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SAEM Clinical Image Series: Foreign Body Ingestion

Posted by Brett Berliner, MD on

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Chief complaint: Foreign Body Ingestion

History of Present Illness:

A 4-year-old male presents to the Pediatric ED for evaluation of swallowed foreign body.

The mother reports the patient was at his grandmother’s house playing near a cabinet when they witnessed him put a small unknown object in his mouth and swallow. Family denies vomiting, difficulty breathing, change in behavior, abdominal pain, or any additional symptoms at this time.

Physical Exam

Vitals: BP 102/65; Pulse 95; Temp 98.2 °F (36.8 °C); Resp 22; SpO2 100%

Constitutional: No distress

HENT:

  • Right Ear: Tympanic membrane normal, no foreign bodies
  • Left Ear: Tympanic membrane normal, no foreign bodies
  • Nose: No foreign bodies
  • Mouth/Throat: Oropharynx is clear and moist and mucous membranes are normal
  • Neck: Normal range of motion

Cardiovascular: Normal rate, regular rhythm and normal heart sounds.

Pulmonary: Breath sounds normal, no stridor, no respiratory distress, no decreased breath sounds, and no wheezes.

Abdominal: Soft. He exhibits no distension. There is no tenderness. There is no guarding.

Neurological: He is alert. He exhibits normal muscle tone.

Laboratory Data

No labs drawn

Case Question: Can you identify the foreign body?

Button battery

When foreign body ingestion is suspected, a radiograph is often the first diagnostic modality following physical exam [1]. On radiograph, the classic “double ring” sign on PA films and “step off” sign on lateral films can be used to identify a button battery.

Ingestion is a true emergency given the risk of esophageal injury and perforation into mediastinal structures including the airway and aorta.

Case Question: Based on location, what is the recommended management?

If the battery is in the esophagus, the close contact between the battery and the moist mucosal surfaces in the esophagus creates a complete circuit. This can cause the button battery to discharge an electric current, potentially causing esophageal necrosis [2]. This current continues until the battery is removed.

The subsequent clinical management of button battery ingestion varies depending on size of the battery, location, and the child’s age.

All button batteries in the esophagus must be removed endoscopically.

If the button battery is in the stomach, management is controversial:

  • Immediate removal should occur for symptomatic patients.
  • If the patient is asymptomatic, large batteries (> 20 mm) can be given up to 48 hours to pass the pylorus before removal is indicated.
  • Asymptomatic smaller batteries can be given 10-14 days to allow for passage with strict return precautions, stool inspection and radiographs at the end of this time period if the battery has not passed.

If the button battery is in the intestines:

  • Immediate removal should occur for symptomatic patients.
  • Asymptomatic batteries can be given 10-14 days to allow for passage with strict return precautions, stool inspection and radiographs at the end of this time period if the battery has not passed.

Magnet co-ingestion is an indication for button battery removal regardless of location.

In this case, immediate removal was not indicated given the patient was asymptomatic, the button battery was located in the stomach and was under 20 mm.

For 24/7 guidance with button battery management, the National Capital Poison Center has a 24 hour hotline and an algorithm posted on their website [3].

Case Discussion

Button battery ingestion is a true emergency. Esophageal button batteries must be immediately removed. Button batteries in the stomach and intestine warrant GI consult and close follow-up if immediate removal is not indicated.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2019 SAEM Annual Meeting | Copyrighted by SAEM 2019 – all rights reserved. View other other cases from this series on ALiEM.

References:

  1. Claudius, I. November 2017 – Pediatric Pearls – Button Battery Ingestion. [online] EM:RAP. Available at: https://www.emrap.org/episode/supersickdka/pediatricpearls [Accessed 9 Jan. 2019]
  2. Krom H, Visser M, Hulst JM, et al. Serious complications after button battery ingestion in children. Eur J Pediatr. 2018;177(7):1063-1070.
  3. Poison Control, National Capital Poison Center. (2019). National Capital Poison Center Button Battery Ingestion Triage and Treatment Guideline. [online] Available at: https://www.poison.org/battery/guideline [Accessed 9 Jan. 2019].

Author information

Brett Berliner, MD

Emergency Medicine Resident
Hackensack University Medical Center

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