Severe esophageal damage due to button battery ingestion: can it be prevented?

A case of corrosive tracheoesophageal fistula: A complication of button battery ingestion

Key Clinical Message

Button battery ingestion has been a common condition encountered by otorhinolaryngologists. Impaction in the esophagus can lead to serious and fatal complications such as tracheoesophageal fistula. Management involves a multidisciplinary team and varies from supportive therapy to surgical intervention.

Abstract

Ingestion of button batteries has been seen with increasing frequency over the past decade. In several small numbers of reported cases, their impaction in the esophagus has led to severe, sometimes fatal, complications. The management of these cases has varied from expectant, supportive therapy to early surgical intervention. We report a case of button battery ingestion that was diagnosed late and resulted in a complication of tracheoesophageal fistula with migration to the thorax which was managed by open surgery.

Preputial advancement flap for delayed urethrocutaneous fistula of the glans following urethral insertion of an 'AAA' battery

INTRODUCTION

Foreign body insertion associated with sexual gratification is known as polyembolokoilomania. Following removal of the foreign body, long-term complications are infrequently seen. Whilst conservative and endoscopic approaches usually suffice, in extreme cases open surgical approaches are required. We describe an unusual case of polyembolokoilomania in a 25-year-old male involving a single 'AAA' battery who developed a urethrocutaneous fistula requiring delayed reconstructive surgery.

CASE PRESENTATION

Following an initial successful open extraction of an 'AAA' battery from the mid penile urethra the patient developed a delayed urethrocutaenous fistula of the glans. This was managed using a single stage closure with a preputial graft on its vascular pedicle thereby preserving the foreskin and avoiding a buccal graft. No intra-operative or post-operative complications occurred with a catheter left in situ for 2 weeks. Formal histology confirmed a foreign body type reaction. Following outpatient review successful cosmetic, functional, and sexual outcomes were recorded with questionnaires and medical photography.

CONCLUSION

Preputial advancement flap with foreskin preservation for distal urethrocutaenous fistula is a successful method of treating delayed urethrocutaenous fistula of the distal urethra in cases of polyembolokoilomania.

Arterio-Esophageal Fistula: A Complication of Button Battery Ingestion

Button battery (BB) ingestion is one of the rare foreign body ingestion (FBI) emergencies. Nevertheless, it carries high morbidity and mortality rates. In this case, we present a child with button battery ingestion complicated after successful removal by massive hematemesis and cardiopulmonary arrest. The patient was resuscitated and admitted to the intensive care unit (ICU). The event resulted in multiple neurological sequelae as demonstrated by radiological study as well as clinical examination.

Button battery ingestion: A serious pitfall of diagnosis of ingested foreign bodies in children from resource-limited settings - A case report

INTRODUCTION AND IMPORTANCE

Button battery ingestion and impaction in the oesophagus can result in severe morbidity and even fatality if not diagnosed and managed urgently. Delayed or missed diagnosis due to the sometimes-vague symptomatology and limited investigations in resource-limited settings further increases the complications rate.

CASE PRESENTATION

Case 1: A 2 years old male child presented with a nine months history of recurrent respiratory tract infections not responding well to medical treatment. A radio-opaque round foreign body (FB) was incidentally seen in the chest. Rigid esophagoscopy and removal were done, but the child had developed a trachea oesophagal fistula. The fistula was managed conservatively by retaining a nasogastric tube until spontaneous fistula closure happened. Case 2: A 2 years old female child presented with a one-year history of poor feeding, vomiting, difficulty in breathing and persistent wet cough, and fever. He underwent tonsillectomy with no improvement. A radio-opaque round FB was incidentally seen in the oesophagus near the carina by a chest x-ray. A thoracotomy had to be done after two failed removal attempts by rigid esophagoscopy.

CLINICAL DISCUSSION

The similarity in the symptomatology of common aerodigestive conditions with FB ingestion compounded with low chances of witnessing the ingestion creates a possible pitfall for clinicians when resulting in a missed or a delayed diagnosis, further raising the complications rate of FB impaction in the oesophagus, such as tracheoesophageal fistula formation or the need for a massive surgery such as thoracotomy to remove the button battery.

CONCLUSION

Complications of foreign body ingestion in the paediatric population can have serious complications. High morbidity and mortality may be attributed to delayed diagnosis and intervention.

Diagnosis and Management of Button Battery Ingestion Complicated by Tracheo-Esophageal and Aorto-Esophageal Fistulas

Button battery ingestion (BBI) is common in children and its prevalence has increased in the last decades. BBI can be responsible for very severe and potentially fatal complications if not promptly detected. We describe the successful management of two cases of BBI that occurred in two previously healthy infants. Both patients presented with vague symptoms and no witness of foreign body ingestion. The prolonged time of exposure to the corrosive effects of disk batteries was responsible for the development of tracheo-esophageal fistula (TEF) and aorto-esophageal fistula (AEF). We demonstrate how prompt diagnosis and management are crucial for the infants’ survival.

Airway Complications Resulting From Pediatric Esophageal Button Battery Impaction: A Systematic Review

Importance

Button batteries (BBs) are commonly found in many household items and present a risk of severe injury to children if ingested. The direct apposition of the trachea and recurrent laryngeal nerves with the esophagus puts children at risk of airway injury secondary to the liquefactive necrotic effects of BB impactions.

Objective

To review airway injuries, including long-term sequelae, after BB ingestion in children.

Evidence Review

For this systematic review, a comprehensive strategy was designed to search MEDLINE, Embase, Cochrane Database of Systematic Reviews, Web of Science, and CINAHL (Cumulative Index of Nursing and Allied Health Literature) from inception to July 31, 2021, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Additional cases were identified from the National Capital Poison Center BB registry. Individual authors were contacted for additional information. Studies with pediatric patients (<18 years) who developed airway injuries after BB ingestion were included. A total of 195 patients were included in the analysis; 95 were male. The mean (SD) age at BB ingestion was 17.8 (10.2) months. The mean (SD) time from BB ingestion to removal was 5.8 (9.0) days. The 2 most common airway sequelae observed in our series were 155 tracheoesophageal fistulae and 16 unilateral vocal cord paralyses. Twenty-three children had bilateral vocal cord paralysis. The mean (SD) duration of ingestion leading to vocal cord paralysis was shorter than that of the general cohort (17.8 [22.5] hours vs 138.7 [216.7] hours, respectively). Children presenting with airway symptoms were likely to have a subsequent tracheoesophageal fistula or vocal cord paralysis.

Conclusions and Relevance

Airway injuries are a severe consequence of BB ingestion, occurring more often in younger children. This systematic review found that tracheoesophageal fistulae and vocal cord paralyses were the 2 most common airway injuries, often requiring tracheostomy. Vocal cord injury occurred after a shorter BB exposure time than other airway injuries. Continued efforts should be directed toward prevention strategies to avoid the devastating sequelae of BB-associated airway injury.

Endoscopic Evaluation for Stricture Formation Post Button Battery Ingestion

Every year, there are over 3300 ingestions of button batteries, mostly by young children. Initial presentation of button battery ingestion may be nonspecific, with a delay in diagnosis and removal resulting in increased risk of complications. We present the case of a five-year-old female who presented with vomiting following unwitnessed button battery ingestion. The battery was impacted in the middle esophagus for at least six hours. Endoscopy was performed for immediate removal and showed a Grade 2B erosion, warranting nasogastric tube placement. The patient remained asymptomatic following discharge and had a barium swallow that was read as normal. However, a repeat endoscopy one month later visualized stricture formation at the previous battery injury site. This case highlights the importance of both clinician and parent awareness of button battery ingestion and demonstrates that endoscopy provides the most accurate assessment of esophageal injury and complication development, even in asymptomatic patients.

A 2-Year-Old Boy Who Developed an Aortoesophageal Fistula After Swallowing a Button Battery, Managed Using a Novel Procedure with Vascular Plug Device as a Bridge to Definitive Surgical Repair

Patient: Male, 2-year-old

Final Diagnosis: Aortoesophageal fistula

Symptoms: Esophageal foreign body • gastrointestinal bleeding

Medication: —

Clinical Procedure: —

Specialty: Gastroenterology and Hepatology • Pediatrics and Neonatology

Urgency of Esophageal Foreign Body Removal: Differentiation Between Coins and Button Cell Batteries

OBJECTIVE

Coin-shaped button battery foreign bodies have a similar initial presentation to coin ingestion, but delayed retrieval of a battery from the esophagus can have devastating consequences. Variations in timing of retrieval for children with ingestion of coin foreign bodies have been reported. The study assesses the sensitivity and specificity of conventional and digital radiographs to differentiate button batteries from coin foreign bodies.

STUDY DESIGN

3B case control study.

STUDY SETTING

Tertiary academic medical center.

METHODS

A radiographic study of the 12 most common commercially available button batteries and 66 coins of varying international origins was performed. Foreign bodies were placed at the cervical esophagus of a cadaver, and anteroposterior (AP) and lateral conventional radiographs of the neck were obtained. Digital AP and lateral radiographs of standalone coins and batteries were also obtained. Images were blindly read by 2 otolaryngologists and 2 radiologists. Statistical analysis was performed to determine accuracy in identifying coins vs batteries.

RESULTS

Using conventional radiographs to identify button batteries yielded a sensitivity of 0.88 and a specificity of 0.92 (positive predictive value [PPV] = 0.75, negative predictive value [NPV] = 0.97). Digital radiography yielded an overall sensitivity of 0.98 and specificity of 0.97 (PPV = 0.87, NPV = 0.99). Features of button batteries were only seen on AP conventional radiographs using reverse contrast.

CONCLUSIONS

Neither conventional nor digital radiographic imaging had perfect accuracy in identifying coins vs batteries. Features of common disc batteries were identified, which may aid in diagnosis. With potential devastating consequences from retained battery in the esophagus, emergent removal of any possible disc battery foreign body should be considered.

Battery swallow-induced tracheoesophageal fistula in a pediatric patient

Tracheoesophageal fistula (TEF) is an abnormal connection between the trachea and esophagus. Rare acquired TEF arises from trauma, caustic fluids ingestion, and iatrogenic injuries (ventilation, esophageal atresia repair, radiation, or tracheal/esophageal stents). We discuss the diagnosis, anesthetic management, and surgical correction of battery swallow-induced TEF, not previously reported in the pediatric anesthesia and otorhinolaryngology literatures.

Successful surgical management of an aorto-oesophageal fistula caused by button battery ingestion

Aorto-oesophageal fistula is a rare complication of foreign body ingestion from which few patients survive. Aggressive surgical treatment is the only form of effective therapy for this fatal complication. We present the successful surgical treatment of an aorto-oesophageal fistula in a child without using cardiopulmonary bypass.

Fatal haemorrhage from an aortoesophageal fistula secondary to button battery ingestion in a 15-month-old child. Case report and literature review

Small children put various objects into their mouths, which is one of their ways of exploring the surrounding world. Apart from toy parts, e.g. Lego® bricks or magnetic spheres, such objects include coins, small stones, as well as batteries used for different electric devices. Such batteries, especially the flat, round button type, may be ingested and become impacted in one of the physiological narrowing sites of the oesophagus, leading to serious complications. The case of a 15-month-old child is presented, who died due to a massive gastrointestinal haemorrhage from an aortoesophageal fistula that developed at the site of a pressure ulcer caused by an impacted button battery. The presented case shows that ingestion of even a small battery may lead to death. The asymptomatic course of the battery ingestion significantly hinders both the assessment of circumstances and the time of the battery ingestion. Sudden death may result from a massive haemorrhage from a pressure-induced injury to a big blood vessel.

Age-Specific Differences in Foreign Bodies Ingested by Children: A Cohort Study of 252 Japanese Cases

Background and Objectives: When children accidentally ingest foreign bodies, they may be unable to communicate adequately; it is often difficult to identify the causative foreign body unless someone is watching over them. In such instances, to identify the causative foreign body during clinical practice, we aimed to determine if it varies according to age. Materials and Methods: From April 2013 to June 2018, 252 records of pediatric patients with a confirmed diagnosis of foreign-body ingestion were retrospectively examined in a Japanese university hospital. Comparisons among multiple age groups, according to type of ingested foreign body, were analyzed using Kruskal‒Wallis tests. The differences between the individual data were tested using the Steel‒Dwass test. Results: The median age of the patients was 15 months, and of the total patients, 140 were boys (55.5%). The types of foreign bodies ingested were as follows, in order of frequency: cigarettes (n = 44, 17%, median age: 12 months), plastics (n = 43, 17%, median age: 11 months), chemicals (n = 27, 11%, median age: 13 months), internal medicines (n = 26, 10%, median age: 33 months), and metals (n = 26, 10%, median age: 35 months). The median age was significantly different among the types of causative foreign bodies (p < 0.01). The patient age for the ingestion of cigarettes was significantly younger than that for ingesting metals or coins. The age for ingesting internal medicines was significantly older than that for ingesting plastics, cigarettes, paper, or chemicals (p < 0.01). Conclusions: The causative foreign body ingested differed according to age. This will be valuable information for physicians that encounter pediatric patients who may have ingested an unknown foreign body in Japanese pediatric emergency or general practice settings.

Clinical Profile and Outcome of Esophageal Button Battery Ingestion in Children: An 8-Year Retrospective Case Series

Objective

To present the clinical profile and outcomes of esophageal button battery ingestion cases treated at our institution over an 8-year period.

Methods

A total of 17 children who presented after ingesting a button battery and were treated at a tertiary care clinic over an 8-year period were included in this retrospective case series study. Data on patient demographics and esophageal location of the battery, time from ingestion to admission, symptoms, grade of mucosal injury, size of the battery, management, complications, and follow-up outcome were recorded.

Results

Median age was 29 months (range, 2–99 months). Boys comprised (n=11, 64.7%) of the study population. The most common location was the proximal esophagus (n=10, 58.8%). The median time from ingestion to admission was 6 h (range, 3–24 h). Hypersalivation alone (n=6, 35.3%) or together with vomiting (n=5, 29.4%) was the most common symptom. Grade IIA mucosal injury was noted in six (n=6, 35.3%) patients. The diameter of the battery was a median of 18.0 mm (range, 14–22 mm). We did not observe any correlation between the size of the battery and the grade of the injury. Early postoperative complications were encountered in one patient (n=1, 5.8%) and late postoperative complications were noted in eight patients (n=8, 47.1%) which required further esophageal dilatations, and follow-up revealed normal findings in eight patients (n=8, 47.1%) and mortality occurred in one patient.

Conclusion

The current case series study describing the clinical profiles and outcomes of 17 children who had ingested an esophageal button battery revealed male predominance, young patient age, and admission after a median of 6 h (3–24 h) of ingestion with nonspecific symptoms. Our findings confirm the success of rigid endoscopy to remove esophageal button batteries and indicate the likelihood of severe complications after removal.

Predictors of nature of ingested foreign bodies in children & assessment of operative outcomes

OBJECTIVE

To examine sensitivity/specificity of history & radiology to identify ingested foreign body (FB) and develop a protocol for management of ingested FBs in paediatric patients; to assess outcomes of removal of lithium button battery foreign body (LBBFB).

METHODS

Retrospective review. Children presenting to ENT emergency with suspected FB ingestion underwent rigid esophagoscopy and FB removal. Average age, number of attempts, duration of ingestion, success rate, and complications were analysed.

RESULTS

Cases of coin/LBBFB ingestion: 916/70. Mean age: 5.8/2.03 years (p < 0.001). Average duration of ingestion: 37/9.5 h (p < 0.001). Patients below 3: 31.3/62.8% (p < 0.001). Suggestive history/radiological signs: 100%/100%, 75.7%/98.6% (p < 0.0001). Site of impaction cricopharynx: 60.3%/74.3% (p = 0.02). LBBFB group: Successful removal in 1st attempt: 66 (94.3%). Cases requiring multiple attempts due to impaction: 4 (5.7%). Parenteral steroids were administered before successful reattempt. No relation was found between duration of ingestion/impaction. Five (7.1%) cases developed complications. Average follow-up duration: 13.59 months.

CONCLUSIONS

Children <3 years with vague history of FB ingestion and suggestive chest x-ray should be sent urgently for FB removal. Parenteral pre-and postoperative short course steroid use may be considered to improve outcomes.

[Treatment of foreign bodies in the upper third of the esophagus without endoscopy: is it a challenge for practitioners working in isolation?]

La prise en charge des corps étrangers du tiers supérieur de l'œsophage est bien codifiée et fait appel le plus souvent à un traitement endoscopique. Ce matériel spécifique, ainsi que des médecins gastro-entérologues entraînés à son utilisation fait parfois défaut dans les pays d'Afrique. D'autres moyens doivent alors être envisagés pour les médecins ayant à prendre en charge ce type de pathologie. L'objectif de cette étude était d'évaluer la prise en charge des corps étrangers du tiers supérieur de l'œsophage par des médecins anesthésistes-réanimateurs dans un centre médico-chirurgical du Tchad. 37 cas d'extraction chez des enfants de 0 à 15 ans étaient analysés. Il s'agissait de pièces de monnaie et de piles au lithium dans respectivement 92% et 8% des cas. La méthode employée était une sonde de Foley à ballonnet dans 43,2% et d'une pince à calcul sous laryngoscopie dans 56,8% des cas. Un cas d'échec ayant nécessité une cervicotomie était noté dans chaque groupe. Quatre complications mineures étaient rapportées dans le groupe « pince à calcul », aucune dans le groupe « Foley ». Les indications d'extraction de corps étrangers du tiers supérieur de l'œsophage doivent être bien connues des médecins amenés à les prendre en charge. En cas d'indisponibilité de l'endoscopie, d'autres techniques alternatives peuvent être utilisées avec un taux de succès satisfaisant. En cas d'échec un recours à la chirurgie peut être nécessaire.

Battery ingestions in children: Variations in care and development of a clinical algorithm

PURPOSE

To review current management and outcomes of ingested batteries and develop a clinical management algorithm.

METHODS

Children <18years old who ingested a battery between 1/2011 and 9/2016 at two tertiary care children's hospitals were reviewed. Demographics, imaging, management and outcomes were analyzed using descriptive statistics, Chi-square and Wilcoxon Rank-sum tests.

RESULTS

There were 180 battery ingestions. The median age was 3.9 (range 0.7-18) years, with 78 (43%) males. The most common symptoms were abdominal pain (17%) and nausea/vomiting (14%). Diagnosis was confirmed with plain radiographs in 170 (94%) patients. Locations on imaging were: stomach (37%), small bowel (24%), esophagus (18%), colon (11%), and non-specific location past the gastroesophageal junction (9%). Treatment was dictated by five different subspecialties including surgery (35%), gastroenterology (25%), emergency medicine (19%), primary care/emergency with a consulting service (13%), and otolaryngology (8%). All esophageal batteries (n=33) had an intervention. Interventions included fluoroscopic balloon extraction (6 attempted, 33% retrieval rate), rigid esophagoscopy (26 attempted, 96% retrieval rate), and EGD (6 attempted, 83% retrieval rate). For batteries distal to the gastroesophageal junction 16 (11%) patients had an intervention. Interventions included EGD (13 patients, 69% retrieval), colonoscopy (1 patient, successful retrieval), and abdominal surgery in two patients.

CONCLUSION

Isolated batteries that pass the gastroesophageal junction rarely require intervention and can be managed conservatively. Given the variability in managing these patients, we developed an evidence based algorithm.

LEVEL OF EVIDENCE

Level 2.

STUDY TYPE

Retrospective Study.

An uncommon source for oesophageal foreign body: Fidget spinner

Fidget spinner is a new handheld toy with potential choking and ingestion hazard. Our objectives are to describe clinical presentation of a child with fidget spinner ingestion and draw attention to danger associated with fidget spinner. A 3-year-old boy presented with painful swallowing and feeling of something stuck in the throat. A chest radiograph revealed a radiopaque foreign body with a disc-like component. Rigid oesophagoscopy revealed a foreign object with disc battery and battery holder circuit board. Clinicians should consider the fidget spinner as one of many varieties of toys that has potential for button battery ingestion or aspiration.

Analysis of Complications After Button Battery Ingestion in Children

AIM

Button battery ingestion (BBI) in children may cause severe complications. This analysis is a literature review of complications after pediatric BBI.

METHODS

Literature was searched on PubMed (1995-2015) using the terms "button battery," "ingestion," and "children." End points were age, type and diameter of battery, complications, affected organ, and fatality.

RESULTS

A total of 31 publications were analyzed. Patients from 4 months to 19 years old were included (n = 136,191, with n = 102,143 or 75% aged <6 y). In 6262, the diameter of the battery was documented. Batteries of 20 mm or greater in size were more prone to complications (n = 226). With regard to the anatomy, BBI caused complications mainly in the esophagus (n = 88, 38.94%). Sixty-one fatal outcomes were reported.

CONCLUSIONS

Children younger than 6 years are the most prone to BBI, with lithium batteries of 20 mm or greater in size associated with complications. Complications have been estimated at 0.165%, with lethality of 0.04%. The esophagus is the most affected organ, but vascular involvement is often fatal.

Recurrent and acquired tracheoesophageal fistulae (TEF)-Minimally invasive management

OBJECTIVE

Recurrent and acquired fistulae are a serious complication of congenital esophageal atresia and tracheoesophageal fistula (TEF) repair and foreign body ingestion (FBI) (e.g., button battery). We report our experience with a minimally invasive approach to recurrent and acquired TEF.

METHODS

Medical records of patients referred for management of recurrent and acquired TEF between 2003 and 2015 were reviewed retrospectively. Patients underwent endoscopic procedures (de-epithelization of fistulous tract and fibrin tissue adhesive-Tisseel^R) under general anesthesia.

RESULTS

Nine children (7 male, 2 female) with age range 3months to 3years (mean 1.5year) were managed. TEF closed spontaneously in four patients, whereas in 5 patients the TEF closed after combined endoscopic procedure. Three patients required repeat endoscopic procedures. Follow-up ranged between 7months to 10years (mean 4.2years).

CONCLUSIONS

Active observation and repeat combined endoscopic procedures are safe alternatives to open surgical repair of acquired and recurrent TEF.

LEVEL OF EVIDENCE

Level IV study.

Speech-language Pathology in Acute Pediatric Chemical or Button Battery Ingestion Injury

OBJECTIVES

Dysphagia is a common consequence of pediatric ingestion injury, yet there is a lack of data relating to recommencement of oral (per os; PO) intake or use of feeding therapy. We describe patterns of early PO intake, and referral to speech-language pathology (SLP) for feeding therapy, during the acute admission of a pediatric cohort postchemical or button battery ingestion injury.

METHODS

Retrospective chart review of pediatric ingestion injuries admitted to a quaternary hospital from 2008 to 2013. Clinical parameters, PO intake progression, and nature of referrals for feeding therapy during the acute admission were examined.

RESULTS

Fifty-one children (26 boys; mean age: 31.5, range 4-170 months) were identified (75% with grade II or III mucosal injuries), of whom 31 (60%) had impaired PO intake. Of these, 5 recommenced premorbid PO intake during admission. At discharge, 16 remained on modified PO intake, and 10 remained nil PO. Eight (26%) were referred to SLP for feeding therapy during acute admission, or within 4 months of discharge. Feeding therapy-referred children were more likely to have pediatric intensive care admission (PICU) (100% vs 26%), and longer hospital admission (36.1 vs 9.3 days for those not referred).

CONCLUSIONS

More than half of the cohort had impaired PO intake, and one-third were nil PO at time of discharge. Referrals for feeding therapy were limited. Our findings may provide some guidance for clinicians, patients, and their families regarding possible PO intake recovery patterns, as well as provide background for evaluating the potential for feeding therapy and SLP involvement within this population.

[Fatal aorto-esophageal fistula due to accidental ingestion of button battery. Algorithm for management of disk-battery ingestion in patients younger than 6 years old]

The ingestion of disc battery is a common problem in children and current treatment may be sometime inadequate. Ingested button batteries have the potential to cause significant morbidity and mortality. Ingestion of button batteries has been seen with increasing frequency over the last decade, particularly for children aged younger than 6 years. If most cases of disc battery ingestion run uneventful courses, however, harmful outcomes are more common with ingestion of lithium batteries (3V) with a diameter greater than or equal to 16 mm. These young children have to benefit from a chest radiograph within 2hours which follow the ingestion. If the battery impacts in the esophagus, emergency endoscopic management is necessary. We report the case of one young child died followed an unknown lithium disk-battery ingestion complicated with an aorto-œsophageal fistula. We propose a protocol of specific coverage for patients aged younger than 6 years old.

Foreign Body Ingestion in Children: Should Button Batteries in the Stomach Be Urgently Removed?

PURPOSE

Foreign body (FB) ingestion is common in children, and button battery (BB) ingestion has been increasing in recent years. This study was to identify factors related to outcomes of FB ingestion, particularly BBs in the stomach. We evaluated whether the current recommendations are appropriate and aimed to suggest indications for endoscopic removal of BB in the stomach in young children.

METHODS

We investigated patient age, shape, size, location of FBs, spontaneous passage time and resulting complications among 76 children. We observed types, size, location of BB and outcomes, and analyzed their associations with complications.

RESULTS

Coins and BB were the two most common FBs. Their shapes and sizes were not associated with the spontaneous passage time. Size, spontaneous passage time, and age were also not associated with any specific complications. For BB ingestion, all 5 cases with lithium batteries (≥1.5 cm, 3 V) presented moderate to major complications in the esophagus and stomach without any symptoms, even when the batteries were in the stomach and beyond the duodenum, while no complications were noted in 7 cases with alkaline batteries (<1.5 cm, 1.5 V) (p=0.001). All endoscopies were conducted within 24 hours after ingestion.

CONCLUSION

The type and voltage of the battery should be considered when determining whether endoscopy is required to remove a BB in the stomach. For lithium battery ingestion in young children, urgent endoscopic removal might be important in order to prevent complications, even if the child is asymptomatic and the battery is smaller than 2 cm.

Sudden death following accidental ingestion of a button battery by a 17-month-old child: a case study

Cases of ingesting button batteries by children are not common clinical situations in forensic medicine. Although it can be a cause of death when associated with digestive perforations, no cases of sudden death have been reported in the literature. We report the case of a 17-month-old girl who presented at home with haematemesis, followed by failed cardiopulmonary resuscitation. The child had been treated on two occasions for nasopharyngitis, 14 and 18 days prior to her death. The post-mortem scan revealed a radio-opaque foreign body in the oesophagus. The autopsy revealed the presence of a round button battery, 20 mm in diameter, blocking the lumen of the oesophagus in its upper third, associated with two parietal oesophageal ruptures opposite each other. There was limited digestive haemorrhage, but above all significant bronchial inhalation of blood. Toxicology analyses showed slightly increased blood levels of the heavy metals of which the battery was composed (lithium, chromium, manganese and molybdenum). The anatomopathological analyses confirmed the recent nature of these ruptures. Ingestions of button batteries localised at the level of the oesophagus are the cases linking to the highest risk of complications, particularly for batteries with a diameter of more than 20 mm and in children under the age of 4. The main difficulty in such clinical situations is identifying when the ingestion occurred, as more often than not, no witnesses are present. We discuss the advantages of anatomopathology and toxicology examinations targeted towards heavy metals in these forensic situations.

Symptoms associated with button batteries injuries in children: An epidemiological review

OBJECTIVES

To provide an epidemiological framework of symptoms related to Foreign Body (FB) injuries due to Button Battery (BB).

METHODS

Data on BB ingestion/inhalation have been obtained from the ButtonBatteryDB. The ButtonBatteryDB is a database collecting information on BB injuries in children (0-18 years of age). Data on 348 BB injures have been derived from the Registry of Foreign Body Injuries "Susy Safe" (269 cases) and from published scientific literature reporting case reports of FB injuries (79 cases).

RESULTS

Most of injured children were male and BBs were found more often in the mouth/esophagus/stomach (ICD935) and in the nose (ICD932). Analyzing symptoms related to BB located in the esophagus/mouth/stomach, we found that children had higher probability of experiencing dysphagia (30.19%, 95% C.I. 17.83-42.55), fever and cough (26.42%, 95% C.I. 14.55-38.28), compared to the other symptoms. Referring to the probability that symptoms occurred simultaneously, fever and cough are more likely (3.72%, 95% C.I. 1.0-6-43) to jointly showing up in children with BB in mouth/esophagus/stomach (ICD935), followed by fever and dysphagia (2.66%, 95% C.I. 0.36-4.96) and by fever and irritability/crying, fever and drooling, dysphagia and irritability/crying (2.13% C.I. 0.00-4.19, 95% C.I.)

CONCLUSIONS

These findings provide new insight in clinical presentation of BB injuries: the identification of unique patterns of symptoms related to BB injuries is useful to perform an early diagnosis (and to guarantee a prompt medical reaction), also when the injury is un-witnessed.

Lithium Battery Ingestion: An Unusual Cause of Bilateral Cord Palsy

Bilateral vocal cord palsy is a rare but life threatening complication of lithium battery ingestion in children. This complication is mostly missed by otorhinolaryngologists due to lack of awareness on the cited subject. We present one such rare case in an infant, where the clinical presentation was found to be unique but hitherto unreported in the medical literature. This clinical record discusses this case in light of the scant current medical literature on the subject and highlights the importance of cautious monitoring of patients presenting with signs of respiratory distress after lithium battery removal.

Severe Vaginal Burns in a 5-Year-Old Girl Due to an Alkaline Battery in the Vagina

BACKGROUND

The ingestion or insertion of alkaline batteries in the body can cause severe damage to hollow organs. We report here a case of severe vaginal burns in a young patient caused by an alkaline battery.

CASE

A 5-year-old girl presented to our outpatient department with pelvic pain and vaginal discharge. Further workup suggested the presence of a vaginal foreign body. Under general anesthesia, an alkaline battery was removed from her vagina, which showed severe burns with partial-thickness necrosis. Complete healing was confirmed at 3 months after initial presentation.

CONCLUSIONS

In this rare case of an alkaline battery present in the vagina of a prepubescent girl, we discuss the available treatment and management options in comparison to similar previously reported cases.

Severe esophageal injuries caused by accidental button battery ingestion in children

INTRODUCTION

Button batteries represent a low percentage of all foreign bodies swallowed by children and esophageal location is even less frequent. However, these cases are more likely to develop severe injuries. The aim of this essay is to report three cases treated in our institution and review previous reports.

MATERIAL AND METHODS

Chart review and literature search.

CASE REPORTS

We treated three children between 2-7- years old with button batteries lodged at esophagus. They all presented esophageal burns (EB), which evolved in esophageal stenosis in two out of the three cases.

RESULTS

We found 29 more cases in literature and the injuries included EB, esophageal perforation (EP) and tracheoesophageal fistula (TEF).

DISCUSSION

Swallowed button batteries rarely remain in esophagus, but these cases present a higher risk of tisular damage. Injuries can take place even after few hours; and therefore, endoscopy must be performed as soon as possible. Further study on button batteries' safety and the establishment of a maximum size for them would be good preventive measures.

X-ray diagnosis with a bloating agent for foreign object ingestion

The location of an ingested foreign object is often difficult to determine by X-ray if gastric air bubbles are not clear in the image. Methods that provide negative contrast can facilitate precise object localization, which is important for object retrieval and treatment of the patient. This case report describes a male child, 2 years and 2 mo of age, who accidentally swallowed a lithium battery while playing at home. A plain X-ray showed that the battery was in the abdomen, but it was unclear whether the object was still inside the stomach. A second X-ray examination performed after oral administration of a bloating agent to produce expansion of the stomach and provide negative contrast confirmed that the ingested battery was still in the stomach. The battery was then carefully removed using magnetic and balloon catheters under fluoroscopic guidance. This case report describes the successful use of an orally administered bloating agent without pain to the child in order to determine the precise location of a foreign object in the abdomen.

Novel technique of repair of large tracheo-esophageal fistula following battery ingestion in children: review of two cases

Surgical repair of acquired tracheo-esophageal fistula may result in tracheal stenosis or esophageal stricture. We used fistula with esophageal cuff as flap to repair the tracheal defect. Esophageal repair was performed by rotating ends through 90° in opposite direction. This technique offers excellent repair in a single stage.

Hemorrhagic shock secondary to button battery ingestion

CONTEXT

Button battery ingestion is a frequent pediatric complaint. The serious complications resulting from accidental ingestion have increased significantly over the last two decades due to easy access to gadgets and electronic toys. Over recent years, the increasing use of lithium batteries of diameter 20 mm has brought new challenges, because these are more detrimental to the mucosa, compared with other types, with high morbidity and mortality. The clinical complaints, which are often nonspecific, may lead to delayed diagnosis, thereby increasing the risk of severe complications.

CASE REPORT

A five-year-old boy who had been complaining of abdominal pain for ten days, was brought to the emergency service with a clinical condition of hematemesis that started two hours earlier. On admission, he presented pallor, tachycardia and hypotension. A plain abdominal x-ray produced an image suggestive of a button battery. Digestive endoscopy showed a deep ulcerated lesion in the esophagus without active bleeding. After this procedure, the patient presented profuse hematemesis and severe hypotension, followed by cardiorespiratory arrest, which was reversed. He then underwent emergency exploratory laparotomy and presented a new episode of cardiorespiratory arrest, which he did not survive. The battery was removed through rectal exploration.

CONCLUSION

This case describes a fatal evolution of button battery ingestion with late diagnosis and severe associated injury of the digestive mucosa. A high level of clinical suspicion is essential for preventing this evolution. Preventive strategies are required, as well as health education, with warnings to parents, caregivers and healthcare professionals.

Emergent Treatment of Button Batteries in the Esophagus

Objectives:

The evolving epidemiology of pediatric button battery ingestion is alarming. Currently, assessment of the degree of damage relies heavily on the initial esophagoscopy in a manner similar to the management of caustic ingestion. We have noted that use of this classic approach may delay the return to normal oral intake. Using several cases treated at our institution, we illustrate the value of “close second-look esophagoscopy” (CSLE) in expediting a return to normal oral intake after button battery ingestion.

Methods:

We present a retrospective case series.

Results:

Five patients (11 to 18 months of age) with button batteries trapped in the cervical esophagus were recently managed at our institution. The batteries were lodged in the esophagus for durations ranging from 6 hours to 4 months. Three cases of initial grade III circumferential necrotic injury were downgraded to grade IIa after a CSLE performed 2 to 4 days after removal, and their management was appropriately changed.

Conclusions:

The injury and healing of cases of button batteries in the proximal esophagus appear to be variable; caustic injury, electrical mucosal damage, and direct pressure are thought to be several contributory factors. Performing a CSLE within 2 to 4 days after battery removal may provide more useful prognostic information. In certain cases, downgrading of the injury may facilitate an earlier return to an oral diet, use of fewer diagnostic tests, and a shorter hospital stay. The utility and timing of imaging, management of diet and medications, and acceptable follow-up plans are discussed within the context of guiding future research.

Accidental button battery ingestion presenting as croup

OBJECTIVES

To report a case of misdiagnosis of an impacted oesophageal button battery in a child, and to describe the associated risk factors for impaction and the management of such cases.

CASE REPORT

An 18-month-old, otherwise fit and well child with stridulous respiration was initially treated for croup. Medical treatment over the course of three months failed, and appropriate imaging subsequently demonstrated an impacted button battery in the upper oesophagus. This was promptly removed. There were no signs of damage on direct visualisation, or on a follow-up contrast swallow image.

CONCLUSION

This case highlights the difficulty of diagnosing oesophageal foreign bodies. We also discuss the characteristics of button batteries which confer a greater risk of impaction, and the associated sequelae and complications.

When button batteries become breakfast: the hidden dangers of button battery ingestion

Injuries due to button battery ingestion continue to evolve with worsening clinical outcomes reported in recent years. These batteries pose a unique hazard to children due to the severity of complications that may arise within a short period of time as well as their availability in almost every home environment in the United States. It is crucial that health care providers maintain a high level of clinical suspicion for foreign body ingestion and facilitate rapid triage and treatment in these cases. Nurses should educate all children and families about button battery safety to prevent injury and decrease the morbidity and mortality related to ingestion.

Button battery foreign bodies in children: hazards, management, and recommendations

OBJECTIVE

The demand and usage of button batteries have risen. They are frequently inadvertently placed by children in their ears or noses and occasionally are swallowed and lodged along the upper aerodigestive tract. The purpose of this work is to study the different presentations of button battery foreign bodies and present our experience in the diagnosis and management of this hazardous problem in children.

PATIENTS AND METHODS

This study included 13 patients. The diagnostic protocol was comprised of a thorough history, head and neck physical examination, and appropriate radiographic evaluation. The button batteries were emergently extracted under general anesthesia.

RESULTS

The average follow-up period was 4.3 months. Five patients had a nasal button battery. Four patients had an esophageal button battery. Three patients had a button battery in the stomach. One patient had a button battery impacted in the left external ear canal. Apart from a nasal septal perforation and a tympanic membrane perforation, no major complications were detected.

CONCLUSION

Early detection is the key in the management of button battery foreign bodies. They have a distinctive appearance on radiography, and its prompt removal is mandatory, especially for batteries lodged in the esophagus. Physicians must recognize the hazardous potential and serious implications of such an accident. There is a need for more public education about this serious problem.

[Ingestion of foreign bodies in the gastrointestinal tract of children and adolescents]

The diagnosis of foreign bodies in the gastrointestinal (G-I) tract can sometimes be difficult. Esophageal foreign bodies are dangerous and should be extracted as soon as possible whereas foreign bodies in the stomach usually pass through the GI-tract without complications. Exceptions are large, sharp or potentially toxic foreign bodies, such as button batteries or magnetic foreign bodies. Extraction by flexible endoscopy with the patient under deep sedation has proven to be effective, relatively minimally invasive and safe. Complications, such as ulcers, fistulas and perforations occur in 13% of patients and are strongly correlated to the localization in the esophagus.

Unwitnessed lithium ion disc battery ingestion: case report and review of best practice management of an increasing clinical concern

Objective:

To describe a case of unwitnessed lithium ion disc battery ingestion, with a review of radiology findings and current best practice management.

Case report:

A three-year-old girl presented following ingestion of a foreign body, which her four-year-old brother claimed was a one pound coin. The patient was managed non-urgently and transferred for specialist ENT assessment 6 hours following the initial ingestion, with no evidence of airway compromise. A corroded battery was removed from the level of the cricopharyngeus after 8 hours, with an associated circumferential mucosal burn.

Conclusion:

There is increasing concern regarding the acknowledged rising incidence of lithium ion disc battery ingestion. The lack of a high index of suspicion and the inability to recognise subtleties on imaging may lead to suboptimal management with a higher degree of unnecessary immediate and delayed morbidity. The recently published American Academy of Pediatrics Guidelines may guide the approach to managing battery ingestions.