| Abstract|| |
Introduction: Button batteries represent a low percentage of all foreign bodies swallowed by children and esophageal location is even less frequent. However, these cases are more likely to develop severe injuries. The aim of this essay is to report three cases treated in our institution and review previous reports. Material and Methods: Chart review and literature search. Case Reports: We treated three children between 2-7- years old with button batteries lodged at esophagus. They all presented esophageal burns (EB), which evolved in esophageal stenosis in two out of the three cases. Results: We found 29 more cases in literature and the injuries included EB, esophageal perforation (EP) and tracheoesophageal fistula (TEF). Discussion: Swallowed button batteries rarely remain in esophagus, but these cases present a higher risk of tisular damage. Injuries can take place even after few hours; and therefore, endoscopy must be performed as soon as possible. Further study on button batteries' safety and the establishment of a maximum size for them would be good preventive measures.
Keywords: Button battery, esophageal burn, esophageal foreign body
|How to cite this article:|
Fuentes S, Cano I, Benavent MI, Gómez A. Severe esophageal injuries caused by accidental button battery ingestion in children. J Emerg Trauma Shock 2014;7:316-21
|How to cite this URL:|
Fuentes S, Cano I, Benavent MI, Gómez A. Severe esophageal injuries caused by accidental button battery ingestion in children. J Emerg Trauma Shock [serial online] 2014 [cited 2020 May 31];7:316-21. Available from: http://www.onlinejets.org/text.asp?2014/7/4/316/142773
| Introduction|| |
Foreign body ingestion in children is a very common problem. It is estimated that 80% of all cases of swallowed foreign bodies occur in children, mainly between six months and three years of age. ,,, Most of them passed through the gastrointestinal tract without any complication; however, certain foreign bodies might cause severe injuries either because of their characteristic features or because of the level they become lodged at. The incidence of button battery ingestion is about ten cases in every million people every year, which is very low.  Only, a minimum percentage of them remains in esophagus; moreover, these cases are developed with severe damage and later complications. The aim of this essay is to report three cases treated in our institution and review previous case reports published, in order to analyze their characteristics and propose paths of management and prevention.
| Materials and Methods|| |
Bibliographic search was performed using MedLine and by combining keywords as: "button battery", "esophageal burn (EB)" and "esophageal foreign body", in which a total of 29 cases were found. The following data were collected for every case report: age, gender, symptoms, time from event, size and position of the battery, and injury caused.
The three cases diagnosed in our hospital were also reviewed.
Data are expressed as number, mean ± standard deviation and median and range when the distribution was asymmetric.
| Case Reports|| |
A healthy seven-year-old girl was referred to our institution due to accidental button battery ingestion. She presented sialorrhea and vomiting. Chest x-ray image showed a circular 20 mm foreign body in upper esophagus. Endoscopy was performed under general anesthesia and a 20- mm button battery was found 12 cm down from dental arcade at cricopharyngeus sling. It was covered in debris and stuck to esophageal mucosa, which presented a 2-cm burn along 2/3 of the esophageal circumference [Figure 1]. Button battery was removed and exploration completed without evidence of further damage. A 16-French nasogastric tube was settled and treatment with proton-pump inhibitors and sucralfate was established. Six hours later, the patient started oral intake without any incidence. On the whole, only six hours had passed from the moment of the ingestion until the performance of the endoscopy.
She underwent control endoscopy, four weeks after the event and esophageal stenosis was found. It was treated by balloon dilatation without complications. Dilatation was repeated every four weeks up to four times, and in the last endoscopy there was neither stenosis nor any other lesions. Now-a-days, one year after the event, she is asymptomatic.
A 2 year-old boy was referred to our institution because of accidental button battery ingestion in the last hour. He was vomiting when admitted and in chest x-ray image, a 20 mm radio-opaque foreign body was found in upper esophagus. Endoscopy was performed under general anesthesia and a button battery was found at 13 cm down from dental arcade. It was partially ruined and covered in debris [Figure 2] and esophageal mucosa around it presented a 3 cm burn. When battery was removed and endoscopy completed, it presented mild esophagitis distal to the affected area. A 12-French nasogastric tube was settled and treatment with proton-pump inhibitors and sucralfate was established. Control endoscopy was performed three days later without evidence of complication apart from the EB and oral intake was restarted afterwards. The child developed esophageal stenosis that required one endoscopic balloon dilatation. The last endoscopy showed a normal esophageal lumen and he is asymptomatic till now even ten months after the event.
A five-year-old girl was brought to our hospital due to accidental button battery ingestion. She presented sialorrhea. Chest x-ray image showed a circular 20 mm foreign body in middle esophagus [Figure 3]. Endoscopy was performed under general anesthesia and a 20-mm button battery was found at 20 cm down from dental arcade. It was stuck to esophageal mucosa, which was burnt at this level. Button battery was removed and exploration was completed without evidence of further damage. Treatment with proton-pump inhibitors and sucralfate was established. She started oral intake the following day without any complication. There was no evidence of esophageal stenosis in the first endoscopic control after four weeks and now-a-days she is asymptomatic.
|Figure 3: Chest x-ray image showing foreign body on theoretical position of middle esophagus|
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| Results|| |
We found 29 more cases in literature ,,,,,,,,,,,,,,,,,,,,,,,,, Their main characteristics are summarized in [Table 1].
Ages range between 4 months and 7 years. It is an asymmetric distribution. Most patients, 78 %, are three years old or younger.
Distribution is similar with 46.7% of girls and 53.3% of boys. General data of foreign body swallowing in children shows a higher incidence in boys.
Button battery size
Button battery mean size is 19.8 ± 3.35, and 80.77% of them are 20 mm or larger.
Most cases presented dysphagia or odyniphagia as main symptom (56%). However, non- specific symptoms as irritability, vomiting and cough are also common.
Time until definitive treatment
Time passed until diagnosis follows a very asymmetric distribution. Median is 1.5 days and range 4 hours to 29 days. Diagnosed was delayed in some cases because the ingestion was unnoticed and because of the non specific symptoms described above. Severe injuries are found even in cases with early diagnosis.
In 90% of total cases, 27 out of 32, batteries were found in upper esophagus.
There were 9 cases of EB, representing 28.13% of all cases. Four of them developed esophageal stenosis later on. Ten out of the whole 32 cases developed it. There were 9 cases of esophageal perforation (EP), 28.13%, and 14 tracheo-esophageal fistulae, 43.75%. Vascular involvement was present in 4 cases, all of which resulted in death.
| Discussion|| |
Foreign body ingestion is a common problem in childhood with an increasing incidence. Fortunately, most of foreign bodies pass thorough the gastro-intestinal tract uneventfully. Intervention for retrieval of foreign bodies is rarely indicated when they are situated beyond esophagus. Although most cases do not develop any complication, severe injury might take place depending on type of object swallowed and their location if they become lodged. ,,,
Button batteries represent about 2% of all foreign bodies, although this percentage seems to be increasing.  Epidemiology of button battery ingestion seems to be changing trends in the last years and there are more cases of severe complications related to them, which were reported recently.  They seldom remain in the esophagus; however, these few cases are prone to develop severe injury even after some hours. ,
Button batteries that are located in esophagus can cause damage mainly by four different and independent mechanisms.
First, they might cause damage in surrounding tissue because of direct pressure, as any other foreign body, although this mechanism alone should not cause severe injuries. 
Secondly, batteries containing mercury have been proved to release it, making its absorption to systemic circulation possible and, therefore, risking systemic toxicity. 
Alkaline leakage can take place when button batteries are immersed in saline solution. It may cause caustic damage in esophageal mucosa as well. 
Finally, experimental models in animals have shown that a button battery can complete an electrolyte circuit when lodged in esophagus, releasing enough electrical energy to burn surrounding tissues immediately and, in addition, the generation of this external electrolytic current might hydrolyze tissue fluids and produce hydroxide at the battery's negative pole. 
Alkaline burns are characterized by liquefactive necrosis, fat saponification, and inflammatory cell infiltration and they represent the most severe histologic damage caused in surrounding tissues.
According to the cases reviewed, button batteries are more likely to become lodged in esophagus in younger children because of the smaller diameter of their esophageal lumen. Most cases of severe injuries involved children younger than 3 years , including the fatalities in this series.
Most of these batteries involved are large ones, i.e. 20 mm or more of diameter. They obviously find difficult going through esophagus. Its anatomical structure explains the reason why button batteries remain most of the cases in the upper portion: cricopharingeus sling, aortic arc and the initial portion of left bronchus make lumen diameter slightly smaller physiologically and therefore, a foreign body is prone to remain at this level.
Swallowing of smaller button batteries has been reported as well, but these cases are likely to pass through the gastrointestinal tract without causing damage as they are not prone to become lodged as the larger ones.
Although dysphagia and odynophagia are very common in these patients, they are not always present and non-specific symptoms might hinder diagnosis in cases where the battery ingestion was unnoticed. This could be the reason why some cases were diagnosed even weeks after the event. , Nine of the reported cases were initially misdiagnosed due to both the lack of clear history of ingestion and presence of symptoms or clinical signs not sufficiently specific to rise the suspect of foreign body ingestion. Therefore, special attention must be paid on infants and young children that show irritability, cough or some other non-specific symptom without any apparent reason. The possibility of foreign body ingestion should be always taken into account.
The cases reviewed show that severe injury may occur even after few hours from event, although injuries tend to be more severe as time goes by.  The high proportion of tracheoesophageal fistula (TEF) among all cases reported might be explained by the fact this is an uncommon circumstance and management is both difficult and controversial, therefore these cases are more likely to be published. EB and perforation are probably more frequent than reported. The four cases reported with vascular involvement cursed with incoercible bleeding leading to cardiac arrest and death in all cases. Arterial-esophageal fistula is an extremely uncommon but usually fatal complication of foreign body ingestion. It has been also described due to instrumentalization of the esophagus, especially in children with cardiovascular anomalies such as right aortic arch or aberrant right subclavian artery. Few of these cases have been reported to survive.  Among all esophageal foreign bodies, button batteries might be more prone to develop this complication, as the damage they cause is not only due to the external pressure, but to the electric current they cause as well. The possibility of fistulisation into a great vessel should be taken into account in children with previous cardiovascular conditions, when the location of the battery is proximal and when an EB is present at the time of endoscopy, especially if the diagnosis was delayed. In two of the cases reported, vascular damage was initially unnoticed as a partial injury or a pseudoaneurismatic rupture of the vessel wall could have taken place, becoming symptomatic for days, after the removal of button battery with fatal consequences. It is essential to pay attention to any fluctuation in hemodynamic parameters (blood pressure and heart rate) in these patients during the observation period after endoscopy.
Management of esophageal button battery requires early diagnosis, therefore suspecting diagnosis in children with characteristics described above is mandatory. Obtaining a thorough history from caretakers or potential witnesses to the ingestion will be helpful in identifying a foreign body. A chest X-ray image should be performed whenever ingestion is suspected, even in the presence of non-specific symptoms, if foreign body ingestion cannot be ruled out by clinical history. A chest X-ray image will be enough to recognize the round foreign body with double-ring shadow or double density, which makes it different from a coin.  They are also slightly more translucent and show a step-off on lateral radiographic views, which can easily be obtained if there is any doubt.
Once diagnosis is established, endoscopy should be performed as soon as possible. Some other methods have been reported to remove the battery as using emetics, a Foley catheter or a magnet. They do not seem to be safe enough and a complete exploration of esophagus should be performed in order to check esophageal mucosa, to assess injury caused and to rule out early complications. , As far as we are concerned, these patients should be managed in a tertiary center with pediatric surgeons or pediatric gastroenterologists trained in endoscopy with experience in both instrumental endoscopy and endoscopical foreign body retrieval. If a pediatric gastroenterologist or endoscopist is performing the procedure, the presence or the availability a pediatric surgeon would be advisable, as the possible complications may require a prompt surgical intervention.
When the button battery is located beyond the stomach, serial radiographic examinations should be used to monitor its progress and to ensure it continues to advance through the intestinal tract.
There is no agreement among authors on management after endoscopy. When an EB is found, it seems reasonable to set a nasogastric tube, start gastric protection treatment with proton-pump inhibitors, and nil per oral until either a radiological contrast study or endoscopy is performed 2 or 3 days later to make sure there is no further damage. In our institution we recommend both endoscopic and radiological control in EB before re-assuming oral intake. Some fistulas are hardly seen on a contrast study and an endoscopic exploration with limited insufflation and without passing the affected area, in order to avoid iatrogenic injury, may help us to assess the esophageal mucosa in a more accurate way. Bronchoscopy is also advisable when an EP is present in order to rule out TEF. 
Conservative and early surgical management have been reported for TEF and perforation with good results. ,, Characteristics of both the patient and the injury will determine the final decision. If the patient is not hemodynamically stable and sepsis is developing secondary to mediastinitis, we recommend surgical exploration at least to drain the affected area, which can be performed laparoscopically. 
Even after an uneventful recovery, these patients should undergo a close follow-up. We strongly recommend a contrast study or an endoscopy within the first 4 weeks to rule out stenosis.
Esophageal stenosis is probably the most common complication after EB due to button battery ingestion, even if it is seems to be under-reported. Endoscopic balloon dilatation seems to be a safe and effective solution in these cases in our experience. We perform balloon dilatation in a number of different pathologies as esophageal caustic burns and post-surgical stenosis with satisfactory results.  We performed endoscopy and balloon dilatation in these patients uneventfully.
The long-term follow-up of our patients showed no more late complications. Even the two patients that developed esophageal stenosis after one to four dilatations, once we evidenced a normal lumen in endoscopy, they remained asymptomatic. Whether these patients are more prone to develop malignancies in their esophagus, as it happens in caustic burns is still to be investigated. There are no reports on literature at present date.
Finally, prevention is the best management of all. Parents and caretakers should be aware of the potential danger of button battery ingestion and the importance of providing immediate care. Security of devices containing button batteries should be reviewed in order to find the way they cannot be released by children. In addition, as some other authors have underlined, the permanence of the battery in esophagus determines the risk of severe injuries; and therefore, the establishment of a maximum size by manufactures will diminish the probability they become lodged there. None of the more severe consequences of battery ingestion were reported to happen in small batteries.
Summing up, incidence of button battery ingestion is increasing in the last years and the early diagnosis when they become lodged in esophagus, is of capital importance to diminish the risk of potential fatal complications. Endoscopic removal and a close follow-up by a multi-disciplinary group of physicians are essential to deal with both early and late complications. ,,
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Dr. Sara Fuentes
Department of Pediatric Surgery, 12 de Octubre University Hospital, Madrid
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]