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Button battery removed from the stomach resulting in a missed aortoesophageal fistula – a multidisciplinary approach to rescuing a very young patient: a case report
© The Author(s). 2018
- Received: 24 January 2018
- Accepted: 28 August 2018
- Published: 18 October 2018
While coins are still the most common foreign bodies swallowed by children, ingestion of batteries has become more frequent among children due to the increasing access to electronic toys and devices.
Coin battery ingestion is potentially life threatening for children. Aortoesophageal fistula is the most common cause of death in children who have swallowed coin batteries, and there have not been any reported survivors.
A 3-year-old Caucasian girl presented to the emergency room of a community hospital complaining of abdominal pain. An abdominal X-ray showed a coin lithium battery located in the fundus of her stomach, and she was transferred to a referral pediatric hospital. In the following hours she developed massive hematemesis and severe hypovolemic shock. An emergency laparotomy was attempted, and the coin battery was removed. The initial surgery and multiple blood transfusions did not, however, improve the clinical situation.
She was then referred to our tertiary referral center, where a multidisciplinary team decided to attempt a combined angiographic and endoscopic approach to resolve a life-threatening aortoesophageal fistula. A 3-year follow-up was uneventful.
Coin batteries are designed for a wide variety of small appliances, such as hearing aids, watches, remote controls, and toys.
Although a change in the clinical approach to battery ingestion is needed to avoid misdiagnosis or delayed treatment, primary prevention of battery ingestion would be even more effective than an improved treatment.
- Aortic rupture
- Balloon-expandable stents
- Thoracic endovascular aortic repair
- Urgent procedure
While batteries are still the most common foreign bodies swallowed by children, ingestion of these batteries has become more frequent among children due to increasing access to electronic toys and devices .
Coin battery ingestion is potentially life threatening for children. Aortoesophageal fistula (AEF) is the most common cause of death in children who have swallowed coin batteries, and there have not been any reported survivors [2–6].
This report describes, for the first time, a successful combined angiographic and endoscopic approach to resolving a life-threatening AEF after ingestion of a lithium cell coin battery.
After 72 hours, the orotracheal tube was removed, and she started to breathe spontaneously again. After 1 week we endoscopically placed a nasoduodenal tube to start enteral feeding. Every 7 days, esophagogastroduodenoscopies (EGDs) were performed to follow the complete mucosal healing, and after 1 month, she started eating again, and was discharged home.
The 1-year endoscopic examination showed only complete re-epithelialization on the previous esophageal bleeding site (Fig. 2b). A 3-year follow-up was uneventful.
Four consecutive CT scans (one every 12 months) showed the correct position of the angiographic stent and no other pathologic signs.
Our patient is being followed-up by our cardiology team.
Coin batteries are specially designed for a wide variety of small appliances, such as hearing aids, watches, remote controls, and toys. The dissolving of a battery’s active ingredients within the upper aerodigestive tract is associated with a strong exothermal reaction within the tissue, causing severe mucosal and full-thickness injuries . Catastrophic and fatal injuries can occur when the battery becomes lodged in the esophagus, where battery-induced injury can extend beyond the esophagus to the trachea or aorta. Increased production of larger, more powerful button batteries (BBs) has coincided with more frequent reporting of fatal hemorrhage secondary to esophageal battery impaction .
The mechanism of injury of esophageal battery impaction is electrochemical. Esophageal tissue traverses the positive and negative electrodes, which lie in proximity. The flow of electricity then leads to pH changes in surrounding tissue [2, 10].
BB ingestions have emerged as the most critical indication for emergent endoscopy in children. Endoscopic intervention for gastric localization of BBs is a matter of controversy. In our case, the BB had apparently caused esophageal injury before reaching the stomach. This suggests that passage of a BB to the stomach alone cannot be used as a criterion to conclude that the child is free from potentially catastrophic underlying esophageal injury. For inflammation extending through to the intima of the aorta, preemptive surgical management with thoracotomy and aortic grafting should be considered, despite the associated morbidity and mortality. Again, given the extremely poor history of success with repair of acute aortoenteric fistula hemorrhage, this aggressive approach may be warranted. For this reason, to avoid serious complications, it is absolutely necessary to promptly remove endoscopically the battery from the esophagus . Furthermore, it is crucial to have clinicians from cardiothoracic surgery and interventional cardiology involved early in the evaluation of these patients, and for them to remain as part of the management team .
European Society of Gastrointestinal Endoscopy (ESGE) guidelines recommend CT scan in all patients with suspected perforation or other complication that may require surgery . In the case of this patient, the critical life-threatening condition did not allow the examination to be done, and the pediatric hospital’s endoscopist chose to perform an esophagogastroscopy, consistent with American Society for Gastrointestinal Endoscopy (ASGE) guidelines, with the intention of directly removing the coin, and treating the bleeding source . According to the literature, it is possible to identify several cases of infant death caused by the ingestion of batteries and their lodging in the esophagus. Approximately 13% of deaths were due to tracheal injury, 7% to tension pneumothorax, and 80% secondary to fatal hemorrhage .
Our multidisciplinary team (pediatric surgeon, endoscopist, catheterization laboratory physician, anesthesiologist, thoracic surgeon) involved in this case was the key to the successful resolution of the AEF. We suggest that this life-threatening condition needs to be treated in a tertiary referral center with a strong emphasis on multidisciplinary coordination.
To date, 59 deaths in children have been reported worldwide, 29 of which were due to AEF or fistulae between other major vessels of the mediastinum . Our case describes a successful multidisciplinary treatment option for AEF, a commonly fatal condition [6, 7].
Battery ingestion injury may become a social hazard, so parents and childcare providers should be taught to prevent battery ingestion. Since 61.8% of batteries ingested by children are obtained from electronic devices, manufacturers should redesign household products to secure the battery compartment, possibly requiring a tool to open it. In our opinion, this problem needs to be addressed by manufacturers of electronic products, who should better secure the battery compartments, not just in toys but in all devices.
Although a change in the clinical approach to battery ingestion is required to avoid misdiagnosis or delayed treatment, the primary prevention of battery ingestion would be even more effective than an improved treatment.
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Availability of data and materials
The data that support the findings of this study are available from the corresponding author upon reasonable request.
AG and MT performed the endoscopic procedure and the endoscopic follow-up. CG performed the angiographic procedure. CA performed the gastrectomy before the combined procedure. MP and GB kept the patient alive during the procedure. All authors read and approved the final manuscript.
Ethics approval and consent to participate
Authors are reporting for the first time, a successful emergency combined angiographic and endoscopic approach to resolving a life-threatening aortoesophageal fistula after ingestion of a lithium-cell coin-battery. The procedure was performed as rescue therapy in an emergency medical condition.
Consent for publication
Written informed consent was obtained from the patient’s legal guardians for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
The authors declare that they have no competing interests.
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