What is the most appropriate next step for a toddler who ingested a button battery and presents with blood-streaked emesis (vomiting with blood) three days after removal, CT (computed tomography) scan or repeat endoscopy?

Repeat Endoscopy is the Most Appropriate Next Step

For a toddler with blood-streaked emesis three days after button battery removal, repeat endoscopy should be performed immediately to assess for evolving esophageal injury, stricture formation, or impending perforation. CT imaging, while valuable in certain contexts, does not provide the direct visualization and therapeutic capability needed in this clinical scenario.

Rationale for Repeat Endoscopy

Direct Visualization of Evolving Injury

• Button battery injuries evolve dynamically over days to weeks after removal, with initial endoscopic findings often underestimating the severity of tissue damage 1
• Blood-streaked emesis three days post-removal is a red flag indicating ongoing mucosal injury, potential ulceration, or early stricture formation that requires direct visualization 2
• The "close second-look esophagoscopy" (CSLE) performed 2-4 days after battery removal provides critical prognostic information and can reveal progression or improvement of injury that was not apparent at initial endoscopy 1

Endoscopy Provides Superior Assessment in This Context

• Endoscopy remains the gold standard for evaluating esophageal mucosal integrity, stricture formation, and healing progress after caustic-type injuries from button batteries 2, 3
• Even in asymptomatic patients, endoscopy has demonstrated stricture formation that was missed on barium swallow studies, highlighting its superior diagnostic accuracy for mucosal complications 2
• Initial grade III circumferential necrotic injuries can be downgraded to grade IIa after CSLE, fundamentally changing management decisions 1

Therapeutic Capability

• If stricture formation is identified during repeat endoscopy, immediate therapeutic intervention (such as dilation) can be performed 4
• Endoscopy allows for tissue biopsy if there are concerns about depth of injury or infection 5

When CT Would Be Indicated Instead

CT is Reserved for Specific High-Risk Scenarios

• CT should be performed before battery removal in cases of delayed diagnosis (>12 hours after ingestion with esophageal impaction) to evaluate for vascular injury, particularly aortoesophageal fistula 3
• CT is indicated when there is clinical suspicion of transmural necrosis or perforation (fever, sepsis, subcutaneous emphysema, severe chest pain, respiratory distress) 5
• The absence of post-contrast wall enhancement on CT indicates transmural digestive necrosis and is an indication for emergency surgery 5

Why CT is Not First-Line in This Case

• Your patient's symptom (blood-streaked emesis) suggests mucosal injury rather than transmural perforation or vascular injury
• CT cannot assess mucosal healing, stricture formation, or the degree of superficial esophageal injury as accurately as direct endoscopic visualization 2
• If the battery was removed within 12 hours and the child is otherwise stable (no fever, respiratory distress, or signs of mediastinitis), the concern is evolving mucosal injury rather than vascular complications 3

Clinical Algorithm for This Scenario

Immediate assessment:

• Evaluate for signs of perforation or mediastinitis (fever, tachycardia, respiratory distress, subcutaneous emphysema, severe chest pain) 5
• If present → obtain CT with contrast to assess for transmural necrosis and vascular injury 5, 3
• If absent but blood-streaked emesis present → proceed directly to repeat endoscopy 2, 1

During repeat endoscopy:

• Grade the esophageal injury using established classification systems 5
• Assess for stricture formation, ongoing ulceration, or healing 2, 1
• Consider therapeutic intervention if stricture is present 4
• Obtain biopsies if depth of injury or infection is uncertain 5

Post-endoscopy management:

• Downgrade or upgrade injury classification based on findings, which will guide feeding decisions and follow-up intervals 1
• Plan for serial endoscopic evaluations every 1-2 weeks until complete healing is documented, as injuries can evolve over weeks 2, 3

Critical Pitfalls to Avoid

• Do not rely on imaging alone (barium swallow or CT) to exclude stricture formation or assess mucosal healing in symptomatic patients—endoscopy is required 2
• Do not assume initial endoscopy findings are definitive—button battery injuries evolve over days, and repeat endoscopy 2-4 days later often reveals different injury grades 1
• Do not delay endoscopy in favor of CT unless there are specific signs of perforation or vascular injury—blood-streaked emesis indicates mucosal pathology best assessed endoscopically 2, 1
• Do not discharge without establishing a clear follow-up endoscopy plan—even asymptomatic children can develop delayed strictures after button battery ingestion 2, 3