Magnetic resonance imaging findings following button battery ingestion

Button Battery Ingestion in Children (PilBouTox®): A Prospective Study Describing the Clinical Course and Identifying Factors Related to Esophageal Impaction or Severe Cases

In this study, we aimed to identify the factors related to esophageal impaction following button battery (BB) ingestion in children. PilBouTox, a prospective multicentric observational cohort study, was conducted from French Poison Control Centers between June 1, 2016 and May 31, 2018. Children (0-12 years old) with BB ingestion were included. After ingestion, patients were monitored for 21 days or more if they remained symptomatic (maximum 1 year). Causes of ingestion, clinical manifestations, medical management, and the outcomes were recorded. In total, 415 patients were included; among them, 35 had esophageal impaction and 14 had severe complications or died. Seven symptoms were closely related (relative risk (RR) > 30) to esophageal impaction: anorexia, drooling, dyspnea, fever, hemodynamic instability, pallor, and pain. Furthermore, BBs > 15 mm were related to esophageal impaction (RR = 19, CI_95% [4.1; 88]). The absence of initial symptoms was a protective factor for esophageal impaction (RR = 0.013, CI_95% [0.002; 0.1]). Nine symptoms were closely related (RR > 30) to major effects and death: dyspnea, cough, dysphagia, drooling, fever, hemodynamic instability, pain, pallor, and vomiting. Seven symptoms were related to esophageal impaction and their rapid recognition could help to ensure that the patient is taken to a health care facility. Nine factors were related to the major effects of BB ingestion. We recommended an X-ray as soon as possible to determine the position of the BB.Trial Registry: Clinical Trial ID: NCT03708250, https://clinicaltrials.gov/ct2/show/NCT03708250.

Oral Versus Intravenous Antibiotics for Pediatric Osteoarticular Infection: When and to Whom?

BACKGROUND

Osteoarticular infections (OAIs) are typically treated initially with intravenous antibiotics. The objective of this study was to evaluate whether an exclusive oral treatment in selected children may be appropriate.

METHODS

The Spanish Network of Osteoarticular Infections is a nationwide multicenter registry comprising 37 hospitals in Spain. The registry prospectively includes clinical characteristics and outcome of children with OAI. One of the hospitals from RioPed offers oral treatment to children meeting certain criteria. Patients were classified into 2 groups. Group 1: management with initial intravenous antibiotic therapy. Group 2: patients exclusively treated with oral antibiotics. A comparison between the 2 groups was performed.

RESULTS

We compared 893 children who initially received intravenous antibiotics (group 1) with 64 children who received exclusively oral therapy (group 2). Patients from group 2 were younger (33.9 vs. 20.3 months; P = 0.001), had a lower percentage of Staphylococcus aureus (23.3% vs. 3.1%; P < 0.001), a higher proportion of Kingella kingae (12.1% vs. 28.1%; P = 0.001), higher erythrocyte sedimentation rate/C-reactive protein (CRP) ratio (1.4 interquartile range 0.6-3.6 vs. 3.3 interquartile range 1.7-5.7; P < 0.001) and showed lower rate of fever (63% vs. 48.8%; P = 0.024) than in group 1. Complications were not found in group 2.

CONCLUSIONS

An exclusively oral administration could be a safe option in selected patients with OAI. Low-risk criteria are proposed: good general condition, no underlying disease, 6 months to 3 years old, appropriate oral tolerance, C-reactive protein <80 mg/L, erythrocyte sedimentation rate/C-reactive protein ratio ≥0.67, no skin injury, no recent surgery, no cervical spondylodiscitis and no local complications at onset.

Vascular Complications in Children Following Button Battery Ingestions: A Systematic Review

CONTEXT

Children presenting to health care facilities with button battery (BB) impaction.

OBJECTIVES

To describe characteristics of children with vascular complications after BB impaction, as well as associated outcomes.

DATA SOURCES

National Capital Poison Center registry and PubMed database from inception to December 2021.

STUDY SELECTION

All reports describing children aged <18 years with vascular, esophageal, or airway complications after BB ingestion.

DATA EXTRACTION

We extracted characteristics including date of publication, age and sex of child, battery type and size, duration and location of impaction, complications, subsequent interventions, and interval between battery removal and death.

RESULTS

A total of 361 cases involved severe complications or death after BB ingestion (321 cases from the National Capital Poison Center registry database, 40 additional cases from PubMed). Nineteen percent (69 of 361) were fatal and 14% (51 of 361) involved vascular injuries. Three-quarters (75%) of vascular complications were aorto-esophageal fistulae and 82% of vascular injuries were not survivable. Fatal vascular cases had significantly longer median impaction time (96 hours versus 144 hours, P <.05) and a wider range of presenting features than survivors.

LIMITATIONS

The total number of cases with vascular complications was small, data reported varied between cases, and no data were available on overall exposure. Long-term morbidity data were not available for the survivors.

CONCLUSIONS

Prolonged BB impaction is a risk factor for vascular complications and death. A high index of suspicion is required for children representing with hematemesis after BB impaction, with prompt transfer to a tertiary center because vascular surgical intervention may offer a chance of survival.

Evaluating the management timeline of tracheoesophageal fistulas secondary to button batteries: A systematic review

INTRODUCTION

During the SARS-CoV-2 pandemic, the incidence of pediatric button battery (BB) ingestions has risen. Children have spent more time at home from school, while many parents try to balance working from home and childcare. Additionally, the amount of electronics powered by BB has increased. Tracheoesophageal fistula (TEF) secondary to a retained aerodigestive BB is a devastating development. Management is challenging, and the clinical timeline of watchful waiting versus surgical intervention for TEF is poorly defined in the literature.

METHODS

In accordance with PRISMA guidelines, databases searched include PubMed, Scopus, and CINAHL from database date of inception through August 13, 2021. All study designs were included, and no language, publication date, or other restrictions were applied. Case series and reports of TEFs secondary to BBs were included. Clinical risk factors and outcomes were compared between the spontaneous closure and surgical repair groups.

RESULTS

A total of 79 studies with 105 total patients were included. Mortality was 11.4%. There were 23 (21.9%) TEFs that spontaneously closed and 71 (67.6%) that underwent surgical repair. Median time to spontaneous closure compared to surgical repair was significantly different (8.0 weeks [IQR 4.0-18.4] vs. 2.0 weeks [IQR 0.1-3.3], p<0.001). Smaller TEFs were more likely to spontaneously close versus being surgically repaired (9.3 mm ± 3.5 vs. 14.9 mm ± 8.3, p=0.022). Duration of symptoms before BB discovery, BB size, time between BB removal and TEF discovery, and location of the TEF were not statistically different between the spontaneous closure and surgical repair groups.

CONCLUSION

A TEF secondary to BB ingestion is a potentially deadly complication. Timing of reported TEF spontaneous closure varies significantly. While smaller TEFs may be amenable to healing without surgical repair, no other significant factors were identified that may be associated with spontaneous closure. If clinical status permits, these data suggest a period of observation of at least 8 weeks prior to surgical intervention may be practical for many BB-induced TEFs.

Association between the corrosion of ingested lithium button battery in the esophagus and its complications in pediatric patients

PURPOSE

The incidence of lithium button battery ingestion has been increasing recently, which results in severe complications. We aimed to demonstrate the association between the corrosion of lithium button batteries in the esophagus on radiographs and their complications.

METHODS

The nine pediatric patients included in this study were classified into two groups based on the presence of severe complications. The presence and degree of corrosion on plain radiographs were evaluated. The degree of corrosion was classified into the following three grades; none: 0%; moderate: 1-50%; severe: 51-100%. Fisher's exact test was used for statistical analyses.

RESULTS

Of the nine patients, five showed complications. The number of patients who had grade none, moderate, and severe degrees of corrosion was three, four, and two, respectively. The incidence of severe complications differed significantly between the incidence of lithium button batteries' contour (without vs. with severe complications [presence/absence of corrosion] = 1/3 vs. 5/0, respectively; P = 0.0476). In cases with "none" degree of corrosion, all three cases had no complication, and in cases with a "severe" degree of corrosion, all two cases had complications.

CONCLUSION

The cases with the presence of corrosion of lithium button batteries had a higher tendency to have severe complications. Therefore, physicians should anticipate the presence of severe complications in pediatric patients with corrosion more than those without corrosion.

Retained metal fragments following esophageal button battery impaction

Button battery (BB) impaction in the esophagus requires immediate endoscopic removal and meticulous follow-up, including serial cross-sectional imaging, preferably with magnetic resonance imaging (MRI). However, BBs quickly degrade in the esophagus, and metallic fragments may remain in the injured mucosa following removal. This metallic debris can cause thermal injury during MRI, potentially aggravating local injury. We aimed to explore whether such metallic fragments could be identified on imaging following BB removal. In this study, we conducted a retrospective review of children (0-18 years) presenting with BB impaction in the esophagus between 2014 and 2020. Endoscopy reports and imaging studies were blindly reviewed by a pediatric gastroenterologist and a pediatric radiologist. Of 161 cases of battery ingestion, 14 (8%) underwent endoscopy, and in 9 (5%) a BB was impacted in the esophagus. The median time from ingestion to BB removal was 8 h (range 2-48 h). The median time from removal to CT was 44 h (range 0.5-104 h). BB appearance ranged from mild corrosion to visible debris. Pre-removal plain films showed irregular battery contour suggesting corrosion (5/7 plain films). In 7/9 CT scans (78%), high-attenuation esophageal content (median 266HU (range 140-1151)), which may represent metallic debris, was identified. Five patients had a follow-up CT which still showed gradual resolution of the high-attenuation content.Conclusions: we describe a new finding on CT following BB removal which might represent metallic debris. Clinicians should be aware of these findings which potentially may be harmful during MRI used in the ongoing assessment of esophageal injury. What is Known: • Button batteries are a dangerous pediatric foreign body with potentially fatal vascular complications. What is New: • Metallic debris was identified on computerized tomography following button battery removal in most children. • We bring to attention this new finding which may affect clinical management, as minimal metallic content can cause burns during MRI.