Button Battery Ingestion

We've had some bad experiences with this, with uh with patients through our esophageal center of patients who have had really, really significant injuries from button battery ingestion, so we just wanted to briefly talk about that. Again, I'll go through this quickly. But button battery ingestions are, ah, more becoming more and more frequent. The national data suggests that there's increasing numbers of, of, ah, emergency department visits for this. Ah, part of the problem is that button batteries are absolutely ubiquitous. They are all over the place now. They're in greeting cards, they're in, ah, you know, remotes and that sort of thing. So case, and this is an actual case, a 9 month old who was brought to the emergency department at 10 o'clock at night with a 3 day history of wretching and respiratory symptoms, and they got this chest X-ray which demonstrates the finding on the film there. And the question is, what would people do then for management? What the key finding is when you see something that looks like a quarter, but it has that line around it, it is not a quarter. It is most likely a button battery. So we don't have the ability to show you with a pointer, but, um, but if you look around the edge of the circle there, you'll see a ring. And that is how you can tell that it's a button battery. So I just wanted to make that point again. And I think what the poll is suggesting is that people would take it out emergently, which is the right answer, and it's 50/50 right now as to whether people would do that with a rigid scope or a flexible scope, and I think that probably relates to who takes it out, whether it's GI or whether it's surgery and whether and how you were trained. So I agree with those results. However, Uh, I've had a couple of occasions over the years that we couldn't get to the operating room very quickly, uh, and there was a short duration of, uh, symptoms. So as, as many of you know, we like to use the Foley catheter technique, and so we did it in those two patients and it worked fine. The key points are it wasn't 3 days of history when you're likely to have a perforation. Uh, uh, and there was a reason we couldn't get to the operating room because the operating room was, uh, was tied up and it was early in the morning. So anyway, just a little caveat that the Foley catheter technique may work in, um, in just a limited, uh, limited reasons or for reasons that you can't get to the operating room very quickly. Did you look electively when you had more time since it was a button battery, or they didn't have any? Yeah, we did, we did look. I'm not sure, we didn't look like. 4 hours later, but we kept them in and watched them and then we did a little uh esophagoscopy on them before they, uh, before they left. So I'm gonna skip a little bit of this because it's a complicated case, but um, this case in particular demonstrates some of the complications, and this child, when the button battery was removed, there was a large tracheoesophageal fistula noted, and on follow-up endoscopy, the child ended up with a severe esophageal stricture, which started them down a path of multiple operations and complications. So just the point that uh these things can be quite difficult and create lots of problems. One of the things that I actually have learned and I'll be very interested on, on the other comments from the folks in the room as well as uh online is what, so you can take this even if you just, you see the button battery endoscopically, you have a history of a day or whatever and you take it out, um, what is the follow-up management for that? How do people, what other tests should be obtained? What would folks do, Mark? So as many of you know, NASPA and the GI. A group put together some criteria and some, some guidelines around management of button batteries with zero input from surgeons, which I find very fascinating, and I'm in two hospitals, one of which GI mostly takes them out, the other one of which pediatric surgery mostly takes them out, and there's a lot of discrepancies in how we manage them. But as we've gone through this, one of the mandates of these multiple MRI's and watching these kids because everybody's afraid of a vascular injury. So I'm really curious to hear what you found. There are a few papers and case studies out there, but uh we find ourselves sort of with these kids handcuffed to the bed with these serial MRI's which if they truly got. An esophagoaortic fistula. I'm not quite sure how we manage that on the floor of our hospital. So the point you raise is exactly the issue that I think is pertinent for this discussion, and as with many of the things we've discussed, there probably isn't a correct answer. But, ah, this is, uh, data that came from a study from Colorado. Ah, the first of all, the number, as I alluded to, the number of ED visits has doubled. Ah, the rate of significant complications has increased almost sevenfold. 90% of the serious outcomes in these are in these 20 millimeter to 25 millimeter batteries. Those are the ones that cause the problems. Part of the issue with them is that they are lithium batteries and they tend to be 3 volt batteries as opposed to 1.5 volt batteries, and the pathophysiology is, is not erosion of the mechanical of the battery itself or even the electricity, it's that it's a caustic injury from the Uh, hydroxide ions that are created that rapidly raise the pH in the tissue and it causes a caustic injury. The complications are oesophageal perforation, stricture, a tracheoesophageal fistula, as this child had. Interestingly, there are a number of cases of vocal cord paralysis not associated with perforation or anything else. It's presumably local effect of the of the um. Uh, caustic injury, and then what you alluded to, which is aortoenteric fistula. It's the most common cause of mortality in the big, uh, national data bank that follows this. It accounted for 46% of the mortalities, uh, and there were another 29% where some sort of vascular compromise was identified as the, uh, as the etiology. So when it's bad, it's really bad, and the problem that I was not personally aware of and it's the issue that you alluded to is that this can happen up to 2 weeks post removal of the battery. And so, um, the, ah, the authors of that paper, uh, who presented, I think 16 different cases, and there were several who died from aortoenteric fistulas, was to get an MRI study after removal of the battery, get an MRI to look at the, uh, potential impact on the surrounding vasculature. Again, what are you going to do about it? I think that's an issue. When it happens, and I've seen one. It is very hard, even if you're standing there waiting for it. It's hard to do anything about it, and you're not going to do anything preemptively, presumably, except be ready. What does that mean? It's so it's a difficult challenge as to what do you do, and if you see irregularity in that area, then what is the follow up for that. So the NASA guidelines have these serial MRIs, but without real clear criteria on what to do. Uh, based on the findings, so we're actually piloting a study to look at, you know, if you have a clean MRI on the, uh, initially post-op, you know, will that lead to an injury? Do they all seem to get better? So I think that this is something, another opportunity for a multi-center trial, and I know that some of our guys are trying to put some things together for this. So hopefully we can get some participants in it so we can answer this question. Yeah, it's one of the challenges is it's not rare, but it's rare enough that it's hard for a single institution to get significant data. So I just wanted to make one comment, and we had a kid a few years ago that had an unrecognized ingestion and probably 10 days of symptoms, went to an outside hospital, had a hematemesis with the battery coming out, and then got him into our GI service. I was asked to see the kid the next morning for access when he was exsanguinating, and clearly it was too late to do anything then, but that prompted us then to look at a mechanism to get these kids to the OR faster. So we currently use our trauma one system. So if we have awareness of a button battery call or person arriving, that goes out as a trauma one page. That means that the OR doesn't start a case if they have a room available. It means the X-ray comes immediately to the emergency room to take a film and the entire trauma mechanism is activated, and it reduced our time from hitting the door to hitting the OR from 1.5 to less than 30 minutes. That's great. That's a great idea. That's a great idea. I like that. So if you have a trauma one mechanism available to you, it's really a good way to um reduce your time to OR. And then just finally, the question of what happens if you, you get one of these kids and the battery is actually in the stomach, where presumably there's much less risk that it's going to do anything bad. And again, just for the sake of time. The authors of the paper advocate that you should scope the patient anyway because they had patients who had significant esophageal injuries, but the battery continued to pass on, so that you can't rule out an esophageal injury just because the battery is in the stomach. So just to be clear, that completely flies in the face of The actual recommendations from poison.gov, which say you do not need to do that. That's correct. So, and that's exactly, and they make that point, that's correct, that it is controversial, which is why I put that on the slide. It is controversial as whether you need to actually do anything about that or not, but some people would advocate that. Even if the battery makes it to the stomach, you still need to scope them to make sure that they have not had an esophageal injury. Let's say you, OK, I wanna make sure I can put this all together now. If you do your esophagoscopy, so the coin's not a problem, I mean, the, the battery is not an issue anymore. Now you're going to look to see if there was injury. And you see that there's injury. What are you gonna do? What do you do for that patient? Do you put an NG tube down, like to to to give you, what do you do when you see that there is a burn to the esophagus? Yeah, I think it's a great question. I think it depends on the extent of the injury. If the injury is relatively minor mucosal injury, I probably wouldn't do anything and follow them symptomatically. If they have uh circumferential erosions and it looks bad, then I would probably re-scope them to look for a stricture formation. OK, so there's some that might say that patient needs an MRI. OK, so, so when I said bring it all together, that's what I was actually, because, because I wouldn't do that, and this is where finally we have a debate, uh, so I wouldn't do that because I don't think that changed your management at all. So what I would do is if they got symptomatic, I would do an esophagram and see if they had a narrowing or a stricture, but the esophagostomy didn't help me. It didn't help me. Unless you're going to either put something across it or get an MRI or do something, the MRI is independent from my, that's looking for a different problem. So I would suggest if you believe this paper, you should get an MRI. So wait, but that's different than evaluating the ongoing injury to the esophagus where you might find a stricture, and the difference between a swallow and a scope. And I agree you can just send them to radiology and get a swallow, that's fine. But the advantage of doing a scope if it's bad is you can reassess what it looks like. You can also dilate them if they are, but you were not, so, but you're not going to do that unless there's, in other words, if you get the esophagram, the esophagram you don't even need right now anyways, because I would wait a couple of weeks, and if they're symptomatic, maybe get an esophagram at that time. And if they are, then you can figure out if you go dilate them. But if there is an injury, then maybe you would get. An MRI. So that might be the only reason if you're gonna do it routinely is get it into whatever, uh, so Dan, you, you mentioned the, uh, recommendation of doing the endoscopy, uh, to evaluate for esophageal injury in a button that is in the stomach. The question is, do you need to remove the button in the stomach at the time of the endoscopy? It's also, uh, you will find papers on either side of that. I think that if, um, typically if people look down there and they are capable of removing the battery endoscopically, they would, people would advocate removing the battery because you're already there. Yeah, I think if you're already there, you might as well remove it. But some of us might be doing that esophagoscopy using a rigid esophaguscope, in which case you may not. Yeah, I think there is some stuff out there in the GI literature about you should remove it from the stomach if it's one of these 20 millimeter batteries or not, but I, because it may or may not pass the ileocecal lab. I don't know. 25, it's 2020 to 25 is the millimeters or the batteries that are the ones we worry about the most, yeah, um. The, uh, my concern about doing the scope is that I think you're gonna, I'm worried you're gonna take something and make it worse if you don't have to do anything. If there's no reason to scope the kid, I would avoid it because I don't think there's only a chance of causing harm. I don't think there's so agreed, there's risk to every procedure, um, but again, it depends on how severe the, it's like any other cause of congestion basically. So, uh, I just want to make one final point about trying to mitigate the degree of injury that you have, because you look at these things and they're terrible and you just wish there was something you could do, and there's some evolving work in animal models using agents that you put on the area of injury, and I think it's 0.25% acetic acid, and so that's what we're gonna plan on doing in our OR when we. Take them out and see any evidence of injury to neutralize it. Amazing. I had no idea. That's you, you, you have to get, we're working on that as well, and we're talking to the pharmacy and it's, it's not just like you can order it. It's not something off the shelf. So I see. But that, that will change things a lot. That's great to know. So bottom line is it's emergent. Get them out as soon as you can. They're bad. Awesome. Thank you. Uh, but, sorry, one question, Dan, for lie injury or any esophageal, uh, injury that's circumferential, do you ever put something across it so that if it closes, you can, uh, get a G tube in? OK, um.