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WITHIN NORMAL LIMITS: The X-Ray and the Button Battery

Lee, Ruri MD; Patel, Himanshu MD; Patel, Shivani MD

Emergency Medicine News: June 2016 - Volume 38 - Issue 6 - p 5
doi: 10.1097/01.EEM.0000484515.48617.db
WITHIN NORMAL LIMITS

Dr. Leeis a fifth-year radiology resident at Westchester Medical Center in Valhalla, NY, whereDr. Himanshu Patelis the director of musculoskeletal radiology at Westchester Medical Center in Valhalla, NY, and an assistant professor of radiology at New York Medical College. Dr. Shivani Patelis an emergency physician at Stamford (CT) Hospital.

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An 11-month-old girl was brought to the emergency department with a two-week history of pooling secretions and feeding intolerance. A chest radiograph was performed, and detected a button battery.

ENT was consulted emergently, and the patient was taken to the operating room for a laryngoscopy. The battery was retrieved, and the patient was found to have erosion and perforation of the posterior esophageal wall, which was repaired. She was discharged home following a prolonged stay in the pediatric ICU. Six months later, the patient presented with cough and repeated bouts of emesis. An esophagram was performed, which showed focal high-grade narrowing in the proximal esophagus. This was an esophageal stricture that developed as a delayed complication of button battery ingestion and battery cell corrosion within the esophagus.

Most cases of button battery ingestion result in spontaneous passage through the gastrointestinal tract, but impaction of the button battery in the esophagus can result in considerable morbidity and even mortality. This holds a high risk for severe injury to esophageal mucosa, including full-thickness erosion resulting in perforation. The mechanism for injury is only partially from pressure necrosis. The primary hazard of button batteries (as opposed to other foreign bodies of similar shape, like coins) lies in its ability to induce a current and hydrolyze tissue fluids to produce hydroxide, causing rapid tissue erosion and injury to the esophageal wall. Eventually, corrosion of the battery cell can result in the leakage of battery contents, which causes further injury and toxicity.

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It was reasonable to conclude based on the radiographic evidence of battery cell corrosion that significant esophageal injury had already occurred. An emergent laryngoscopy showed a full-thickness injury resulting in perforation of the posterior esophageal wall.

Button battery ingestion poses a risk for delayed complications such as tracheoesophageal fistula and esophageal stricture, in addition to an acute injury. Early diagnosis is key in managing ingested button batteries, and in cases of impaction within the esophagus, prompt retrieval is crucial not only to avoid acute injury but to prevent delayed complications that may necessitate additional invasive interventions.

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