Severe gastric damage caused by button battery ingestion in a 3-month-old infant

Histopathologic Findings of Button Battery-Related Changes in a Perforated Meckel's Diverticulum: Report of Three Cases

Background: A button battery can cause perforation of Meckel's diverticulum if sequestered in this blind ending bowel segment. Reported cases focused on clinical manifestations, management options, radiologic and intraoperative findings. We highlight the histopathologic features in perforated Meckel's diverticula due to ingested button batteries. Case report: Three toddlers presented with perforated Meckel's diverticula after button battery ingestion. Histologic examination of the diverticula showed multiple burn-like mucosal ulcerations and liquefactive wall perforations of the tips, associated with prominent siderotic pigment deposits and calcifications. There were various residual materials with variable staining patterns in the luminal debris, necrotic tissue and adjacent to submucosal blood vessels. Conclusion: There is accelerated deposition of iron and calcium associated with button batteries.

Disc battery ingestion in paediatric age

AIM

The aim of the present study was to analyse clinical data of children referred for disc battery ingestion in order to assess short- and long-term reported injuries and to identify outcome predictors and trends, define the urgency of intervention and refine treatment guidelines.

METHODS

The records of all children admitted to Santobono-Pausilipon Children's Hospital, Naples, Italy for disc battery ingestion from January 2016 to December 2020 were retrospectively reviewed. Odds ratio were computed to assess the association between the different study variables and the rate of complications.

RESULTS

We enrolled 118 children. Mild to major complications related to the ingested disc batteries were reported in 12/118 (10.2%) patients. Disc battery oesophageal retention, disc battery diameter >20 mm, together with age below 1 year and symptomatic presentation were the most important factors associated with poor clinical outcome.

CONCLUSION

Our data confirm that ingested disc batteries are a serious health hazard and require a timely and qualified medical evaluation. We have identified three predictors of outcome severity: oesophageal retention, large-diameter cells and symptom onset. Disc batteries lodged beyond the oesophagus appear substantially harmless and we may support a more conservative approach.

Battery Ingestion in Children, an Ongoing Challenge: Recent Experience of a Tertiary Center

INTRODUCTION

Morbidity related to childhood battery ingestions (BI) has increased recently due to the expanding use of larger lithium cells. A prompt endoscopic removal is vital to prevent severe complications in cases of esophageal batteries (EB).

MATERIALS AND METHODS

A retrospective, descriptive study of admissions for BI requiring endoscopic removal in a tertiary hospital's pediatric emergency department (Jan. 2011/Dec. 2020).

RESULTS

We had 35 cases, with an increasing incidence in the last 6 years; median age, 26 m (8 m-10 years), witnessed ingestion in 86%. On the X-ray: 14 (40%) had an EB, 21 (60%), a gastric battery (GB). Symptoms were present in 57% (100% EB/24% GB), and vomiting was the most frequent (50%). Endoscopy revealed: EB, 13 (37%); GB, 17 (49%); duodenal battery, 1 (3%); no battery, 4 (11%). Median time to removal: EB, 7 h (2 h-21days); GB, 12 h (2 h-3 days). All the patients with EB on the X-ray (14) had severe mucosal injury (Zargar classification): Grade IIIa, 7 (50%); IIIb, 5 (36%); IV, 2 (14%). CT-scan showed perforation in 2 patients (total, 4; 29% of EB). In patients with GB (21), 14 (67%) had mucosal damage; 13 (93%), mild (< Grade III, two esophageal erosions); 1 (7%) IIIa (esophageal ulceration). A statistically significant association between exposure time, younger age or battery size and severity of endoscopic lesions was found in EB location. There were no mortality cases. Acute complications occurred in 57% of EB: infection, 50%; perforation, 29%; pneumomediastinum/stridor, 14%; pneumothorax/subglottic stenosis/hemodynamic instability, 7 vs. 0% GB. Stenosis subsequently developed in 6 (43%) of EB: mild, 4 cases (29%); severe, 2 cases (14%, one resolved after endoscopic dilation; one needed a gastrostomy and esophagocoloplasty).

CONCLUSION

We verified recent increase in admissions due to battery ingestions and associated complications, despite the availability of an emergency pediatric endoscopy team. The patients with EB had more severe mucosal injury and poorer short/long-term outcomes. Children with GB had milder lesions, although the presence of a GB did not exclude esophageal injury. The availability of actual data from national referral centers will support advocacy efforts among stakeholders, including industry representatives and policy makers, in preventing worldwide button battery injury.

Cylindrical and button battery ingestion in children: a single-center experience

PURPOSE

The purpose of our study was to perform a comparative analysis of the examination and treatment outcomes of children with cylindrical and button batteries (BB) ingestion depending on their size and anatomical locations.

METHODS

This study was a retrospective analysis of 124 children aged from 1 month to 18 years who ingested batteries and were treated in a tertiary care center from January 1, 2014 to March 31, 2019. The data studied included age, sex, presenting symptoms at the time of evaluation, type and size of battery and modality of management.

RESULTS

Twenty-three (18.5%) patients ingested cylindrical batteries (CBs), and 101 (81.5%) ingested BBs. The duration of hospital stay was significantly longer (p = 0.004) in the group of children who ingested BBs larger than 20 mm. Endoscopic removal was performed in 75 (60.5%) children, 46 (37.1%) were followed up and three (2.4%) underwent open surgeries. Children with CBs ingestion, in 55% of cases, had gastric mucosal injuries. Children with BBs impacted in the esophagus in 96% cases had visible severe mucosal damage, whereas patients with gastric BB ingestion 19.5% had superficial gastric mucosal damage.

CONCLUSION

Performing timely endoscopic retrieval in children who are admitted early to the hospital will reduce the risk of damage to the gastrointestinal mucosa, especially in the stomach. Unlike BBs, CBs, despite their large size, have advantageous shapes, uneventfully pass the esophagus and are more often retained in the stomach; thus, mucosal injuries are more often observed in the stomach. Consequently, endoscopic extraction is the treatment of choice for children with BB ingestion.

Button battery ingestion in children: Experience from a tertiary center on 56 patients

BACKGROUND/AIM

The ubiquitous use of portable electronic devices has resulted in an increased incidence of button battery (BB) ingestion in children. BB ingestion represents a distinct category of ingested foreign body due to the associated high morbidity and mortality. The aim of this study was to report our experience in the management of BB ingestion in children.

METHODS

We reviewed the clinical and endoscopic characteristics of 56 children (≤ 18 years) who presented to our hospital emergency department (ED) with BB ingestion between December 2016 and November 2019. Data with respect to patient demographics, time of presentation to ED to endoscopic retrieval of BB, the endoscopic findings, and complications, if any, were collected.

RESULTS

We encountered a total of 56 children with BB ingestions. While 10 BBs passed off spontaneously without any complication, 27 BBs were extracted endoscopically from the stomach. A total of 19 BB impactions occurred: 9 at the cricopharynx/upper esophageal sphincter (UES), 5 in the mid esophagus, 4 in the lower esophagus, and one at the pyloric ring. All impactions occurred with larger BBs (diameter ≥ 10 mm). Complications occurred in 3 children (5.35%) following retrieval; 2 developed upper esophageal strictures on follow-up, which were treated with serial dilations and one experienced esophageal perforation and peritonitis requiring laparotomy. There was no mortality in our study.

CONCLUSIONS

A vast majority of ingested BBs pass off spontaneously or require minimal endoscopic intervention. Serious complications arise in a small minority especially in BBs > 10 mm in size with a potential for esophageal impaction.

Diagnosis, Management, and Prevention of Button Battery Ingestion in Childhood: A European Society for Paediatric Gastroenterology Hepatology and Nutrition Position Paper

ABSTRACT

Button batteries (BB) remain a health hazard to children as ingestion might lead to life-threatening complications, especially if the battery is impacted in the esophagus. Worldwide initiatives have been set up in order to prevent and also timely diagnose and manage BB ingestions. A European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) task force for BB ingestions has been founded, which aimed to contribute to reducing the health risks related to this event. It is important to focus on the European setting, next to other worldwide initiatives, to develop and implement effective management strategies. As one of the first initiatives of the ESPGHAN task force, this ESPGHAN position paper has been written. The literature is summarized, and prevention strategies are discussed focusing on some controversial topics. An algorithm for the diagnosis and management of BB ingestions is presented and compared to previous guidelines (NASPGHAN, National Poison Center). In agreement with earlier guidelines, immediate localization of the BB is important and in case of esophageal impaction, the BB should be removed instantly (preferably <2 hours). Honey and sucralfate can be considered in ingestions ≤12 hours while waiting for endoscopic removal but should not delay it. In case of delayed diagnosis (first confirmation of the BB on X-ray >12 hours after ingestion or time point of removal >12 hours after ingestion) and esophageal impaction the guideline suggests to perform a CT scan in order to evaluate for vascular injury before removing the battery. In delayed diagnosis, even if the battery has passed the esophagus, endoscopy to screen for esophageal damage and a CT scan to rule out vascular injury should be considered even in asymptomatic children. In asymptomatic patients with early diagnosis (≤12 hours after ingestion) and position of the BB beyond the esophagus, one can monitor with repeat X-ray (if not already evacuated in stool) in 7 to 14 days, which is different from previous guidelines where repeat X-ray and removal is recommended after 2-4 days and is also based on age. Finally, prevention strategies are discussed in this paper.

Endoscopic Findings Associated With Button Battery Ingestion in Children: Do We Need to Change the Protocol for Managing Gastric Location?

BACKGROUND

Ingested button batteries (BB) can cause corrosive damage of digestive mucosa within minutes. Immediate endoscopic removal of esophageal BB has been clearly established, but the management of BB located in the stomach is still controversial.

AIM

To describe demographic, clinical, radiologic, and endoscopic characteristics of a series of pediatric patients evaluated for BB ingestion.

METHODS

Retrospective analysis of clinical charts belonging to children younger than 15 years, who underwent endoscopic removal of BB at Clínica Alemana of Santiago, between November 2007 and November 2011.

RESULTS

Twenty-five patients subjected to upper endoscopy were analyzed; median age, 31 months; 15 were male (60%), and 11 patients (46%) were symptomatic after ingestion. The BB ingestion was confirmed by radiograph. Endoscopy revealed 10 patients with BB in the esophagus, 12 patients in the stomach and 3 distal to duodenum. Range time between ingestion and endoscopy was 2 to 10 hours for esophageal BB and 2 hours to 3 days for gastric BB. Eight of the 22 BBs removed had a diameter of 20 mm or greater, 6 of them were located in the esophagus and 2 in stomach. The BB color changes were observed in 14 of the 22 BBs. Breakage of battery edges was present in 11 of the 22 batteries. All patients with esophageal BB and 6 of those 12 with gastric BB presented mucosal damage.

CONCLUSION

Esophageal BB cause damage within hours. The BB located in the stomach may also cause damage early. Extraction of gastric BB before 48 hours should be considered.

Foreign body and caustic ingestions in children: A clinical practice guideline

Foreign body and caustic ingestions in children are usually the most common clinical challenges for emergency physicians, general pediatricians and pediatric gastroenterologists. Management of these conditions often requires different levels of expertise and competence. Endoscopy is often necessary but there is a high risk of misusing this tool with incorrect timing and indications. The imprecise clinical history frequently leaves clinicians uncertain about timing and nature of the ingestion. Few clinical guidelines regarding management of these ingestions in children have been published, none of which from the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP). An expert panel of Italian endoscopists was convened by the SIGENP Endoscopy Working Group to produce the present article that outlines practical clinical approaches to the pediatric patient with a variety of foreign body and caustic ingestions. The Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) has also endorsed the project since many adult endoscopists usually manage children with these conditions. Differently from the other published guidelines, the proposed one focuses on the role of the endoscopists (regardless of whether they are adult or pediatric gastroenterologists) in the diagnostic process of children with foreign body and caustic ingestions.

Chemical Burn Injury in the Scrotal Area Caused by Button Cell Battery: A Case Report

: Here we reported a one-year-old infant with tissue damage in the scrotum area, in which a small button cell battery had been found in his diaper. Evidence suggested that the lesion was caused by contact with the leaky battery with the scrotal skin. The treatment procedure was prescribed by a dermatologist. The healing process was tracked over the examination times. After two months, the site of the lesion showed complete remission. The findings suggested that in such cases, after removing the chemical agent, blisters, and necrotic tissues, therapeutic measures should be performed similarly to the thermal burns.

Gastric injury secondary to button battery ingestions: a retrospective multicenter review

BACKGROUND AND AIMS

Removal of gastric button batteries (BBs) remains controversial. Our aim was to better define the spectrum of injury and to characterize clinical factors associated with injury from retained gastric BBs.

METHODS

In this multicenter retrospective cohort study from January 2014 through May 2018, pediatric gastroenterologists from 4 pediatric tertiary care centers identified patients, aged 0 to 18 years, who had a retained gastric BB on radiography and subsequently underwent endoscopic assessment. Demographic and clinical information were abstracted from electronic health records using a standard data collection form.

RESULTS

Sixty-eight patients with a median age of 2.5 years underwent endoscopic retrieval of a gastric BB. At presentation, 17 (25%) were symptomatic. Duration from ingestion to endoscopic removal was known for 65 patients (median, 9 hours [interquartile range, 5-19]). Median time from ingestion to first radiographic evaluation was 2 hours. At endoscopic removal, 60% of cases had visual evidence of mucosal damage, which correlated with duration of BB retention (P = .0018). Time to retrieval of the BB was not statistically significant between symptomatic and asymptomatic subjects (P = .12). After adjusting for age and symptoms, the likelihood of visualizing gastric damage among patients who had BBs removed 12 hours post ingestion was 4.5 times that compared with those with BB removal within 12 hours of ingestion.

CONCLUSIONS

In this study, swallowed BBs posed a risk of damage to the stomach, including a single case of impaction and perforation of the gastric wall. Clinicians may want to consider retrieval within 12 hours of ingestion of gastric BBs. Larger prospective studies to assess risk of injury are needed.

Mitigating Risks of Swallowed Button Batteries: New Strategies Before and After Removal

Despite ongoing efforts of the national Button Battery Task Force (BBTF), cases of major morbidity and mortality continue to be reported at a higher rate after ingestion of higher voltage and larger button batteries. Initiation of sucralfate or honey shortly after some button battery ingestions is crucial to prevent further injury while awaiting emergent removal. Endoscopic acetic acid irrigation post removal of button battery may halt deeper injury. Gastroenterologists need to be aware of the updates to the National Capital Poison Center algorithm for button battery ingestion.

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.

Paediatric Gastrointestinal Endoscopy: European Society for Paediatric Gastroenterology Hepatology and Nutrition and European Society of Gastrointestinal Endoscopy Guidelines

This guideline refers to infants, children, and adolescents ages 0 to 18 years. The areas covered include indications for diagnostic and therapeutic esophagogastroduodenoscopy and ileocolonoscopy; endoscopy for foreign body ingestion; corrosive ingestion and stricture/stenosis endoscopic management; upper and lower gastrointestinal bleeding; endoscopic retrograde cholangiopancreatography; and endoscopic ultrasonography. Percutaneous endoscopic gastrostomy and endoscopy specific to inflammatory bowel disease has been dealt with in other guidelines and are therefore not mentioned in this guideline. Training and ongoing skill maintenance are to be dealt with in an imminent sister publication to this.

Multiple Gastric Erosion Early after a 3 V Lithium Battery (CR2025) Ingestion in an 18-Month-Old Male Patient: Consideration about the Proper Time of Intervention

Introduction. Button battery ingestion is considered an emergency situation in pediatric patients that needs to be managed promptly; otherwise, it may lead to serious and potentially lethal complications, especially when it is impacted in the esophagus. Less attention has been given in cases where the battery passes into the stomach, with guidelines for emergency intervention being based on the presence of symptoms. Case Report. We present a case of an 18-month-old male patient who presented to our emergency department after button battery ingestion. He did not have any symptoms and no pathological findings were encountered during clinical examination. X-ray investigation revealed the presence of the battery in the stomach. The patient was admitted for observation and two hours later he had two episodes of vomiting. He underwent urgent endoscopic removal of the battery where multiple acute gastric mucosal erosion in place of direct contact of the battery's negative pole with the mucosa of the gastric antrum was found. Conclusion. In specific cases the urgent endoscopic intervention for removal of an ingested button battery that is located in the stomach even in asymptomatic patients should be suggested.

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.

Button Battery Ingestion in Children: A Paradigm for Management of Severe Pediatric Foreign Body Ingestions

Gastrointestinal injuries secondary to button battery ingestions in children have emerged as a dangerous and difficult management problem for pediatricians. Implementation of a multidisciplinary team approach, with rapid and coordinated care, is paramount to minimize the risk of negative outcomes. In addition to providing a comprehensive review of the topic, this article outlines the authors' referral center's experience with patients with severe battery ingestion, highlighting the complications, outcomes, and important lessons learned from their care. The authors also propose an algorithm for clinical care that may be useful for guiding best management of pediatric button battery ingestion.

Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee

Foreign body ingestions in children are some of the most challenging clinical scenarios facing pediatric gastroenterologists. Determining the indications and timing for intervention requires assessment of patient size, type of object ingested, location, clinical symptoms, time since ingestion, and myriad other factors. Often the easiest and least anxiety-producing decision is the one to proceed to endoscopic removal, instead of observation alone. Because of variability in pediatric patient size, there are less firm guidelines available to determine which type of object will safely pass, as opposed to the clearer guidelines in the adult population. In addition, the imprecise nature of the histories often leaves the clinician to question the timing and nature of the ingestion. Furthermore, changes in the types of ingestions encountered, specifically button batteries and high-powered magnet ingestions, create an even greater potential for severe morbidity and mortality among children. As a result, clinical guidelines regarding management of these ingestions in children remain varied and sporadic, with little in the way of prospective data to guide their development. An expert panel of pediatric endoscopists was convened and produced the present article that outlines practical clinical approaches to the pediatric patient with a variety of foreign body ingestions. This guideline is intended as an educational tool that may help inform pediatric endoscopists in managing foreign body ingestions in children. Medical decision making, however, remains a complex process requiring integration of clinical data beyond the scope of these guidelines. These guidelines should therefore not be considered to be a rule or to be establishing a legal standard of care. Caregivers may well choose a course of action outside of those represented in these guidelines because of specific patient circumstances. Furthermore, additional clinical studies may be necessary to clarify aspects based on expert opinion instead of published data. Thus, these guidelines may be revised as needed to account for new data, changes in clinical practice, or availability of new technology.