BUTTON BATTERY INGESTION AND INGESTIONS

Children at greatest risk are those younger than 5 years of age and those with battery ingestions 20 mm and multiple battery ingestions (5).

Cases of BB ingestion may be difficult to distinguish from the more common coin ingestions, discussed in a later section. Plain radiographs of the chest and abdomen should be examined carefully for the double halo sign on anteroposterior views and the ‘‘stepoff’’ sign on lateral views, which help distinguish the offset poles of a BB from regular coins. Endoscopic removal may be difficult if there is adhesion of the battery to the mucosa because of the caustic injury. Removal forceps with a ‘‘rat tooth’’ design (Raptor forceps,

US Endoscopy, Mentor, OH) can often successfully grasp the stepoff between the 2 poles of the battery for removal. Alternatively, a retrieval net (Roth Net, US Endoscopy) may be effective also. In patients in whom the battery’s adherence to the mucosa prohibits removal by flexible endoscopy, use of a rigid endoscope by surgery or otolaryngology may be necessary, although this may increase the risk of perforation substantially.

Controversial Aspects

Endoscopic intervention (Fig. 1) for gastric BB remains controversial. Data from a large cohort in the national registry

are reassuring, with no reported significant gastric injuries from BB ingestions (5). The potential danger, however, is evident through a report of an infant with gastric injury (11). In addition, one of the fatalities reported from aortoesophageal fistula presented with a gastric BB that had apparently caused esophageal injury before reaching the stomach (6). This suggests that passage of a BB to the stomach alone cannot be used as a criterion that the child is free from potentially catastrophic underlying injury. This leaves some discretion to the clinician regarding the appropriate management of gastric batteries. The newly proposed clinical recommendationsin the present article represent a significant departure fromprevious care algorithms in considering endoscopic evaluation incases of gastric batteries. The intent of these recommendations,however, is to evaluate whether any demonstrable esophagealinjury is present instead of gastric injury. This recommendationis based on expert opinion originating from the growing experience

of catastrophic injury without a defined esophageal impaction,because no prospective, randomized studies have been performedon this subject. Factors supporting observation alone, withoutendoscopic removal of gastric batteries, are confirmed shortduration of ingestion (<2 hours), size of the battery <20 mm,absence of clinical symptoms, and a child 5 years of age or older.

Consistent with American Society for Gastrointestinal Endoscopyguidelines, larger batteries (20 mm) in the stomach should bechecked by radiograph and removed if in place after >48 hours