A 3-year-old boy presents to the emergency room with several days of decreased oral intake and sudden-onset hematemesis today. On examination, he is alert with mild epigastric pain. A plain abdominal radiograph shows a button battery located near the pylorus. His grandfather remembers the child playing with a pack of batteries when he was changing his hearing aid battery a few days ago. What is the best next step?​

 

A Admit the patient for observation and serial radiographs

 

B Discharge the child home with instructions to monitor for passage of the button battery in his stools

 

C Administer an emetic

 

D Endoscopic evaluation and removal of the button battery

 

E Give the child honey and sucralfate​

D

D

D

Correct answer

D Endoscopic evaluation and removal of the button battery

 

Impaction of a button battery in the esophagus is a surgical emergency that needs to be evaluated and treated immediately. Once the diagnosis has been made, endoscopic removal within 2 hours is recommended to minimize the risk of serious complications. Having cardiac or vascular surgery on standby is prudent in cases of suspected aorto-esophageal fistula.

 

The management of button batteries in the stomach is less straightforward. Serious gastric injury due to button battery ingestion has been reported. Endoscopy should be considered to evaluate for esophageal injury and to remove the button battery. This is particularly important in the following situations: (1) unwitnessed ingestion or delayed diagnosis (>12 hours after ingestion), (2) magnet co-ingestion, (3) symptoms (e.g., hematemesis), or (4) ingestion of a button battery >15mm in diameter in children < 5 years of age. Batteries that are still in the stomach after 2-4 days should also be removed endoscopically. Asymptomatic patients >6 years of age who have ingested a button battery < 15 mm in diameter can be observed. Ultimately, each decision must be made on a case-by-case basis after risk factor stratification and consideration of the potential for both in-transit injury to the esophagus and to the stomach.

 

In this patient, his young age and the likely long duration since ingestion increase the risk of serious injury. Most hearing aid batteries are < 12 mm in diameter and are less likely to become impacted in the esophagus. However, the presence of symptoms, particularly hematemesis, are extremely concerning and warrant immediate endoscopic evaluation. In such situations, both the esophagus and stomach should be assessed. The battery should also be removed during endoscopy if possible. In rare circumstances, surgical removal may be required.

 

Discharging or observing this patient increases the risk of perforation. Administering an emetic is ineffective and could potentially exacerbate any necrotic or ulcerated areas. Giving honey and/or sucralfate is only recommended if ingestion happened within 12 since the risk of perforation increases after 12 hours. Honey should not be given to children < 1 year of age.

 

 

 

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Edited September 10, 20233 yr by Admin

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D