Drooling, Irritability, and Refusal to Eat in a 22-Month-Old Child

Abstract

Question: A 22-month-old child was taken to the emergency room by his parents owing to continuous drooling, irritability, and refusal of food intake. He presented with a body temperature of 37.4°C, heart rate of 144 bpm, and blood pressure of 100/60 mm Hg. Laboratory tests showed a white blood cell count of 28.1 × 103 cells/μL, a hemoglobin of 13.5 g/dL, and a C-reactive protein of 19.1 mg/L. There were no electrolyte imbalances or coagulopathy. A plain chest radiograph revealed a disc-shaped metallic object in the upper esophagus, but no evidence of pneumomediastinum (Figure A). The parents were unaware that a foreign body ingestion had occurred. An esophagogastroduodenoscopy (EGD) was performed urgently and showed a 2-cm metallic object lodged in the upper esophagus just below the upper esophageal sphincter (Figure B). What is the diagnosis? Look on page 545 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. EGD showed a metallic, disc-shaped object with eroded mucosal tissue in the upper esophagus. This turned out to be a 2-cm, 3-volt lithium-ion button battery that had separated from a tympanic thermometer. In the United States, 3366–3471 button battery ingestion cases were reported to poison control centers annually from 2011 to 2013.1American Association of Poison Control Centers. National Poison Data System Annual Reports. Available at: www.poison.org/battery/stats.asp. Accessed October 8, 2014.Google Scholar Button batteries do not give rise to problems unless they become stuck in the digestive tract, commonly in the esophagus.2Kuhns D.W. Dire D.J. Button battery ingestions.Ann Emerg Med. 1989; 18: 293-300Abstract Full Text PDF PubMed Scopus (26) Google Scholar The main mechanisms of battery-induced tissue injury are as follows: (1) generation of an external current, (2) leakage of alkaline electrolyte, and (3) physical pressure on adjacent tissue.3Litovitz T. Whitaker N. Clark L. et al.Emerging battery-ingestion hazard: clinical implications.Pediatrics. 2010; 125: 1168-1177Crossref PubMed Scopus (293) Google Scholar When button battery ingestion is suspected, a prompt plain film study is useful in verifying the ingestion and determining the site. A button battery stuck in the esophagus should be eliminated as soon as possible, preferably within 2 hours.3Litovitz T. Whitaker N. Clark L. et al.Emerging battery-ingestion hazard: clinical implications.Pediatrics. 2010; 125: 1168-1177Crossref PubMed Scopus (293) Google Scholar In this case, the patient was brought to the hospital almost 1 day after the symptoms appeared. The EGD showed severe adhesion between the esophageal mucosa and the button battery. With concern for esophageal perforation during retrieval of the battery, we performed endoscopic removal (Figure C) under general anesthesia with a pediatric surgical team on standby. During the procedure, no acute complication occurred. On immediate follow-up endoscopic examination, a partial thickness burn injury was seen (Figure D). EGD 7 days later showed a mild esophageal stricture (Figure E), and a contrast esophagogram showed stenosis in the upper esophagus (Figure F). Physicians need to be aware of the potential complications related to button battery ingestion, and the importance of immediate removal of batteries lodged in the esophagus. After retrieval of a battery from the esophagus, any mucosal damage seen must be monitored for late complications, such as tracheal stenosis, esophageal perforation, tracheoesophageal fistula, aortoesophageal fistula, or mediastinitis.