Immediate Endoscopic Removal of Button Battery is Essential for a 20-Month-Old with Esophageal Foreign Body
Emergent endoscopic removal of the button battery is the most appropriate immediate intervention for this 20-month-old girl with a button battery lodged in the middle of her esophagus, regardless of her current asymptomatic status. 1
Rationale for Emergent Endoscopic Removal
Button batteries lodged in the esophagus represent a true medical emergency due to their potential to cause:
- Rapid development of pressure necrosis
- Electrical burns
- Chemical injury from leaking battery contents
- Esophageal perforation
- Tracheoesophageal fistula
- Aortoesophageal fistula (potentially fatal)
The American Academy of Pediatrics recommends endoscopic removal within 2 hours (maximum 6 hours) of ingestion 1. In this case, with a 3-hour history of suspected ingestion and radiographic confirmation of the battery in the esophagus, immediate endoscopic removal is mandatory.
Procedural Approach
- First-line approach: Flexible endoscopy for removal of the button battery 2, 1
- Alternative if needed: Rigid endoscopy may be considered as a second-line option if standard retrieval methods fail due to tight impaction 1
- Combined techniques: In cases of difficult extraction, a combination of endoscopic balloon extraction with forceps retrieval (push-and-pull effect) may be necessary 1, 3
Post-Removal Management
After successful removal, the following steps are critical:
- Careful assessment and documentation of mucosal damage and extent of esophageal burns
- Consideration of nasogastric tube placement if significant erosion is found
- Scheduled endoscopic evaluation within 2-4 weeks to assess for stricture formation, even if the patient remains asymptomatic 1, 4
- Plain radiographs to confirm complete passage of the battery and check for any retained fragments 1
- Monitoring for late complications for at least 2-4 weeks after ingestion 1
Why Other Options Are Inappropriate
- Discharge with monitoring instructions: Completely inappropriate given the high risk of rapid tissue damage. Studies show severe injuries can develop within hours of button battery impaction in the esophagus 5, 6
- Oral administration of activated charcoal: Not effective for foreign body ingestion and may complicate subsequent endoscopy
- Oral administration of fluids: Contraindicated as it may increase risk of aspiration during endoscopy and won't facilitate passage of the battery
- Foley catheter balloon technique: Not recommended for button battery removal due to the risk of causing or worsening esophageal injury
Important Considerations
- Do not delay endoscopic removal for additional imaging studies or contrast studies, as these waste critical time and may impair endoscopic visualization 1
- Even asymptomatic patients can develop severe complications, including strictures, as demonstrated in case reports 4, 7
- The European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) also recommends immediate removal of esophageal button batteries, preferably within 2 hours of ingestion 7
Button battery ingestion with esophageal impaction is a true emergency requiring prompt intervention to prevent potentially life-threatening complications, regardless of the patient's current clinical status.