ingestion while still minimizing littering, the design of these tabs was changed in the 1970s from one in which the tab came off and fell inside the can, to the current one in which the pull-tab remains attached to the can after opening (stay-tabs). Nevertheless, a survey of the radiology records of a large children’s hospital uncovered 19 cases of stay-tab ingestions over a 16-year period, indicating that they still represent an ingestion hazard.⁶ In that series, only 4 of the 19 ingested tabs were identified radiographically. No national data are available on the frequency of ingestions of soda can tabs, nor is there a good estimate of the risk of complications caused by ingestions of these tabs.

Even though the poor radiopacity of aluminum has been adequately detailed in the literature,^5,7 awareness of this fact remains inconsistent. In the 2 cases reported by Eggli and colleagues, ingestion had occurred 9 months prior in one case and 10 months prior in the other case; in one of the cases, the parents had been assured by several physicians, based on normal physical examination and radiographic findings, that their child’s dysphagia was unrelated to the reported pull-tab ingestion.⁵ In our patient’s case, the referring physician had consulted with the radiologist at the urgent care facility, who had asserted that if a metallic foreign object had been present, it would have been visible on radiographs.

The low radiodensity of aluminum makes pull-tabs difficult to detect.^5-7 Other technical factors such as radiographic settings and the orientation of aluminum-containing objects can also hinder detection. This is well-illustrated by our patient’s case, in which a second radiograph showed the foreign body, which had not been visible on initial films. One could imagine that, in the case of a younger or less-reliable child, a clinician could have decided against endoscopy based on the apparently negative findings on the initial radiographs.

Handheld metal detectors have been proposed as a noninvasive and accurate way of confirming the presence of an ingested metallic foreign object and could be used for confirmation in cases of negative radiographic findings.⁸ Administration of an oral radiocontrast agent may help identify a foreign object, but it risks obscuring the esophageal mucosa, increases the risk of aspiration in case of an esophageal foreign body, and delays endoscopy.³

In summary, aluminum objects such as soda can tabs are not reliably detected on plain radiographs. Because delayed removal of these objects can lead to significant morbidity, endoscopy or additional imaging should be pursued if ingestion is suspected, even in cases in which the foreign body is not visible on a plain radiograph. 

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