ACMT Visual Pearl: Watt – Ever is that Foreign Body?

1. Button Battery

This image shows a suspected button battery in the esophagus, for which urgent endoscopic removal is indicated.  A clear double halo sign is visible on the anterior image, which is indicative of a button battery ingestion (Figure 2).  While not clearly demonstrated here, a lateral image might also show a step-off sign which is another indicator of a button battery ingestion (Figure 3). The orientation of the image being flat on the coronal plane suggests esophageal location of the battery.

Figure 2: AP chest x-ray demonstrating a foreign body with a double halo sign. Case courtesy of samei g m abadelrsool, Radiopaedia.org, rID: 149168.

Figure 3: lateral chest x-ray demonstrating a foreign body with a step-off sign. Case courtesy of samei g m abadelrsool, Radiopaedia.org, rID: 149168.

Background

Button batteries are small, coin-shaped batteries found in portable electronics such as watches, hearing aids, and small toys. They are typically 5 to 25 mm in diameter and 1 to 6 mm in width. They are composed of a variety of metals; however, ingestion of larger lithium batteries is associated with severe outcomes including esophageal perforations, tracheoesophageal fistulas, and massive hemorrhage [1].

Button battery ingestions have increased in frequency over the last 20 years. Currently, there are approximately 3,500 button battery ingestions per year, with children less than 5 years old at the highest risk [1,2]. This is likely due to the increasing numbers of small electronics and toys found in homes today that are powered by these batteries[3]. Cases are frequently misdiagnosed due to nonspecific initial symptoms and presentation.

Button batteries produce an external electrolytic current that can hydrolyze tissues resulting in liquefactive necrosis. This can lead to ulcerations, perforations, fistulas (tracheoesophageal or major blood vessels), massive hemorrhage, or death [4,5].

How does a button battery ingestion present?

If the history is unknown, the clinical presentation can be nonspecific [6].

Symptoms can include:

• Noisy breathing
• Drooling
• Hoarse voice
• Sore throat
• Vomiting
• Increased secretions
• Chest discomfort
• Dyspnea
• Refusal or inability to tolerate oral intake.
• General fussiness.
• Fever

What do I look for on an X-ray?

X-rays can help determine foreign body type, size, and location.

• Orientation of the foreign body [7]
  • Esophageal foreign bodies will typically appear flat in the coronal plane.
  • Tracheal foreign bodies will typically appear flat in the sagittal plane due to the tracheal rings.
• Radiologic signs of a button battery [8]
  • The “Halo sign” represents a double ring around the border of the battery.
  • “Step off sign” is a two-layered appearance with a “step off” from a larger diameter pole to a smaller diameter pole.

What is the management of a button battery ingestion?

• When you encounter patients who have ingested button batteries, it is recommended to refer to the Battery Ingestion Triage and Treatment Guidelines to assist you in management [6].
• Esophageal batteries should be urgently removed via endoscopy as tissue damage can occur within 2 hours post-ingestion [2,6].
• Gastric button battery management is somewhat controversial and dependent on the patient’s symptoms, the size of the battery, and the age of the child [6,9].
  • Symptomatic patients with abdominal pain, vomiting, or minimal PO intake should have endoscopic removal, ideally within 12 hours to reduce the risk of gastric damage.
  • Asymptomatic patients over age 12, or with an ingested battery less than 12 mm in diameter and no other co-ingestion may have expectant management at home.
    • These patients should return at any time if symptoms develop.
  • Repeat radiology is recommended if passage is not confirmed at 48 hours.
  • Consultation with a gastroenterologist is recommended for patients less than 12 years old with battery ingestion over 12mm to assist in decision-making.

Other treatment considerations

• Airway support as needed.
• Pre-hospital studies have shown benefit to honey or sucralfate administration in the setting of button battery ingestion, provided at <12 hours post-ingestion [6,10,11]. This does not obviate the need for emergent removal but may lessen damage while the battery is in place.
  • If a child over 12 months old can swallow and honey is available, parents can provide 2 teaspoons (10 ml) every 10 minutes for up to 6 doses.
  • Providers can administer 1g of sucralfate every 10 minutes for up to three doses.
  • These treatments are thought to coat the battery and help prevent the rise in pH [10,11].

Bedside Pearls

• Button battery ingestions can have non-specific presentations but have a high morbidity.
• Diagnosis is typically made with an x-ray. Look for a halo sign and step-off sign to help identify a button battery.
• Esophageal batteries are typically oriented in the coronal plane. Tracheal foreign bodies are typically oriented in the sagittal plane.
• Button batteries in the esophagus require urgent removal, ideally within 2 hours.
• Honey and sucralfate have been proven to help reduce mucosal damage when given <12 hours post-ingestion.
• Be aware of the Button Battery Ingestion Triage and Treatment Guidelines