FOREIGN BODY ESOPHAGUS PART 2 (BUTTON BATTERY)
1.
Why button battery ingestion is common these days?
Because
of increase use of various new electronic devices use of batteries have risen
which has increased the incidence of ingestion.
·
Toys & Electronic Games
·
TV Remote Controls
·
Flashlights & Calculators
·
Watches & Hearing Aids
2.
Although the incidence
of ingestion of button battery remains same why is there significant increase
in adverse effects by almost 7 folds?
The
cause behind this dramatic increase in morbidity and mortality seems to be
linked to 2 specific changes in the BB market through that time period:
increased diameter and a change to lithium cells.
3.
Why is lithium cell
dangerous?
Lithium cells though have a higher potential of 3
V as compared to 1.5 V seen in other cell types. It has a longer shelf
life, better stability in cooler temperature and lighter in weight.
4 Battery structure
·
The active portion of the battery consists of a
negative terminal and a positive terminal.
·
The
negative terminal of the battery is typically made of zinc or lithium, and the
positive terminal of one of the following substances.
o
Lithium manganese
(3 volts, most common)
o
Manganese
dioxide (1.5 volts)
o
Oxygen
(zinc-air cells, 1.5 volts)
o
Silver
oxide (1.5 volts)
o
Mercuric
oxide (1.5 volts)
·
The
negative terminal is the narrow portion of the battery where the electric
current flows into the tissue and usually creates the most damage.
·
The
negative and positive terminals are typically separated by a disc that is
embedded with potassium hydroxide, sodium hydroxide, or an organic solution
with varying concentrations.
·
The
terminals and salt solution are encased in steel and/or nickel.
5. How to identify Button Batteries?
·
Button batteries range in diameter from 6 to 25 mm, batteries
that are larger than 12 mm in diameter are most likely to become lodged in the
esophagus, especially in young children.
·
The
chemical content, diameter, and height of the battery can be determined from
the imprinted code found on the battery case as determined by the International
Electrotechnical Commission.
·
The
first letter gives the chemical identification of the positive terminal as
follows:
o
L:
Manganese dioxide
o
S:
Silver oxide
o
P:
Oxygen
·
A
battery with a three number code has the diameter given by the first number
(eg, SR516 is 5 mm in diameter).
·
A
battery with a four number code has the diameter given by the first two numbers
(eg, CR2032 is 20 mm in diameter).
·
The
last two numbers give the battery height in tenths of millimeters (eg, CR2032
is 3.2 mm in height).
·
The
package code also corresponds to the battery diameter in millimeters. For
example, a battery with a package code of 23 has a diameter of 23 mm.
6.
How do button batteries damage esophagus?
3
basic mechanisms
I.
Electrical
injury—on contact with the esophagus as the circuit gets completed there is
flow of current from negative terminal of battery to esophageal/intestinal
structures causing hydrolysis, corrosive
injury
II.
Pressure
necrosis
III.
Leakage
of contents—KOH, NaOH can leak and cause liquefactive necrosis when the outer
seal gets eroded by gastric acid.
THE INJURY DUE TO BUTTON BATTERY IS CAUSTIC RATHER THAN THERMAL
7.
Can used batteries cause injury?
·
Older
used batteries have some residual charge and can lead to injury
·
Newer
batteries have 3 fold greater risk of injury.
8.
The injury by button battery is due to alkaline pH causing
liquefactive necrosis.
9.
How to approach a case of button battery ingestion ?
·
History
·
Physical
examination
·
Investigation
·
Treatment.
10.
What history are important ?
·
What
was the size of battery?
·
Whether
a new or old used battery?
·
Duration
of ingestion
·
Number
of button batteries ingested
·
Co-ingestion
with magnets
·
Any
esophageal or intestinal conditions like stricture
11.
Why is the duration of ingestion important?
Animal models document that
necrosis within the esophageal lamina propria may begin as soon as 15 minutes
from the time of ingestion, with extension to the outer muscular layer within
30 minutes.
This corresponds with anecdotal reports of significant esophageal stricture within 2 hours of ingestion.
DAMAGE
CAN OCCUR WITHIN 2 HOURS
12.
Intestine can get trapped between the magnet and button battery.
13.
What are the signs and symptoms are that can be present ?
Most patients are asymptomatic although one or more of the
following symptoms may be present
·
Chest
pain
·
Cough
·
Anorexia
·
Nausea/vomiting
·
Hematemesis
·
Diarrhea
·
Epigastric
pain
·
Abdominal
pain
·
Fever
In cases of perforation and
tracheoesopgaheal fistula they can present with
·
Fever
·
Features
of shock
·
Respiratory
distress and failure
·
Subcutaneous
Crepitus
14.
What is the role of X ray?
·
X
ray of chest with abdomen is done
·
X
rays are useful for identification of
o
Site
of impaction
o
Difference
between button battery and coin
o
Signs
of esophageal perforation
o
Size
of button battery
o
Number
of battery ingested
15.
How do we differentiate between a button battery and coin?
The characteristic features of button batteries versus coins are
as follows:
§
Button batteries have a bilaminar structure, making them appear
as a double-ring or halo on plain radiographs. The double-ring shadow helps to
differentiate battery from coin ingestions.
§
On lateral view of the foreign body, the button battery has a
step-off at the separation between the anode and cathode. By contrast, the coin
has a sharp, crisp edge.
16.
Negative-Narrow-Necrotic” Mneumonic
·
The
current generates the hydroxide at the negative terminal of the battery.
·
The
negative terminal is the more narrow side of the button battery when
viewed laterally.
·
The
anatomic orientation of the battery can predict where the necrosis will
be and the subsequent injury.
17.
How do we approach a patient a case of button battery ingestion
?
·
Stabilisation
·
Endoscopic
removal as needed.
18.
What is the role of honey or sucralfate?
·
For asymptomatic children with acute button
battery ingestions (eg, witnessed or
likely to have occurred within 12 hours) who are older than one year of
age and without allergies to honey or its components, one
oral dose of pure honey (eg, 5 to 10 mL) as soon as possible after ingestion.
·
Once in the emergency department, the child may
receive another dose of honey or, if no history of allergy, a single dose of sucralfate 500 mg prior to confirmation of esophageal impaction by
radiography and emergency battery removal.
19.
Sucralfate or honey is contraindicated if timing of ingestion is
unknown or in cases of delayed
presentation or in cases of esophageal perforation.
20. For endoscopic removal
of button battery 2 protocols can be followed.
·
One
given by ESPGHAN and NASPGHAN
·
One
given by NBIH(National Battery Ingestion Hotline) of USA.
21. One recommended by
NASPGHAN AND ESPGHAN (NELSON 21e has this)
22.
The protocol by NBIH
23.
What are the complications of Button battery ingestion?
Complications from button battery ingestion are rare, but
potentially devastating. They include,
·
tracheoesophageal fistula,
·
vocal cord paralysis,
·
esophageal perforation,
·
esophageal stenosis,
·
mediastinitis,
·
spondylodiscitis,
·
aspiration pneumonia,
·
perforation of the aortic arch,
·
gastric hemorrhage,
·
gastric perforation, and
·
intestinal perforation
24.
How to manage a case of long battery ingestion?
·
Less
chances of corrosive injury and less risk of leakage
·
The
concern is of length
·
If
in esophagus should be removed but beyond stomach expectant management in
asymptomatic cases.
25.
What is the most common cause of death in BBI?
Aortoesophageal fistula
KEY
POINTS FROM A CASE SERIES PUBLISHED BY CHILDRENS HOSPITAL COLORADO
·
A
BB can fuse to the mucosa rapidly, leading to difficult removal that may
require rigid esophagoscopy.
·
Identification
of a gastric foreign body does not preclude esophageal injury, especially in
unwitnessed ingestions when the total time of BB exposure is unknown. BBs can
transiently lodge in the esophagus and cause severe erosion and ongoing injury.
Even after passage of the battery to the stomach, necrosis of the esophagus and
surrounding tissues is an ongoing process that can lead to fistulization and
associated severe outcomes.
·
Despite
a reassuring esophagram and clinical stability 5 days after ingestion,
devastating hemorrhage from esophageal erosion secondary to BBI can
unexpectedly occur weeks out from the initial ingestion. Because of the high
arterial pressure from AEF, Blakemore tubes may not be able to control or
stabilize bleeding.
·
As
mucosal injury occurs with even short exposure to BBs, every effort should be
made to expedite removal when possible. MRI is a useful tool for
post–battery-ingestion evaluation of the extension of injury beyond the
esophagus and may help guide treatment decisions.
·
Despite
minimal findings of edema and ulceration on initial esophagoscopy at removal of
the BB, esophageal necrosis and surrounding inflammation progresses despite no
further exposure, making timing of associated morbidity from BB exposure
somewhat unpredictable.
Comments
Post a Comment