A 2-year-old boy is brought to the emergency department by his mother due to ingestion of a foreign body 2 hours ago. The child was playing with his older brother's watch and removed the back of the watch face. As the patient's mother was taking the watch away, she saw him put a button battery from the watch into his mouth and swallow it. Since the ingestion, the child has been playful and able to drink water without emesis. He has no chronic medical conditions, and immunizations are up to date. Temperature is 36.7 C (98 F), blood pressure is 90/50 mm Hg, pulse is 106/min, and respirations are 20/min. Pulse oximetry is 100% on room air. Physical examination shows a smiling young child sitting in his mother's lap and blowing bubbles. The lungs are clear to auscultation, and there are no retractions. The abdomen is soft, nontender, and nondistended; bowel sounds are normoactive. X-rays reveal a circular radiopaque foreign body with a double-ring shadow in the distal esophagus; there is no pleural effusion, mediastinal widening, or subdiaphragmatic air. Which of the following is the best next step in management of this patient?
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Ingested button batteries carry a potentially fatal risk of local and systemic injury. Like other esophageal foreign bodies, button batteries can cause necrosis from direct pressure. However, button batteries also conduct electricity, potentially leading to ulceration, liquefication necrosis, and perforation. In addition, the battery's corrosive components can also lead to caustic burns. In rare cases, an aortoesophageal fistula can form, causing hemorrhage and death.
Neck and chest x-rays classically reveal a circular, radiopaque object with a double ring due to the button battery's bilaminar design. Esophageal button batteries require immediate endoscopic removal even if the patient is asymptomatic. If the button battery is beyond the esophagus (eg, stomach, intestines) at presentation, mucosal injury is less common. However, these patients must be monitored closely and undergo endoscopic or surgical removal if the battery is not progressing and/or symptoms (eg, abdominal pain, hematemesis) develop.
(Choices B, C, and D) Reassurance and/or waiting for foreign body passage in stool is appropriate for asymptomatic patients who have a witnessed ingestion of small, blunt, nontoxic objects (eg, coins). Repeat x-rays are often indicated in these cases to ensure passage beyond the esophagus and stomach. Management of esophageal button batteries is emergent removal due to potential perforation and death if treatment is delayed.
(Choice E) An upper gastrointestinal series can identify structural (eg, stricture) or functional (eg, dysphagia) abnormalities of the esophagus. Although such conditions can occur as a late complication of button battery ingestion, an upper gastrointestinal series has no role in acute management of ingestion.
Educational objective:
Button battery ingestion can lead to ulceration, necrosis, and perforation. Button batteries lodged in the esophagus represent a medical emergency and should be removed immediately under direct endoscopic visualization.