What is the next immediate intervention for a 20-month-old girl who swallowed a button battery 3 hours ago, is vital signs stable (VSS), has no acute distress (NAD), and has a chest X-ray (CXR) showing a button battery in the middle esophagus?

Immediate Endoscopic Removal of Button Battery in Esophagus

Emergent endoscopic removal (within 2 hours, maximum 6 hours) is the mandatory immediate intervention for this 20-month-old girl with a button battery lodged in the middle esophagus. 1, 2

Rationale for Emergent Intervention

Button batteries in the esophagus represent a true medical emergency due to:

• Rapid development of pressure necrosis
• Electrical burns to surrounding tissue
• Chemical injury from battery contents
• Risk of perforation, which can occur within hours of ingestion

The battery has already been in the esophagus for 3 hours, making immediate intervention critical to prevent severe complications. Despite the patient being currently stable with normal vital signs and no acute distress, tissue damage is likely already occurring. 1

Management Algorithm

1. Immediate action: Proceed directly to emergent endoscopic removal without delay

   • Do NOT delay for additional imaging studies
   • Do NOT perform contrast studies (barium/gastrografin), as these waste critical time and may impair endoscopic visualization 2

2. Endoscopic approach:

   • Flexible endoscopy is the first-line approach for removal 2, 1
   • If standard retrieval methods fail due to tight impaction, consider:
     • Combined techniques such as endoscopic balloon extraction with forceps retrieval (push-and-pull effect) 3
     • Rigid endoscopy as a second-line option, particularly useful for upper esophageal batteries 2

3. Post-removal evaluation:

   • Careful assessment of mucosal damage after battery removal
   • Document the degree and extent of esophageal burns
   • Consider nasogastric tube placement if significant erosion is found 4

Potential Complications to Monitor

Even after successful removal, close monitoring is essential as this patient is at risk for:

• Esophageal stricture formation (can develop even when initial symptoms resolve) 4
• Tracheoesophageal fistula 5
• Aortoesophageal fistula (potentially fatal)
• Retained metal fragments in the esophageal mucosa (which may cause thermal injury during follow-up MRI) 6

Follow-up Plan

• Scheduled endoscopic evaluation within 2-4 weeks to assess for stricture formation, even if the patient remains asymptomatic 1, 4
• Consider CT imaging to identify potential metallic debris that may remain in the esophageal tissue 6
• Monitor for delayed complications for at least 2-4 weeks after ingestion 1

Common Pitfalls to Avoid

• Delaying intervention for additional imaging or contrast studies
• Assuming that absence of symptoms indicates absence of injury
• Failing to arrange appropriate follow-up even when the patient appears to recover completely
• Underestimating the potential for severe delayed complications despite successful initial management

Remember that tissue damage from button batteries begins immediately upon contact with the esophageal mucosa, and the severity of injury correlates directly with the time to removal. The 3-hour duration of impaction in this case already places the patient at significant risk for complications.