Otherwise stable:
immediate endoscopic removal

Active bleeding or clinically unstable:
Endoscopic removal in OR with surgery/CV surgery present

If evidence of any esophageal injury:
Admission, NPO, IV anbx

Consider CT Angiography to exclude aortic injury.
Consider MRI of chest to determine proximity of injury to aorta

No significant injury to surrounding tissue or proximity to aorta

Esophagram to exclude leak before advancing diet as tolerated

Demonstration of injury close to aorta

Continue NPO and Anbx and serial MRI q 5–7 days until injury seen to recede from aorta

If presence of hematemesis or UGI bleeding within 21 days of removal,
assume aortoenteric fistula and emergently prepare for thoracotomy with CV surgery

<5 years of age AND BB ≥20 mm

≥5 years of age AND/OR BB <20 mm

Consider assessment of any esophageal injury and endoscopic removal, if possible, within 24–48 hours

If esophageal injury present:
Admit, NPO, IV anbx, and consider CT Angiography, MRI of chest

Repeat x-ray in 48 hours for BB ≥20 mm, repeat at 10–14 days for BB <20 mm if failure to pass in stool

Endoscopic removal if develops GI symptoms or not passed stomach by time of x-ray at time described above