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Mercury absorption following button battery ingestion
Mercury Absorption
Following
Button Battery Ingestion
By D.H. Bass and A.J.W. Millar Rondebosch, South Africa 0 A case of button battery ingestion with resulting disintegration of the battery, mercury spillage, and absorption of elemental mercury from the colon is reported. In the light of this case and other recorded complications following button battery ingestion, a plan of management is suggested. Copyright 8 1992 by W.B. Saunders Company INDEX WORDS:
Mercury ingestion; battery ingestion.
T
HE INCREASING frequency of button battery ingestion has been well documented.‘-3 It is universally accepted that any button battery lodged in the esophagus should be removed urgently in order to prevent erosion and perforation, which may be caused by a combination of pressure, electrical current, and leakage of the highly alkaline electrolyte.4 However, the vast majority of button batteries which reach the stomach will be passed in the stools without complication, but removal is occasionally indicated if symptoms or signs of complications develop or when the onward progress of the battery appears to have ceased. Disintegration of ingestion button batteries has previously been reported in only six casesi,s.6 with little morbidity and with evidence of mercury poisoning in only one instance .h We wish to report our experience of a case where disintegration of a button battery occurred in the large bowel and resulted in systemic absorption of mercury.
CASE REPORT A ?-year-old boy was brought to the trauma unit at the Red Cross War Memorial Children’s Hospital 6 hours after swallowing a button battery that he had removed from a pocket calculator. The child was clinically well and an abdominal x-ray showed the battery lying in the stomach. A single dose each of magnesium sulphate and metaclopromide were given orally in an attempt to encourage onward progression of the battery and the parents were asked to observe the child at home and to return the following day or earlier if symptoms developed. On his return to the trauma unit the next morning (20 hours after ingestion) the child was clinically well but a repeat abdominal x-ray showed the battery situated in the left upper quadrant surrounded by droplets of mercury. A pediatric bisacodyl suppository was given and blood and urine samples were obtained. A second x-ray was taken after the suppository had resulted in a bowel action without passage of the battery. The battery was passed in the stool 26 hours after ingestion showing evidence of both corrosion of the metal casing and mercury leakage through the plastic grommet seal. The urinary mercury concentration was 74 ug/mL (normal, 0 to 20 kg/L) but both renal and liver function tests were normal. The child was seen again 1 week later, at which stage the urinary mercury level had fallen to 6 kg/L and there was still no evidence of renal dysfunction, or neural toxicity. JournalofPed/atricSurgery,
Vol27, No
12
(December),
1992: pp
1541.1542
DISCUSSION
Button batteries possess unique structural properties which demand that they be treated more seriously than other foreign bodies ingested. Both in vitro and animal studies’s5 have shown that these charged batteries are electrically active in any moist environment and that the low-voltage current produced may cause damage to adjacent tissue. Also, corrosion of the plastic seal resulting in discharge of the battery contents is facilitated by an acid environment.’ Caustic erosions associated with button battery ingestions have been documented in the esophagus, stomach, and small bowel’,’ but leakage of mercury or other metals has only once been reported first-hand.” In our experience, the majority of button batteries ingested have been of the mercuric oxide type measuring 11 to 15.6 mm in diameter.3 It is thought that the more toxic mercuric oxide is mostly converted to nontoxic, and less easily absorbed elemental mercury on discharge of the battery so that mercury poisoning after button battery ingestion is unlikely.’ However, it should be remembered that some of these batteries contain up to 5 g of mercuric oxide, which is more than the estimated lethal dose.” Signs of acute poisoning by elemental mercury include those referable to the central nervous system, namely lethargy, excitement, hyperreflexia and tremor. Historically, the usual cause of death was renal failure. In this cast mercury discharged from a button battery was absorbed from the colon in sufficient quantities to reach potentially toxic systemic levels. Thus, disintegration of the battery may commence in the upper gastrointestinal tract, but mercury leakage may only occur as far distal as the colon. Although neither the present patient nor that described by Kulig et alh suffered observed ill-effects from the mercury absorption, the possibility of more severe complications due to liberation of both mercury and potassium hydroxide cannot be discounted, particularly when passage of the battery is delayed. These considerations support the need for both From the Trauma Unit and Department of Paediattic Sutgety Universiryof Cape Town, Institute of Child Health and Red Cross War Memorial Children S Hospital. Rondebosch, South Africa. Address reprint requests to Dr D.H. Bass, Trauma Unit, Red Cross War Memorial Children’s Hospital, Klipfontein Rd, 7700 Rondebosch. South Africa. Copyright c:~1992 by W.B. Saunders Company 0022.34819212712-0022$03.0010 1541
BASS AND MILLAR
1542
careful clinical and radiological monitoring of ingested button batteries. It seems advisable to neutralize stomach pH with antacids and/or H2 receptor blockers as the grommet seal does not perish as rapidly in a neutral pH environment.7 At the same time the administration of a prokinetic agent and an aperient appears logical. Should the battery remain in the stomach over a 12- to 24-hour period, removal is indicated. This can be satisfactorily carried out under light sedation using a magnet with fluoroscopic control.9 Fiberoptic endoscopic removal is an alternative but usually requires a general anesthetic in a small child. Operative removal is rarely necessary and would only be indicated by evidence of intestinal perforation. Arrest of onward progress of the battery distal to the duodenum would require close clinical and radiological monitoring. Using these manage-
ment guidelines in most cases, this was our first complication in a total experience of 44 battery ingestions. Unnecessary operative removal was performed once and failed attempts at endoscopic removal twice some years ago.3 Three batteries remaining in the stomach for more than 12 hours have been removed using a magnet. Finally, as with all noxious ingestions, the public should be made aware of the potential dangers of button batteries and their careful disposal. The manufacturers’ responsibility is to provide safe childproof packaging, clear labeling of battery contents, and a written warning of possible toddler ingestion. ACKNOWLEDGMENT The authors would like to thank P. Ball for having typed the manuscript.
REFERENCES 1. Litovitz TL: Button battery ingestions: A review of 56 cases. JAMA 249:2495-2500,1983 2. Votteler TP, Nash JC, Rutledge JC: The hazard of ingested alkaline disk batteries in children. JAMA 249:2504-2506, 1983 3. Millar AJW, Rode H, Cywes S, et al: Button-battery ingestions-A hazard of modern living. S Afr Med J 68:868-871,1985 4. Blatnik DS, Toohil RJ, Lehman RH: Fatal complication from an alkaline battery foreign body in the oesophagus. Ann Otol Rhino1 Laryngol86:611-615, 1977 5. Reilly DI: Mercury battery ingestion. Br Med J 1:859, 1977
6. Kulig K, Rumeck CM, Dulfy JP: Disk battery ingestion, elevated urine mercury levels and enema removal of battery fragments. JAMA 249:2502-2504,1983 7. Erpicum PJA, Davies MRQ: Button-battery ingestion. S Afr Med J 69:346-347, 1986 (letter) 8. Temple DM, McNeese MC: Hazards of battery ingestion. Pediatrics 71:100-103, 1983 9. Jaffe RB, Cornelli HM: Fluoroscopic removal of ingested alkaline batteries. Radiology 150:585,1984
Following
Button Battery Ingestion
By D.H. Bass and A.J.W. Millar Rondebosch, South Africa 0 A case of button battery ingestion with resulting disintegration of the battery, mercury spillage, and absorption of elemental mercury from the colon is reported. In the light of this case and other recorded complications following button battery ingestion, a plan of management is suggested. Copyright 8 1992 by W.B. Saunders Company INDEX WORDS:
Mercury ingestion; battery ingestion.
T
HE INCREASING frequency of button battery ingestion has been well documented.‘-3 It is universally accepted that any button battery lodged in the esophagus should be removed urgently in order to prevent erosion and perforation, which may be caused by a combination of pressure, electrical current, and leakage of the highly alkaline electrolyte.4 However, the vast majority of button batteries which reach the stomach will be passed in the stools without complication, but removal is occasionally indicated if symptoms or signs of complications develop or when the onward progress of the battery appears to have ceased. Disintegration of ingestion button batteries has previously been reported in only six casesi,s.6 with little morbidity and with evidence of mercury poisoning in only one instance .h We wish to report our experience of a case where disintegration of a button battery occurred in the large bowel and resulted in systemic absorption of mercury.
CASE REPORT A ?-year-old boy was brought to the trauma unit at the Red Cross War Memorial Children’s Hospital 6 hours after swallowing a button battery that he had removed from a pocket calculator. The child was clinically well and an abdominal x-ray showed the battery lying in the stomach. A single dose each of magnesium sulphate and metaclopromide were given orally in an attempt to encourage onward progression of the battery and the parents were asked to observe the child at home and to return the following day or earlier if symptoms developed. On his return to the trauma unit the next morning (20 hours after ingestion) the child was clinically well but a repeat abdominal x-ray showed the battery situated in the left upper quadrant surrounded by droplets of mercury. A pediatric bisacodyl suppository was given and blood and urine samples were obtained. A second x-ray was taken after the suppository had resulted in a bowel action without passage of the battery. The battery was passed in the stool 26 hours after ingestion showing evidence of both corrosion of the metal casing and mercury leakage through the plastic grommet seal. The urinary mercury concentration was 74 ug/mL (normal, 0 to 20 kg/L) but both renal and liver function tests were normal. The child was seen again 1 week later, at which stage the urinary mercury level had fallen to 6 kg/L and there was still no evidence of renal dysfunction, or neural toxicity. JournalofPed/atricSurgery,
Vol27, No
12
(December),
1992: pp
1541.1542
DISCUSSION
Button batteries possess unique structural properties which demand that they be treated more seriously than other foreign bodies ingested. Both in vitro and animal studies’s5 have shown that these charged batteries are electrically active in any moist environment and that the low-voltage current produced may cause damage to adjacent tissue. Also, corrosion of the plastic seal resulting in discharge of the battery contents is facilitated by an acid environment.’ Caustic erosions associated with button battery ingestions have been documented in the esophagus, stomach, and small bowel’,’ but leakage of mercury or other metals has only once been reported first-hand.” In our experience, the majority of button batteries ingested have been of the mercuric oxide type measuring 11 to 15.6 mm in diameter.3 It is thought that the more toxic mercuric oxide is mostly converted to nontoxic, and less easily absorbed elemental mercury on discharge of the battery so that mercury poisoning after button battery ingestion is unlikely.’ However, it should be remembered that some of these batteries contain up to 5 g of mercuric oxide, which is more than the estimated lethal dose.” Signs of acute poisoning by elemental mercury include those referable to the central nervous system, namely lethargy, excitement, hyperreflexia and tremor. Historically, the usual cause of death was renal failure. In this cast mercury discharged from a button battery was absorbed from the colon in sufficient quantities to reach potentially toxic systemic levels. Thus, disintegration of the battery may commence in the upper gastrointestinal tract, but mercury leakage may only occur as far distal as the colon. Although neither the present patient nor that described by Kulig et alh suffered observed ill-effects from the mercury absorption, the possibility of more severe complications due to liberation of both mercury and potassium hydroxide cannot be discounted, particularly when passage of the battery is delayed. These considerations support the need for both From the Trauma Unit and Department of Paediattic Sutgety Universiryof Cape Town, Institute of Child Health and Red Cross War Memorial Children S Hospital. Rondebosch, South Africa. Address reprint requests to Dr D.H. Bass, Trauma Unit, Red Cross War Memorial Children’s Hospital, Klipfontein Rd, 7700 Rondebosch. South Africa. Copyright c:~1992 by W.B. Saunders Company 0022.34819212712-0022$03.0010 1541
BASS AND MILLAR
1542
careful clinical and radiological monitoring of ingested button batteries. It seems advisable to neutralize stomach pH with antacids and/or H2 receptor blockers as the grommet seal does not perish as rapidly in a neutral pH environment.7 At the same time the administration of a prokinetic agent and an aperient appears logical. Should the battery remain in the stomach over a 12- to 24-hour period, removal is indicated. This can be satisfactorily carried out under light sedation using a magnet with fluoroscopic control.9 Fiberoptic endoscopic removal is an alternative but usually requires a general anesthetic in a small child. Operative removal is rarely necessary and would only be indicated by evidence of intestinal perforation. Arrest of onward progress of the battery distal to the duodenum would require close clinical and radiological monitoring. Using these manage-
ment guidelines in most cases, this was our first complication in a total experience of 44 battery ingestions. Unnecessary operative removal was performed once and failed attempts at endoscopic removal twice some years ago.3 Three batteries remaining in the stomach for more than 12 hours have been removed using a magnet. Finally, as with all noxious ingestions, the public should be made aware of the potential dangers of button batteries and their careful disposal. The manufacturers’ responsibility is to provide safe childproof packaging, clear labeling of battery contents, and a written warning of possible toddler ingestion. ACKNOWLEDGMENT The authors would like to thank P. Ball for having typed the manuscript.
REFERENCES 1. Litovitz TL: Button battery ingestions: A review of 56 cases. JAMA 249:2495-2500,1983 2. Votteler TP, Nash JC, Rutledge JC: The hazard of ingested alkaline disk batteries in children. JAMA 249:2504-2506, 1983 3. Millar AJW, Rode H, Cywes S, et al: Button-battery ingestions-A hazard of modern living. S Afr Med J 68:868-871,1985 4. Blatnik DS, Toohil RJ, Lehman RH: Fatal complication from an alkaline battery foreign body in the oesophagus. Ann Otol Rhino1 Laryngol86:611-615, 1977 5. Reilly DI: Mercury battery ingestion. Br Med J 1:859, 1977
6. Kulig K, Rumeck CM, Dulfy JP: Disk battery ingestion, elevated urine mercury levels and enema removal of battery fragments. JAMA 249:2502-2504,1983 7. Erpicum PJA, Davies MRQ: Button-battery ingestion. S Afr Med J 69:346-347, 1986 (letter) 8. Temple DM, McNeese MC: Hazards of battery ingestion. Pediatrics 71:100-103, 1983 9. Jaffe RB, Cornelli HM: Fluoroscopic removal of ingested alkaline batteries. Radiology 150:585,1984