FOREIGN BODY ESOPHAGUS PART 2 (BUTTON BATTERY)

1.  

    

Why button battery ingestion is common these days?

Because of increase use of various new electronic devices use of batteries have risen which has increased the incidence of ingestion.

·                     Toys & Electronic Games

·                     TV Remote Controls

·                     Flashlights & Calculators

·                     Watches & Hearing Aids

 

2.      Although the incidence of ingestion of button battery remains same why is there significant increase in adverse effects by almost 7 folds?

The cause behind this dramatic increase in morbidity and mortality seems to be linked to 2 specific changes in the BB market through that time period: increased diameter and a change to lithium cells.

 

3.      Why is lithium cell dangerous?

Lithium cells though have a higher potential of 3 V as compared to 1.5 V seen in other cell types. It has a longer shelf life, better stability in cooler temperature and lighter in weight.

 

4                Battery structure

                  ·         About 30-60% of battery is composed of inert substance.

·         The active portion of the battery consists of a negative terminal and a positive terminal.

·          The negative terminal of the battery is typically made of zinc or lithium, and the positive terminal of one of the following substances.

o   Lithium manganese (3 volts, most common)

o   Manganese dioxide (1.5 volts)

o   Oxygen (zinc-air cells, 1.5 volts)

o   Silver oxide (1.5 volts)

o   Mercuric oxide (1.5 volts)

 

·         The negative terminal is the narrow portion of the battery where the electric current flows into the tissue and usually creates the most damage.

·         The negative and positive terminals are typically separated by a disc that is embedded with potassium hydroxide, sodium hydroxide, or an organic solution with varying concentrations.

·         The terminals and salt solution are encased in steel and/or nickel.

5.      How to identify Button Batteries?

·         Button batteries range in diameter from 6 to 25 mm, batteries that are larger than 12 mm in diameter are most likely to become lodged in the esophagus, especially in young children.

·         The chemical content, diameter, and height of the battery can be determined from the imprinted code found on the battery case as determined by the International Electrotechnical Commission.

·         The first letter gives the chemical identification of the positive terminal as follows:

o   L: Manganese dioxide

o   S: Silver oxide

o   P: Oxygen

·         A battery with a three number code has the diameter given by the first number (eg, SR516 is 5 mm in diameter).

·         A battery with a four number code has the diameter given by the first two numbers (eg, CR2032 is 20 mm in diameter).

·         The last two numbers give the battery height in tenths of millimeters (eg, CR2032 is 3.2 mm in height).

·         The package code also corresponds to the battery diameter in millimeters. For example, a battery with a package code of 23 has a diameter of 23 mm.

 

6.      How do button batteries damage esophagus?

 

3 basic mechanisms

                                I.            Electrical injury—on contact with the esophagus as the circuit gets completed there is flow of current from negative terminal of battery to esophageal/intestinal structures  causing hydrolysis, corrosive injury

                             II.            Pressure necrosis

                           III.            Leakage of contents—KOH, NaOH can leak and cause liquefactive necrosis when the outer seal gets eroded by  gastric acid.

THE INJURY DUE TO BUTTON BATTERY IS CAUSTIC RATHER THAN THERMAL

 

7.      Can used batteries cause injury?

·            Older used batteries have some residual charge and can lead to injury

·            Newer batteries have 3 fold greater risk of injury.

 

8.      The injury by button battery is due to alkaline pH causing liquefactive necrosis.

 

9.      How to approach a case of button battery ingestion ?

·         History

·         Physical examination

·         Investigation

·         Treatment.

 

10.  What history are important ?

·         What was the size of battery?

·         Whether a new or old used battery?

·         Duration of ingestion

·         Number of button batteries ingested

·         Co-ingestion with magnets

·         Any esophageal or intestinal conditions like stricture

 

11.  Why is the duration of ingestion important?

Animal models document that necrosis within the esophageal lamina propria may begin as soon as 15 minutes from the time of ingestion, with extension to the outer muscular layer within 30 minutes.

This corresponds with anecdotal reports of significant esophageal stricture within 2 hours of ingestion.

 

DAMAGE CAN OCCUR WITHIN 2 HOURS

 

12.  Intestine can get trapped between the magnet and button battery.

 

13.  What are the signs and symptoms are that can be present ?

Most patients are asymptomatic although one or more of the following symptoms may be present

·         Chest pain

·         Cough

·         Anorexia

·         Nausea/vomiting

·         Hematemesis

·         Diarrhea

·         Epigastric pain

·         Abdominal pain

·         Fever

In cases of perforation and tracheoesopgaheal fistula they can present with

·         Fever

·         Features of shock

·         Respiratory distress and failure

·         Subcutaneous Crepitus

 

14.  What is the role of X ray?

·         X ray of chest with abdomen is done

·         X rays are useful for identification of

o   Site of impaction

o   Difference between button battery and coin

o   Signs of esophageal perforation

o   Size of button battery

o   Number of battery ingested

 

15.  How do we differentiate between a button battery and coin?

The characteristic features of button batteries versus coins are as follows:

§  Button batteries have a bilaminar structure, making them appear as a double-ring or halo on plain radiographs. The double-ring shadow helps to differentiate battery from coin ingestions.

 

§  On lateral view of the foreign body, the button battery has a step-off at the separation between the anode and cathode. By contrast, the coin has a sharp, crisp edge.

 

16.  Negative-Narrow-Necrotic” Mneumonic

·         The current generates the hydroxide at the negative terminal of the battery.

·         The negative terminal is the more narrow side of the button battery when viewed laterally.

·         The anatomic orientation of the battery can predict where the necrosis will be and the subsequent injury.

 

17.  How do we approach a patient a case of button battery ingestion ?

·         Stabilisation

·         Endoscopic removal as needed.

 

18.  What is the role of honey or sucralfate?

·         For asymptomatic children with acute button battery ingestions (eg, witnessed or likely to have occurred within 12 hours) who are older than one year of age and without allergies to honey or its components, one oral dose of pure honey (eg, 5 to 10 mL) as soon as possible after ingestion.

·         Once in the emergency department, the child may receive another dose of honey or, if no history of allergy, a single dose of sucralfate 500 mg prior to confirmation of esophageal impaction by radiography and emergency battery removal.

 

19.  Sucralfate or honey is contraindicated if timing of ingestion is unknown or in cases of delayed  presentation or in cases of esophageal perforation.

 

20.  For endoscopic removal of button battery 2 protocols can be followed.

·         One given by ESPGHAN and NASPGHAN

·         One given by NBIH(National Battery Ingestion Hotline) of USA.

 

21.  One recommended by NASPGHAN AND ESPGHAN (NELSON 21e has this)

 

 

 

22.  The protocol by NBIH

 

 

23.  What are the complications of Button battery ingestion?

Complications from button battery ingestion are rare, but potentially devastating. They include,

·         tracheoesophageal fistula,

·         vocal cord paralysis,

·         esophageal perforation,

·         esophageal stenosis,

·         mediastinitis,

·         spondylodiscitis,

·         aspiration pneumonia,

·         perforation of the aortic arch,

·         gastric hemorrhage,

·         gastric perforation, and

·         intestinal perforation 

 

24.  How to manage a case of long battery ingestion?

 

·         Less chances of corrosive injury and less risk of leakage

 

·         The concern is of length

 

·         If in esophagus should be removed but beyond stomach expectant management in asymptomatic cases.

 

25.  What is the most common cause of death in BBI?

Aortoesophageal fistula

 

KEY POINTS FROM A CASE SERIES PUBLISHED BY CHILDRENS HOSPITAL COLORADO

·         A BB can fuse to the mucosa rapidly, leading to difficult removal that may require rigid esophagoscopy.

 

·         Identification of a gastric foreign body does not preclude esophageal injury, especially in unwitnessed ingestions when the total time of BB exposure is unknown. BBs can transiently lodge in the esophagus and cause severe erosion and ongoing injury. Even after passage of the battery to the stomach, necrosis of the esophagus and surrounding tissues is an ongoing process that can lead to fistulization and associated severe outcomes.

·         Despite a reassuring esophagram and clinical stability 5 days after ingestion, devastating hemorrhage from esophageal erosion secondary to BBI can unexpectedly occur weeks out from the initial ingestion. Because of the high arterial pressure from AEF, Blakemore tubes may not be able to control or stabilize bleeding.

 

·         As mucosal injury occurs with even short exposure to BBs, every effort should be made to expedite removal when possible. MRI is a useful tool for post–battery-ingestion evaluation of the extension of injury beyond the esophagus and may help guide treatment decisions.

 

·         Despite minimal findings of edema and ulceration on initial esophagoscopy at removal of the BB, esophageal necrosis and surrounding inflammation progresses despite no further exposure, making timing of associated morbidity from BB exposure somewhat unpredictable.

 

 

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