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Neglected esophageal button battery ingestion: Local protocol for management
Egyptian Journal of Ear, Nose, Throat and Allied Sciences (2013) 14, 27–31
Egyptian Society of Ear, Nose, Throat and Allied Sciences
Egyptian Journal of Ear, Nose, Throat and Allied Sciences www.ejentas.com
REVIEW
Neglected esophageal button battery ingestion: Local protocol for management Shahin AbdollahiFakhim, Gholamreza Bayazian *, Mojtaba Sohrabpour Pediatrics Otolaryngology Department, Pediatrics Hospital, Tabriz University of Medical Sciences, Tabriz, Iran Received 25 August 2012; accepted 30 September 2012 Available online 22 November 2012
KEYWORDS
Abstract Button battery ingestion is a hazardous condition which is associated with the increasing technology in household products and using button battery for power supply. Most of the button battery ingestions are unwitnessed so parents’ unawareness of the potential lethal outcomes may delay the doctor visit. Lack of a clear approach or strategy for diagnosis and treatment in the first line medical caregivers is the major concern. The current study presents two cases with neglected button battery ingestion referred to the emergency ward of Pediatrics Hospital of Tabriz. With regard to review of articles and authors’ experiences a management protocol to early diagnosis is outlined for any suspected patients while the proper treatments to decline the life threatening complications are suggested which are simple to do for local practitioners.
Disc battery ingestion; Button battery ingestion; Esophageal foreign body
ª 2012 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V. All rights reserved.
Contents 1. 2. 3. 4. 5.
Introduction . Case 1 . . . . . Case 2 . . . . . Discussion . . Conclusion . . References . .
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* Corresponding author. Address: ENT ward - Imam Reza Hospital, Tabriz, Iran. Tel.: +98 9126953782. E-mail address: [email protected] (G. Bayazian). Peer review under responsibility of Egyptian Society of Ear, Nose, Throat and Allied Sciences.
Production and hosting by Elsevier
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27 28 28 29 31 31
1. Introduction As children become older, they try to know the world by exclusively putting objects in their mouths. Thus, most of the patients with esophageal foreign bodies are between one and three years old. Although coins are the most common foreign bodies in the esophagus, lodgment of button batteries is
2090-0740 ª 2012 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ejenta.2012.09.001
28 rapidly increasing in toddlers.1,2 With the widespread use of button batteries in household products such as remote controls, toys, calculators, hearing aids, and watches, more ingestions by children have been reported in the literature. As Kimball et al. (2010) mentioned, a total of 2063 disc battery ingestions in 1998 were documented by the American Association of Poison Control Centers.3 This number increased by 80% over the next eight years. Based on a study by T. Litovitz et al. (2010), a total of 8648 patients were reported to the National Battery Ingestion Hotline between July, 1990 and September, 2008.4 They noticed that in children younger than six year old, batteries were most often obtained directly from the products in 61.8%, loose in 29.8% and directly from the packaging in 8.2%. Accordingly, Litovitz et al. (2010) reported most batteries that were ingested by children younger than 6 years were obtained from remote controls (37.7%), games or toys (15.1%), calculators (7.5%) and watches (5.5%).4 As applying button batteries increases in household products, the manufacturers tend to use large diameter disk batteries (20–25 mm versus less than 15 mm) and more powerful ones (like lithium cells) which are more hazardous to children. Since objects with less than 15–18 mm diameter pass easily through the gastro-esophageal tract, larger diameter button batteries are more likely to lodge in the esophagus and may cause severe complications or even death.5 Mucosal damage to the esophagus occurs in an hour of lodgment of button battery. In four hours, erosions pass through muscular layers of the esophagus and within six hours the esophagus perforates which eventually leads to severe complications such as mediastinitis, tracheoesophageal fistula, aortoesophageal fistula and death.6,7 Other serious complications are esophageal perforations, esophageal strictures or stenosis which usually require repeated dilatations, vocal cord paralysis from recurrent laryngeal nerve damage, cardiac or respiratory arrests, pneumothorax, pneumoperitoneum, tracheal stenosis or tracheomalacia, aspiration pneumonia, empyema, lung abscess, and spondylodiscitis.5,8,9 Therefore, a rapid and accurate diagnosis is critical. Unspecific and ambiguous presentations especially in unwitnessed ingestions, however, may lead to misdiagnosis. Clinical suspicions in first line caregivers are the mainstay of diagnosis. A plain radiography from the chest in anteroposterior and lateral views can properly instantiate the diagnosis.10,11 After diagnosis, an immediate endoscopy is usually performed to remove the battery and to examine the esophagus for probable mucosal damage. In this article, the three cases of neglected button battery lodgment in the esophagus which happened in less than a year at the Pediatrics Hospital of Tabriz-Iran are presented to highlight the potentially lethal ingestion hazards. The researchers have reviewed the previous studies on diagnosis and treatment of button battery ingestion in order to reach a proper management.
Sh. AbdollahiFakhim et al.
Figure 1 Esophagogram reveals no sign of esophageal perforation.
resulted in admission to the second level hospital where the proper diagnosis was conducted with management to flexible endoscopy. The pediatrician was unable to remove the button battery, so referred the patient to the Pediatric Hospital for consulting with otolaryngologist and pediatric surgeons. The patient was admitted with nausea, vomiting, drooling and dysphagia mostly to solid foods with no fever. When the rigid endoscopy procedure was done, a lot of fibrotic tissues proximal to the button battery at the cricopharynx level were observed which decreased the lumen diameter to approximately 7–8 mm and the subsequent dysphagia. The mucus around the battery was dissected and the 20 mm button battery was removed. Next, the fibrotic tissues were excised and a nasogastric tube was inserted after irrigation. Antibiotics, anti acids (Ranitidine) and steroids were prescribed and nasogastric gavages started after several hours. Two days after operation, the esophagography revealed no signs of esophageal perforation or mucosal irregularities (Fig. 1). Therefore, the oral feeding of liquid regimen was started successfully. After two months, the follow-up esophagogram revealed an esophageal stricture which required a thorax surgeon’s consultation for esophageal bougienage.
2. Case 1
3. Case 2
A 13-month old boy experienced an episode of choking in two months before admission, followed by vomiting was referred to a local caregiver who ensured the parents that no serious hazards would exist. After several visits for the fluctuant symptoms of vomiting and subsequent poor feeding, the diagnosis was common cold and gastroenteritis. Prolonged symptoms
A 17-month old infant was referred to the emergency ward because of an esophageal foreign body-probably a coin-reported three days ago. Initial symptoms were refusing to eat, drooling and vomiting. The clinician prescribed antibiotics and antihistamines (Diphenhydramin) and ensured the parents that no serious problems would exist.
Neglected esophageal button battery ingestion: Local protocol for management
29
ward, chest radiography in AP and lateral views were performed which were unsuccessful to distinguish between coin and button battery. The parents were investigated for the probability of button battery ingestion, but they misinformed the clinicians as they were sure no button battery was accessible to the child. The ingestion was, however, unwitnessed. Considering anesthesia, the patient underwent an operation after six hour NPO. Endoscopic findings proved some necrosed tissues and mucosal damage around a 20 mm button battery without esophageal perforation or penetration to the muscular layer. Postoperative esophagogram was normal, therefore, oral feeding was started a day after operation. Control esophagography did not reveal any strictures except for a mild gastroesophageal reflux (Fig. 2). 4. Discussion
Figure 2 Esophagus is within a normal range in controlling esophagoscopy with mild gastroesophageal reflux.
After two days, choking and coughing after eating added to the presentation which led the parents refer to another clinician. An AP chest X-ray revealed an opaque round foreign body with the probable diagnosis of coin ingestion. Therefore, the patient was referred to the hospital. In the emergency
Figure 3
Nowadays, button batteries, especially of large diameters, have emerged as a serious and potentially lethal ingestion hazard. The incidence of devastating injury and fetal complication rises because of their increasing use in household products. Lovits and coworkers noticed a 6- to 7-folded increase in the rate of major or fatal outcomes by the three-year period (0.443% in 2007–2009) comparing with the past three-year period (0.066% in 1985–1987).5 Similarly, they reported that the ingestion of 20–25 mm-diameter cells increased from 1% to 18% for the ingested button batteries (1990–2008), paralleling the rise in lithium cell ingestions (1.3–24%.5 The critical problem is unfortunate misdiagnosis, mostly because of nonspecific presentations that eventually postpone the proper management, especially when ingestion is unwitnessed and the parents misinform the clinicians.12 Physicians and first line caregivers are, therefore, required to be sensitive
(a) Step off sign in lateral view indicates button battery (b) rotation makes difficult to distinguish button battery.
30
Sh. AbdollahiFakhim et al.
to the importance of early diagnosis for protecting the patients from life threatening complications. Based on the Lovits’ et al. report, the clinicians usually miss the diagnosis of a button battery lodged in the esophagus in at least 27% of major outcomes and 54% of fatal cases.5
Figure 4 os.
In the current case series, also proper diagnosis was made after a plenty of time which resulted in serious outcomes. The exact time of battery ingestion was unclear in the first case (more than five days), two months and three days in the other cases, respectively. Apparently, the absence of knowledge
A protocol to diagnosis and management for known and suspected button battery ingestion AP: anteroposterior, NPO: nil per
Neglected esophageal button battery ingestion: Local protocol for management about potential hazards of button battery ingestion in parents and even physicians plays an important role in delayed diagnosis. Educating parents on hazards of button battery ingestion by children in mass media is highly recommended by the government. In a survey, evaluating physician’s attitudes and approaches to the management of battery ingestion,13 among the 312 members of the endoscopic and pediatric sections of the British Society of Gastroenterology, 36.2% were not concerned at all and gave no therapy; 9% did not know how to manage the problem. Twenty-two percent would not remove batteries even if they were lodged in the esophagus. Thus, changing the physicians’ attitudes and concerning them about serious life threatening complications may lead to proper early diagnosis. Since most patients present with symptoms of esophageal foreign bodies such as nausea and vomiting, dysphagia, odynophagia, drooling, poor feeding, difficulty in swallowing, refusing to eat, coughing and choking with eating, if such symptoms are present the diagnosis of esophageal foreign body is considerable. Plain radiography is the most popular and available assessment to confirm the diagnosis. As Lee et al. (2008) reported, the sensitivity of plain radiography has to be 94.4% when plain films are used to assess the need for urgent operative removal.10 Anteroposterior (AP) and lateral views of the chest should be obtained while the landmarks of button battery be carefully noticed. There are some subtle differences to identify the button battery, such as double rim, a halo of reduced density around the circumference of a battery in AP view, and a step-off and greater depth in lateral view. Although these differences are noticeable, there are no definite characteristics to distinguish between a coin and a button battery. In patients reported in this study, a lateral view of chest was completely compatible with button battery in case 1 (Fig. 3a) but not determinable in case 2 (Fig. 3b). It seems rational, therefore, to treat a button battery in any circular opaque metal foreign body by plain radiography until proven otherwise. In Fig. 4, a management protocol to early diagnosis is outlined for any suspicious patients while the proper treatments to decline the life threatening complications are suggested. Patients with metal opaque foreign body known or suspicious for button battery are mandated to emergency endoscopy. Exceptions are patients more than six years old or those with FB less than 15 mm because in recent studies there are no clinically significant (moderate, major, or fatal) outcomes with 15 to 18 mm button cell ingestions.5 After button battery removal, insertion of the nasogastric tube and prescription of anti microbial agents and anti reflux agents should be considered. Early esophagogram to exclude any perforation and to
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start oral feeding should be followed by late esophagogram to find any esophageal stricture or stenosis after 3–6 months.14 5. Conclusion In conclusion, researchers in this study highly recommend an early diagnosis by clinical suspicions for ingesting button battery to avoid life threatening complications. Clinical suspicions should be confirmed by a plain radiography followed by an emergency endoscopy if it reveals a round opaque foreign body. The earlier the diagnosis is made, the less serious and devastating complications occur. References 1. Little DC, Shah SR, Peter SDS, Calkins CM, et al. Esophageal foreign bodies in the pediatric population: our first 500 cases. J Pediatr Surg. 2006;914–918, 41(May (5)). 2. Maroma T, Goldfarb A, Russo E, Roth Y. Battery ingestion in children. Int J Pediatr Otorhinolaryngol. 2010;74:849–854. 3. Kimball SJ, Park AH, Rollins MD, Grimmer JF, et al. A review of esophageal disc battery ingestions and a protocol for management. Arch Otolaryngol Head Neck Surg. 2010;136(9):866–871. 4. Litovitz T, Whitaker N, Clark L. Preventing battery ingestions: an analysis of 8648 cases. Pediatrics. 2010;125:1178–1183. 5. Litovitz T, Whitaker N, Clark L, White NC, et al. Emerging battery-ingestion hazard: clinical implications. Pediatrics. 2010;125: 1168–1177. 6. Maves M, Carithers J, Birck H. Esophageal burns secondary to disc battery ingestion. Ann Otol Rhinol Laryngol. 1984;93: 364–369. 7. Litovitz T, Schmitz B. Ingestion of cylindrical and button batteries: an analysis of 2382 cases. Pediatrics. 1992;89:747. 8. Bernstein JM, Burrows SA, Saunders MW. Lodged oesophageal button battery masquerading as a coin: an unusual cause of bilateral vocal cord paralysis. Emerg Med J. 2007;24. 9. Samad L, Ali M, Ramzi H. Button battery ingestion: hazards of esophageal impaction. J Pediatr Surg. 1999;34:1527–1531. 10. Lee SC, Ebert CS, Fordham L, Rose AS. Plain films in the evaluation of batteries as esophageal foreign bodies. Int J Pediatr Otorhinolaryngol. 2008;72:1487–1491. 11. Maves M, Lloyd T, Carithers J. Radiographic identification of ingested disc batteries. Pediatr Radiol. 1986;16:154–156. 12. Eren S, Avcı A, Nasır A, Gu¨rkan F. Esophageal button battery ingestion: a delayed diagnosis. Turk Respir J. 2007;8(1):32–33. 13. Studley J, Linehan I, Ogilvie A, Dowling B. Swallowed button batteries: is there a consensus on management? Gut. 1990;31(8): 867–870. 14. Garey CL, Laituri CA, Kaye AJ, Ostlie DJ, et al. Esophageal perforation in children: a review of one institution’s experience. J Surg Res. 2010;164:13–17.
Egyptian Society of Ear, Nose, Throat and Allied Sciences
Egyptian Journal of Ear, Nose, Throat and Allied Sciences www.ejentas.com
REVIEW
Neglected esophageal button battery ingestion: Local protocol for management Shahin AbdollahiFakhim, Gholamreza Bayazian *, Mojtaba Sohrabpour Pediatrics Otolaryngology Department, Pediatrics Hospital, Tabriz University of Medical Sciences, Tabriz, Iran Received 25 August 2012; accepted 30 September 2012 Available online 22 November 2012
KEYWORDS
Abstract Button battery ingestion is a hazardous condition which is associated with the increasing technology in household products and using button battery for power supply. Most of the button battery ingestions are unwitnessed so parents’ unawareness of the potential lethal outcomes may delay the doctor visit. Lack of a clear approach or strategy for diagnosis and treatment in the first line medical caregivers is the major concern. The current study presents two cases with neglected button battery ingestion referred to the emergency ward of Pediatrics Hospital of Tabriz. With regard to review of articles and authors’ experiences a management protocol to early diagnosis is outlined for any suspected patients while the proper treatments to decline the life threatening complications are suggested which are simple to do for local practitioners.
Disc battery ingestion; Button battery ingestion; Esophageal foreign body
ª 2012 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V. All rights reserved.
Contents 1. 2. 3. 4. 5.
Introduction . Case 1 . . . . . Case 2 . . . . . Discussion . . Conclusion . . References . .
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* Corresponding author. Address: ENT ward - Imam Reza Hospital, Tabriz, Iran. Tel.: +98 9126953782. E-mail address: [email protected] (G. Bayazian). Peer review under responsibility of Egyptian Society of Ear, Nose, Throat and Allied Sciences.
Production and hosting by Elsevier
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27 28 28 29 31 31
1. Introduction As children become older, they try to know the world by exclusively putting objects in their mouths. Thus, most of the patients with esophageal foreign bodies are between one and three years old. Although coins are the most common foreign bodies in the esophagus, lodgment of button batteries is
2090-0740 ª 2012 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ejenta.2012.09.001
28 rapidly increasing in toddlers.1,2 With the widespread use of button batteries in household products such as remote controls, toys, calculators, hearing aids, and watches, more ingestions by children have been reported in the literature. As Kimball et al. (2010) mentioned, a total of 2063 disc battery ingestions in 1998 were documented by the American Association of Poison Control Centers.3 This number increased by 80% over the next eight years. Based on a study by T. Litovitz et al. (2010), a total of 8648 patients were reported to the National Battery Ingestion Hotline between July, 1990 and September, 2008.4 They noticed that in children younger than six year old, batteries were most often obtained directly from the products in 61.8%, loose in 29.8% and directly from the packaging in 8.2%. Accordingly, Litovitz et al. (2010) reported most batteries that were ingested by children younger than 6 years were obtained from remote controls (37.7%), games or toys (15.1%), calculators (7.5%) and watches (5.5%).4 As applying button batteries increases in household products, the manufacturers tend to use large diameter disk batteries (20–25 mm versus less than 15 mm) and more powerful ones (like lithium cells) which are more hazardous to children. Since objects with less than 15–18 mm diameter pass easily through the gastro-esophageal tract, larger diameter button batteries are more likely to lodge in the esophagus and may cause severe complications or even death.5 Mucosal damage to the esophagus occurs in an hour of lodgment of button battery. In four hours, erosions pass through muscular layers of the esophagus and within six hours the esophagus perforates which eventually leads to severe complications such as mediastinitis, tracheoesophageal fistula, aortoesophageal fistula and death.6,7 Other serious complications are esophageal perforations, esophageal strictures or stenosis which usually require repeated dilatations, vocal cord paralysis from recurrent laryngeal nerve damage, cardiac or respiratory arrests, pneumothorax, pneumoperitoneum, tracheal stenosis or tracheomalacia, aspiration pneumonia, empyema, lung abscess, and spondylodiscitis.5,8,9 Therefore, a rapid and accurate diagnosis is critical. Unspecific and ambiguous presentations especially in unwitnessed ingestions, however, may lead to misdiagnosis. Clinical suspicions in first line caregivers are the mainstay of diagnosis. A plain radiography from the chest in anteroposterior and lateral views can properly instantiate the diagnosis.10,11 After diagnosis, an immediate endoscopy is usually performed to remove the battery and to examine the esophagus for probable mucosal damage. In this article, the three cases of neglected button battery lodgment in the esophagus which happened in less than a year at the Pediatrics Hospital of Tabriz-Iran are presented to highlight the potentially lethal ingestion hazards. The researchers have reviewed the previous studies on diagnosis and treatment of button battery ingestion in order to reach a proper management.
Sh. AbdollahiFakhim et al.
Figure 1 Esophagogram reveals no sign of esophageal perforation.
resulted in admission to the second level hospital where the proper diagnosis was conducted with management to flexible endoscopy. The pediatrician was unable to remove the button battery, so referred the patient to the Pediatric Hospital for consulting with otolaryngologist and pediatric surgeons. The patient was admitted with nausea, vomiting, drooling and dysphagia mostly to solid foods with no fever. When the rigid endoscopy procedure was done, a lot of fibrotic tissues proximal to the button battery at the cricopharynx level were observed which decreased the lumen diameter to approximately 7–8 mm and the subsequent dysphagia. The mucus around the battery was dissected and the 20 mm button battery was removed. Next, the fibrotic tissues were excised and a nasogastric tube was inserted after irrigation. Antibiotics, anti acids (Ranitidine) and steroids were prescribed and nasogastric gavages started after several hours. Two days after operation, the esophagography revealed no signs of esophageal perforation or mucosal irregularities (Fig. 1). Therefore, the oral feeding of liquid regimen was started successfully. After two months, the follow-up esophagogram revealed an esophageal stricture which required a thorax surgeon’s consultation for esophageal bougienage.
2. Case 1
3. Case 2
A 13-month old boy experienced an episode of choking in two months before admission, followed by vomiting was referred to a local caregiver who ensured the parents that no serious hazards would exist. After several visits for the fluctuant symptoms of vomiting and subsequent poor feeding, the diagnosis was common cold and gastroenteritis. Prolonged symptoms
A 17-month old infant was referred to the emergency ward because of an esophageal foreign body-probably a coin-reported three days ago. Initial symptoms were refusing to eat, drooling and vomiting. The clinician prescribed antibiotics and antihistamines (Diphenhydramin) and ensured the parents that no serious problems would exist.
Neglected esophageal button battery ingestion: Local protocol for management
29
ward, chest radiography in AP and lateral views were performed which were unsuccessful to distinguish between coin and button battery. The parents were investigated for the probability of button battery ingestion, but they misinformed the clinicians as they were sure no button battery was accessible to the child. The ingestion was, however, unwitnessed. Considering anesthesia, the patient underwent an operation after six hour NPO. Endoscopic findings proved some necrosed tissues and mucosal damage around a 20 mm button battery without esophageal perforation or penetration to the muscular layer. Postoperative esophagogram was normal, therefore, oral feeding was started a day after operation. Control esophagography did not reveal any strictures except for a mild gastroesophageal reflux (Fig. 2). 4. Discussion
Figure 2 Esophagus is within a normal range in controlling esophagoscopy with mild gastroesophageal reflux.
After two days, choking and coughing after eating added to the presentation which led the parents refer to another clinician. An AP chest X-ray revealed an opaque round foreign body with the probable diagnosis of coin ingestion. Therefore, the patient was referred to the hospital. In the emergency
Figure 3
Nowadays, button batteries, especially of large diameters, have emerged as a serious and potentially lethal ingestion hazard. The incidence of devastating injury and fetal complication rises because of their increasing use in household products. Lovits and coworkers noticed a 6- to 7-folded increase in the rate of major or fatal outcomes by the three-year period (0.443% in 2007–2009) comparing with the past three-year period (0.066% in 1985–1987).5 Similarly, they reported that the ingestion of 20–25 mm-diameter cells increased from 1% to 18% for the ingested button batteries (1990–2008), paralleling the rise in lithium cell ingestions (1.3–24%.5 The critical problem is unfortunate misdiagnosis, mostly because of nonspecific presentations that eventually postpone the proper management, especially when ingestion is unwitnessed and the parents misinform the clinicians.12 Physicians and first line caregivers are, therefore, required to be sensitive
(a) Step off sign in lateral view indicates button battery (b) rotation makes difficult to distinguish button battery.
30
Sh. AbdollahiFakhim et al.
to the importance of early diagnosis for protecting the patients from life threatening complications. Based on the Lovits’ et al. report, the clinicians usually miss the diagnosis of a button battery lodged in the esophagus in at least 27% of major outcomes and 54% of fatal cases.5
Figure 4 os.
In the current case series, also proper diagnosis was made after a plenty of time which resulted in serious outcomes. The exact time of battery ingestion was unclear in the first case (more than five days), two months and three days in the other cases, respectively. Apparently, the absence of knowledge
A protocol to diagnosis and management for known and suspected button battery ingestion AP: anteroposterior, NPO: nil per
Neglected esophageal button battery ingestion: Local protocol for management about potential hazards of button battery ingestion in parents and even physicians plays an important role in delayed diagnosis. Educating parents on hazards of button battery ingestion by children in mass media is highly recommended by the government. In a survey, evaluating physician’s attitudes and approaches to the management of battery ingestion,13 among the 312 members of the endoscopic and pediatric sections of the British Society of Gastroenterology, 36.2% were not concerned at all and gave no therapy; 9% did not know how to manage the problem. Twenty-two percent would not remove batteries even if they were lodged in the esophagus. Thus, changing the physicians’ attitudes and concerning them about serious life threatening complications may lead to proper early diagnosis. Since most patients present with symptoms of esophageal foreign bodies such as nausea and vomiting, dysphagia, odynophagia, drooling, poor feeding, difficulty in swallowing, refusing to eat, coughing and choking with eating, if such symptoms are present the diagnosis of esophageal foreign body is considerable. Plain radiography is the most popular and available assessment to confirm the diagnosis. As Lee et al. (2008) reported, the sensitivity of plain radiography has to be 94.4% when plain films are used to assess the need for urgent operative removal.10 Anteroposterior (AP) and lateral views of the chest should be obtained while the landmarks of button battery be carefully noticed. There are some subtle differences to identify the button battery, such as double rim, a halo of reduced density around the circumference of a battery in AP view, and a step-off and greater depth in lateral view. Although these differences are noticeable, there are no definite characteristics to distinguish between a coin and a button battery. In patients reported in this study, a lateral view of chest was completely compatible with button battery in case 1 (Fig. 3a) but not determinable in case 2 (Fig. 3b). It seems rational, therefore, to treat a button battery in any circular opaque metal foreign body by plain radiography until proven otherwise. In Fig. 4, a management protocol to early diagnosis is outlined for any suspicious patients while the proper treatments to decline the life threatening complications are suggested. Patients with metal opaque foreign body known or suspicious for button battery are mandated to emergency endoscopy. Exceptions are patients more than six years old or those with FB less than 15 mm because in recent studies there are no clinically significant (moderate, major, or fatal) outcomes with 15 to 18 mm button cell ingestions.5 After button battery removal, insertion of the nasogastric tube and prescription of anti microbial agents and anti reflux agents should be considered. Early esophagogram to exclude any perforation and to
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start oral feeding should be followed by late esophagogram to find any esophageal stricture or stenosis after 3–6 months.14 5. Conclusion In conclusion, researchers in this study highly recommend an early diagnosis by clinical suspicions for ingesting button battery to avoid life threatening complications. Clinical suspicions should be confirmed by a plain radiography followed by an emergency endoscopy if it reveals a round opaque foreign body. The earlier the diagnosis is made, the less serious and devastating complications occur. References 1. Little DC, Shah SR, Peter SDS, Calkins CM, et al. Esophageal foreign bodies in the pediatric population: our first 500 cases. J Pediatr Surg. 2006;914–918, 41(May (5)). 2. Maroma T, Goldfarb A, Russo E, Roth Y. Battery ingestion in children. Int J Pediatr Otorhinolaryngol. 2010;74:849–854. 3. Kimball SJ, Park AH, Rollins MD, Grimmer JF, et al. A review of esophageal disc battery ingestions and a protocol for management. Arch Otolaryngol Head Neck Surg. 2010;136(9):866–871. 4. Litovitz T, Whitaker N, Clark L. Preventing battery ingestions: an analysis of 8648 cases. Pediatrics. 2010;125:1178–1183. 5. Litovitz T, Whitaker N, Clark L, White NC, et al. Emerging battery-ingestion hazard: clinical implications. Pediatrics. 2010;125: 1168–1177. 6. Maves M, Carithers J, Birck H. Esophageal burns secondary to disc battery ingestion. Ann Otol Rhinol Laryngol. 1984;93: 364–369. 7. Litovitz T, Schmitz B. Ingestion of cylindrical and button batteries: an analysis of 2382 cases. Pediatrics. 1992;89:747. 8. Bernstein JM, Burrows SA, Saunders MW. Lodged oesophageal button battery masquerading as a coin: an unusual cause of bilateral vocal cord paralysis. Emerg Med J. 2007;24. 9. Samad L, Ali M, Ramzi H. Button battery ingestion: hazards of esophageal impaction. J Pediatr Surg. 1999;34:1527–1531. 10. Lee SC, Ebert CS, Fordham L, Rose AS. Plain films in the evaluation of batteries as esophageal foreign bodies. Int J Pediatr Otorhinolaryngol. 2008;72:1487–1491. 11. Maves M, Lloyd T, Carithers J. Radiographic identification of ingested disc batteries. Pediatr Radiol. 1986;16:154–156. 12. Eren S, Avcı A, Nasır A, Gu¨rkan F. Esophageal button battery ingestion: a delayed diagnosis. Turk Respir J. 2007;8(1):32–33. 13. Studley J, Linehan I, Ogilvie A, Dowling B. Swallowed button batteries: is there a consensus on management? Gut. 1990;31(8): 867–870. 14. Garey CL, Laituri CA, Kaye AJ, Ostlie DJ, et al. Esophageal perforation in children: a review of one institution’s experience. J Surg Res. 2010;164:13–17.