Button Battery Ingestion in Children: A Paradigm for Management of Severe Pediatric Foreign Body Ingestions

A peculiar foreign body ingestion in 2-year-old girl complicated by esophageal perforation: case report and review of the literature

Foreign body ingestion is a common pediatric gastrointestinal emergency, which should be suspected in all patients who present with signs of airway obstruction or upper GI bleeding, especially if it developed after the child was left unwitnessed for a while. The most common foreign bodies identified in the literature are button batteries or coins. Early identification and management of suspected foreign body ingestion is crucial as it can lead to devastating complications including bleeding, fistula formation, perforation, mediastinitis, or abscess. Here we report a case of a peculiar foreign body ingestion resulting in esophageal perforation in a 2-year-old girl.

Esophageal Button Battery Retrieval: Time-In May Not Be Everything

The management of ingested foreign bodies is a challenging task because each case is unique with multiple varying factors including a patient's age, anatomical considerations, clinical presentation, and the type and location of the foreign body ingested. Additionally, concern over complications associated with button battery ingestion typically drives management decisions. The common practice is the urgent retrieval of the foreign body within two to six hours of presentation. An unusual case is presented here that demonstrated significantly delayed endoscopic removal of an ingested button battery without complication, avoiding the many risks associated with any emergent endoscopic procedure. However, this practice is a case-by-case decision because there is a lack of literature to guide the current management.

Age-specific causes of upper gastrointestinal bleeding in children

The etiology of upper gastrointestinal bleeding (UGIB) varies by age, from newborns to adolescents, with some of the causes overlapping between age groups. While particular causes such as vitamin K deficiency and cow's milk protein allergy are limited to specific age groups, occurring only in neonates and infants, others such as erosive esophagitis and gastritis may be identified at all ages. Furthermore, the incidence of UGIB is variable throughout the world and in different hospital settings. In North America and Europe, most UGIBs are non-variceal, associated with erosive esophagitis, gastritis, and gastric and duodenal ulcers. In recent years, the most common causes in some Middle Eastern and Far Eastern countries are becoming similar to those in Western countries. However, variceal bleeding still predominates in certain parts of the world, especially in South Asia. The most severe hemorrhage arises from variceal bleeding, peptic ulceration, and disseminated intravascular coagulation. Hematemesis is a credible indicator of a UGI source of bleeding in the majority of patients. Being familiar with the most likely UGIB causes in specific ages and geographic areas is especially important for adequate orientation in clinical settings, the use of proper diagnostic tests, and rapid initiation of the therapy. The fundamental approach to the management of UGIB includes an immediate assessment of severity, detecting possible causes, and providing hemodynamic stability, followed by early endoscopy. Unusual UGIB causes must always be considered when establishing a diagnosis in the pediatric population because some of them are unique to children. Endoscopic techniques are of significant diagnostic value, and combined with medicaments, may be used for the management of acute bleeding. Finally, surgical treatment is reserved for the most severe bleeding.

Management of Foreign Bodies Crossing the Gastroesophageal Junction in Children

OBJECTIVE

Foreign body (FB) ingestion is a common problem in children and is an important public health problem in terms of causing serious complications. This study aims to evaluate the complication management and intervention rates of FBs crossing the gastroesophageal junction.

MATERIALS AND METHODS

The hospital records of all children who presented to our clinic because of ingestion of FB between August 2019 and August 2021 were retrospectively reviewed. Patients who had an FB crossing the esophagogastric junction on plain radiographs showing the entire gastrointestinal tract taken at the time of admission were included in this study. Patients who had an FB removed from the esophagus by endoscopy were excluded from this study.

RESULTS

Of the 127 patients included in this study, 66 (52%) were male and 61 (48%) were female, with a mean age of 4.94 ± 3.15 years (3 months-17 years), and 59% (n = 75) of the patients were under 5 years of age. The most common type of FB was a coin (47%). The first pediatric cases in the literature were a clothespin discovered in the stomach and a Meckel's diverticulum perforated by a sunflower seed shell. Management included spontaneous passing (89%), endoscopy (7%), and open surgery (4%).

CONCLUSION

Although FBs passing through the esophagogastric junction may be asymptomatic in most cases, the need for close monitoring and surgical intervention should be kept in mind in these patients.

Video Laryngoscope Assistance in Button Battery Retrieval

Foreign body ingestion remains a common cause of pediatric emergency surgery with button battery ingestion of particular concern. Newer, higher power lithium batteries can cause catastrophic damage of the gastrointestinal tract through erosion of mucosa into surrounding structures. Prompt diagnosis and treatment are paramount. We present a case of an 11-month-old with a button battery lodged in the proximal esophagus. The extraction was difficult and only made possible with the assistance of a video laryngoscope. We make the case for more routine usage of video laryngoscopy for removal of foreign bodies in the upper esophagus.

Arterio-Esophageal Fistula: A Complication of Button Battery Ingestion

Button battery (BB) ingestion is one of the rare foreign body ingestion (FBI) emergencies. Nevertheless, it carries high morbidity and mortality rates. In this case, we present a child with button battery ingestion complicated after successful removal by massive hematemesis and cardiopulmonary arrest. The patient was resuscitated and admitted to the intensive care unit (ICU). The event resulted in multiple neurological sequelae as demonstrated by radiological study as well as clinical examination.

Evolving threat of pediatric ingestions: a discussion of cannabis and button batteries and their implications for children

PURPOSE OF REVIEW

Pediatric button battery and cannabis ingestions are rising in incidence and have the potential for significant harm. This review will focus on the clinical presentation and complications of these two common inadvertent ingestions in children, as well as recent regulatory efforts and advocacy opportunities.

RECENT FINDINGS

The rising incidence of cannabis toxicity in children has corresponded with its legalization across several countries in the last decade. Inadvertent pediatric cannabis intoxication is most commonly due to the ingestion of edible forms discovered by children in their own home. The clinical presentation can be nonspecific, therefore clinicians should have a low threshold for including it on their differential diagnosis. Button battery ingestions are also increasing in incidence. While many children are asymptomatic at presentation, button battery ingestions can quickly cause esophageal injury and lead to several serious and potentially life-threatening complications. Prompt recognition and removal of esophageal button batteries is essential for reducing harm.

SUMMARY

Cannabis and button battery ingestions are important for physicians who take care of children to recognize and manage appropriately. Given their rising incidence, there are many opportunities for policy improvements and advocacy efforts to make a difference in preventing these ingestions altogether.

Buttoned Shut: Management of Complete Unilateral Nasal Obstruction Secondary to Button Battery Injury

Pediatric button battery ingestion is known to cause potentially devastating injuries to the aerodigestive tract. Placement of a button battery in the nasal passages and subsequent damage it may cause poses a unique management problem as it may involve bony and membranous scarring, aesthetic irregularities, and long-term nasal obstruction. We present a case of a child with complete stenosis of the right nasal vestibule after a button battery injury. With a multidisciplinary surgical approach between an otolaryngologist and a plastic surgeon, the nasal airway patency was restored via a series of dilations and stents. The patient now has a patent right nasal airway that measures equal in diameter to the contralateral side. We conclude that in the case of a child with a button battery in the nose, repair of stenosis may be approached similarly to a case of unilateral choanal atresia, including dilations and stents.

FOREIGN BODY ASPIRATION AND INGESTION IN CHILDREN

Aspiration and ingestion of a foreign body is most frequently seen in children younger than 3 years. Foreign body aspiration is always a life-threatening, urgent state demanding quick recognition and treatment to avoid potentially lethal complications. Most foreign bodies that are ingested pass spontaneously through the gastrointestinal tract without complications, however, some could lead to problems if they become lodged. A literature review was performed via MEDLINE database using key terms. Primary care providers should be trained to give proper initial care. Aspirated/ingested foreign bodies in children removed by rigid or flexible bronchoscopy/gastroscopy always are challenging procedures that require well-planned anesthesia management and excellent intercommunication between anesthesiologists and surgeons. Extracorporeal membrane oxygenation can be used as a rescue mode of support in children with life-threatening foreign body aspiration for stabilization before, during and after removal of the aspirated foreign body. It is of utmost importance that all foreign body extractions, if possible, be done in centers supplied with all the necessary equipment and trained personnel. However, prevention of foreign body aspiration and ingestion is still the best therapy.

Pediatric button battery ingestion: A single center experience and risk score to predict severe outcomes

PURPOSE

The purpose of this study was to analyze the management and outcomes of primary button battery ingestions and their sequelae at a single high-volume center, and to propose a risk score to predict the likelihood of a severe outcome.

METHODS

The medical record was queried for all patients under 21 years old evaluated at our institution for button battery ingestion from 2008 to 2021. A severe outcome was defined as having at least one of the following: deep/circumferential mucosal erosion, perforation, mediastinitis, vascular or airway injury/fistula, or development of esophageal stricture. From a selection of clinically relevant factors, logistic regression determined predictors of a severe outcome, which were incorporated into a risk model.

RESULTS

143 patients evaluated for button battery ingestion were analyzed. 24 (17%) had a severe outcome. The independent predictors of a severe outcome in multivariate analysis were location of battery in the esophagus on imaging (96%), battery size >/ = 2 cm (95%), and presence of any symptoms on presentation (96%), with P < 0.001 in all cases. Predicted probability of a severe outcome ranged from 88% when all three risk factors were observed, to 0.3% when none were present.

CONCLUSION

We report the presentation, management, and complication profiles of a large cohort of BB ingestions treated at a single institution. A risk score to predict severe outcomes may be used by providers initially evaluating patients with button battery ingestion in order to allocate resources and expedite transfer to a center with pediatric endoscopic and surgical capabilities.

LEVEL OF EVIDENCE

Level IV.

TYPE OF STUDY

Clinical Research Paper.

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.

Utilizing a critical airway response team expedites esophageal button battery removal

BACKGROUND

Esophageal button battery ingestion is a significant problem that can lead to significant complications such as tracheoesophageal fistula, esophageal perforation, and aortoesophageal fistula. Due to this, prompt recognition and treatment is integral in the care of these patients.

METHODS

Patients who presented to a single institution from August 2015 to April 2022 with esophageal button battery ingestion were included in this study. All esophageal button battery ingestion patients were included in a clinical algorithm for Critical Airway Response Team (CART) activation in October 2019. Time from diagnosis to treatment was compared for pre-CART clinical algorithm implementation to post-CART.

RESULTS

Data on pre-CART patients (n = 6) and post-CART patients (n = 7) was collected. Including esophageal button battery ingestions to CART activations shortened the time from chest x-ray to button battery removal from 73 ± 32 min to 35 ± 11 min (p < 0.05).

CONCLUSION

These data highlight the importance of implementation of a clinical care algorithm to shorten the time from diagnosis to treatment in patients with esophageal button battery ingestion.

LEVEL OF EVIDENCE

III.

Management of Gastrointestinal Foreign Bodies with Brief Review of the Guidelines

Foreign body (FB) ingestion is a common health problem that affects children more than adults. According to gastroenterologists' guidelines, the management of FB ingestion differs slightly between adult and children. This review aimed to compile adult and children guidelines and establish an understandable association to reveal the requirements and timing of the endoscopic procedure, which is the most effective and least complicated technique for gastrointestinal FBs. Coins, pins, and chicken and fish bones have been the most commonly ingested FBs. However, with their increasing use in recent years, large batteries with lithium-ion conversion, stronger magnets composed of rare earth metals, such as neodymium, and superabsorbent objects have become the most morbid and mortal, necessitating new management strategies. Although the approach to gastrointestinal FBs is controversial, with different treatment options available in different disciplines, many studies have demonstrated the efficacy and safety of endoscopic procedures. Many factors influence the timing of endoscopy, including the nature, size, and location of the ingested object and the patient's clinical condition.

Role of Honey and Acetic Acid in Mitigating the Effects of Button Battery in Esophageal Mucosa: A Cadaveric Animal Model Experimental Study

The objective of our study was to evaluate the role of honey and acetic acid in mitigating the mucosal injury posed by button battery using esophagus specimens from goat cadavers. This was an in vitro experimental cadaveric animal model laboratory study. We used 40 specimens of cadaveric goat esophagus and divided into four groups (A, B, C and D). The first comparison was between group A (specimens with button battery only) and group B (specimens with button battery coated with honey) for the difference in the degree of mucosal injury and change in pH and temperature. The second comparison was between group C (specimens with button battery removed after six hours) and group D (specimens with 5% acetic acid applied following the removal of the battery after six hours) for the difference in the progression of the mucosal injury and change in pH and temperature. The observer was blinded regarding the allocation of the groups. We used Fisher's exact test and independent sample t-test, to evaluate the statistical association. There was a statistically significant reduction in the degree of mucosal injury in specimens applied with button battery coated with honey compared to the specimens applied with button battery only. Similarly, progression of the mucosal injury was halted in specimens with the application of acetic acid following the removal of the button battery. Honey and acetic acid can mitigate the mucosal effects posed by the button battery in cadaveric goat esophageal specimens.

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.

Ear, Nose, and Throat Foreign Bodies in the Paediatric Population: Did the COVID-19 Lockdown Change Anything?

Background

In the pediatric population, the ear, nose, and throat (ENT) foreign body is a common presentation for emergency departments (ED) and ENT units. COVID-19 has led to a significant impact on the health care system and the overall mental well-being of the general population. With the health care system under significant strain, we noted a continued presence of children with foreign bodies, with some requiring removal under a general anesthetic.

Aim

We aimed to assess if lockdown measures increased or decreased the incidence of children presenting to the hospital with ear, nose, and throat foreign bodies and to evaluate their management by the ED and ENT specialties.

Method

A retrospective data of children presenting with a foreign body in the ear, nose, and throat from March 2020 to August 2020 was compared with the data for the same period in 2019.

Results

Our study showed an overall decrease in children presenting with foreign bodies in 2020 compared to 2019 (n=90 and n=106, respectively). However, the number of children needing general anesthetic remained the same, and those presenting with foreign bodies in the upper aerodigestive tract were higher in 2020.

Conclusion

Children with foreign ear, nose, and throat bodies continued to present to the hospital during the COVID-19 lockdown. Our study shows an overall decrease in the number of children presenting with Ear, Nose, and Throat foreign body during the lockdown, but not statistically significantly different.

Bilateral Vocal Cord Fibrosis: A Delayed Complication of Button Battery Ingestion

A 14-month-old girl initially presented to the Accident and Emergency (A&E) department following a choking episode and subsequent vomiting. The child left the department before being seen but re-presented the following morning with stridor, drooling, and increased work of breathing. A chest and lateral neck soft tissue X-ray performed in the A&E department revealed an ingested button battery in the oesophagus. Emergency oesophagoscopy was performed and a 22 mm button battery was removed from the oesophagus at the level of the cricopharyngeus muscle, with no immediate complications. Following extubation, the patient was initially well but later required a prolonged hospital stay due to recurrent episodes of stridor, voice changes and aspiration pneumonia. Follow-up microlaryngoscopy and laryngeal electromyography (EMG) diagnosed bilateral vocal cord palsy and cricoarytenoid fibrosis. This case highlights the need for increased public awareness, urgent diagnosis and standardised management of battery ingestion, and discusses the potential for the development of serious latent complications.

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.

Airway Complications Resulting From Pediatric Esophageal Button Battery Impaction: A Systematic Review

Importance

Button batteries (BBs) are commonly found in many household items and present a risk of severe injury to children if ingested. The direct apposition of the trachea and recurrent laryngeal nerves with the esophagus puts children at risk of airway injury secondary to the liquefactive necrotic effects of BB impactions.

Objective

To review airway injuries, including long-term sequelae, after BB ingestion in children.

Evidence Review

For this systematic review, a comprehensive strategy was designed to search MEDLINE, Embase, Cochrane Database of Systematic Reviews, Web of Science, and CINAHL (Cumulative Index of Nursing and Allied Health Literature) from inception to July 31, 2021, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Additional cases were identified from the National Capital Poison Center BB registry. Individual authors were contacted for additional information. Studies with pediatric patients (<18 years) who developed airway injuries after BB ingestion were included. A total of 195 patients were included in the analysis; 95 were male. The mean (SD) age at BB ingestion was 17.8 (10.2) months. The mean (SD) time from BB ingestion to removal was 5.8 (9.0) days. The 2 most common airway sequelae observed in our series were 155 tracheoesophageal fistulae and 16 unilateral vocal cord paralyses. Twenty-three children had bilateral vocal cord paralysis. The mean (SD) duration of ingestion leading to vocal cord paralysis was shorter than that of the general cohort (17.8 [22.5] hours vs 138.7 [216.7] hours, respectively). Children presenting with airway symptoms were likely to have a subsequent tracheoesophageal fistula or vocal cord paralysis.

Conclusions and Relevance

Airway injuries are a severe consequence of BB ingestion, occurring more often in younger children. This systematic review found that tracheoesophageal fistulae and vocal cord paralyses were the 2 most common airway injuries, often requiring tracheostomy. Vocal cord injury occurred after a shorter BB exposure time than other airway injuries. Continued efforts should be directed toward prevention strategies to avoid the devastating sequelae of BB-associated airway injury.

Disc battery ingestion in paediatric age

AIM

The aim of the present study was to analyse clinical data of children referred for disc battery ingestion in order to assess short- and long-term reported injuries and to identify outcome predictors and trends, define the urgency of intervention and refine treatment guidelines.

METHODS

The records of all children admitted to Santobono-Pausilipon Children's Hospital, Naples, Italy for disc battery ingestion from January 2016 to December 2020 were retrospectively reviewed. Odds ratio were computed to assess the association between the different study variables and the rate of complications.

RESULTS

We enrolled 118 children. Mild to major complications related to the ingested disc batteries were reported in 12/118 (10.2%) patients. Disc battery oesophageal retention, disc battery diameter >20 mm, together with age below 1 year and symptomatic presentation were the most important factors associated with poor clinical outcome.

CONCLUSION

Our data confirm that ingested disc batteries are a serious health hazard and require a timely and qualified medical evaluation. We have identified three predictors of outcome severity: oesophageal retention, large-diameter cells and symptom onset. Disc batteries lodged beyond the oesophagus appear substantially harmless and we may support a more conservative approach.

Management of oesophageal impaction of button batteries in Queensland

BACKGROUND

Oesophageal button battery impaction (OBBI) is a medical emergency requiring timely removal due to rapid oesophageal tissue injury. The aim of this study was to characterize circumstances of OBBI and identify potential barriers to timely removal of button batteries (BB) in the paediatric population.

METHODS

This is a retrospective review of OBBI cases between January 2018 to June 2019. Medical records were used to obtain patient demographics, battery size and type, battery source, location of initial presentation and outcomes. Time to obtaining x-ray, transfer to tertiary centre and to removal of button battery were recorded.

RESULTS

Eight cases of OBBI were recorded during the 18 months study timeframe. Six patients were male and two were female, aged 0.97 to 2.8 years. Six were from an English-speaking background and two were from families of non-English speaking background. Battery removal occurred at Queensland Children's Hospital (QCH) in seven of eight cases. Time from ingestion to initial presentation to hospital ranged from 39 min to 123 h with a mean time of 2 h and 13 min. Overall, the total time from ingestion of BB to removal ranged from 2 h 54 min to 126 h 51 min.

CONCLUSION

Despite being recognized as a time critical emergency, diagnostic, geographic and logistic challenges in Queensland make optimal care a challenge. Primary prevention strategies coupled with an expanded network for safe battery removal, and novel management strategies such as honey and acetic acid could improve care and reduce morbidity.

Evolving Trends of Button Battery Ingestion in Indian Children at a Tertiary Care Hospital

INTRODUCTION

Foreign body ingestion is a common problem encountered in the pediatric age group. Impaction of lithium batteries of greater than 20-mm diameter in the esophagus is associated with severe complications. This study aimed at analyzing the evolving trends of button battery ingestion in pediatric age groups at our tertiary care center in terms of clinical presentation, intraoperative findings, and the correlation of various clinical variables.

METHODS

A retrospective observational study was done. All children younger than 18 years with impaction of a button battery of size greater than 20 mm in the esophagus between January 2015 and December 2018 were included in the study. All children underwent removal of the battery using direct laryngoscopy/rigid esophagoscopy under general anesthesia.

RESULTS

There were 100 children included in the study with a mean age of 29.92 months having 93 children (93%) younger than 6 years. The mean duration of impaction was 34.7 hours. Increased duration of impaction was associated with an increased risk of complications and an increased difficulty in removal. There was a significant correlation between the site of impaction and the age of the patient. Complications were seen in 10% of cases with severe complications in 6 cases. No fatalities were reported in this study.

CONCLUSIONS

Button batteries impacted in the esophagus can lead to severe complications including death. There has been an increasing trend in the ingestion of button batteries over the last 4 years. A prompt diagnosis and emergent removal of the battery are crucial to minimize the rate of complications. Symptoms of stridor and dysphagia must be given more attention, and these children are prioritized because they are more prone to have complications. Furthermore, primary prevention and caregiver education should be emphasized, and the need for a legislation to change the policies for securing the batteries in their products must be endorsed.

Surgical repair of massive hemorrhage secondary to button battery ingestion causing aortoesophageal fistula

BACKGROUND

In pediatrics, foreign body ingestion poses unique challenges. Each case is unique given variability in timing, type, and size of object, compounded by underlying comorbidities and age. In the mid-1990s, mortality and morbidity associated with button battery (BB) ingestion (BBI) emerged corresponding to modification in battery fabrication towards higher voltage, large-diameter lithium cells.

AIMS

To describe the case and management of a BBI in a pediatric patient necessitating the use of cardiopulmonary bypass and deep hypothermic circulatory arrest (DHCA).

MATERIALS AND METHODS

A 17-month-old female presented with the sudden loss of consciousness at home. Chest X-ray revealed an esophageal foreign body suspicious for BBI. A massive upper gastrointestinal bleeding was temporized with packing. The patient was urgently taken to the operating room for sternotomy, establishment of cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest (DHCA), removal of BB, repair of the left common carotid artery, esophageal, and tracheal injuries.

DISCUSSION

Successful management of BBI requires coordinated care and a multidisciplinary approach. A high degree of clinical suspicion for BBI is imperative to facilitate early aggressive interventions. Lateral and anteroposterior chest films should be obtained in any suspected BBI.

CONCLUSION

This case demonstrates the utility of CPB and DHCA where control of bleeding secondary to BBI is not otherwise possible.

Management of esophageal button battery ingestions: resource utilization and outcomes

PURPOSE

Institutions are adopting the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) guidelines for pediatric esophageal button battery ingestion (EBBI). Our objective was to evaluate the guidelines' impact on in-hospital resource utilization and short-term clinical outcomes in hemodynamically stable patients after endoscopic battery removal.

METHODS

A single-center retrospective review of all EBBI admissions from 2010 to 2020. Patients were divided into two groups based on adoption of national guidelines: pre-guideline (2010-2015) and post-guideline (2016-2020).

RESULTS

Sixty-five patients were studied (pre-guideline n = 23; post-guideline n = 42). Compared with pre-guideline, post-guideline use of magnetic resonance imaging (MRI) increased (2/23 [8.7%]; 30/42 [71.4%]; p < 0.001). Post-guideline increases resulted for median days (IQR) receiving antibiotics (0 [0, 4]; 6 [3, 8]; p = 0.01), total pediatric intensive care unit admission (0 [0, 1]; 3 [0, 6]; p < 0.001), and total hospital length of stay (5 [2, 11]; 11.5 [4, 17]; p = 0.02). Two patients in the post-guideline group had delayed presentations despite normal imaging: one with TEF and one with aorto-esophageal fistula. All survived to discharge.

CONCLUSION

In EBBI cases managed using the consensus based NASPHAGN guidelines, we report increased resource utilization without improved patient outcomes. Further research should evaluate post-guideline costs and resource utilization.

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.

A novel approach to button battery removal in a two-and-half year-old patient's esophagus after ingestion: a case report

Background

Accidental swallowing of a foreign body occurs more frequently in children than in adults. Among these cases, button battery impaction in the esophagus may cause severe complications. While prevention is always ideal, if button battery impaction is suspected, immediate diagnosis and retrieval are important.

Case presentation

We introduce a novel method for retrieval of a button battery after ingestion by a 2.5-year-old child. When the patient arrived at our center, the battery was incarcerated in the upper esophagus. The battery could not be removed, despite the use of several methods such as alligator forceps under endoscopy and net retrieval. We decided to use a novel method that combined endoscopic balloon extraction and forceps retrieval. This resulted in a push-and-pull effect, creating synergy and easy removal of the battery. There were no long term complications based on the follow-up endoscopy examination.

Conclusions

This new procedure was very effective for removing the esophageal foreign body. When button battery in esophagus was too tight to be removed by the traditional retrieval methods, this procedure was suggested to use. It could be performed at medical institutions. If it fails or esophageal perforation (iatrogenic or spontaneous) occurs, pediatric surgeons could take over immediately.

Evaluation of a Symptom-Based Algorithm for Managing Battery Ingestions in Children

OBJECTIVES

 While complications from battery ingestion can be severe, especially with the emergence of stronger battery elements, not all ingestions require prompt removal. We aim to evaluate a symptom-focused algorithm for battery ingestion that emphasizes observation over intervention to investigate its safety.

MATERIALS AND METHODS

 Patients were identified through a query of foreign-body ingestion radiographs obtained between 2017 and 2020. A retrospective chart review was then performed of all patients who presented with button battery ingestions to identify compliance with our algorithm, overall outcomes, and complications.

RESULTS

 In total, 2% of all radiographs (44/2,237) demonstrated button battery ingestions. The median age of patients was 3.8 years (interquartile range, 2.6-5.3). Most batteries were found in the stomach (64%, n = 28), but were also identified in the esophagus (14%, n = 6), small bowel (14%, n = 6), and colon (9%, n = 4). All esophageal batteries were managed with immediate endoscopic retrieval. Ten gastric batteries were not managed per protocol, with seven admitted for observation despite being asymptomatic and repeat abdominal X-rays demonstrating persistent gastric location of the battery. Four patients underwent esophagogastroduodenoscopy; however, in two patients the battery had migrated past the stomach prior to intervention. All small bowel batteries and three of four asymptomatic colon batteries were managed per protocol; one patient had additional imaging that demonstrated battery passage.

CONCLUSION

 Adherence to a symptom-focused protocol for conservative management of button battery ingestions beyond the gastroesophageal junction is safe and frequently does not require admission, serial imaging, or intervention.

Evolving Clinical Care in Esophageal Button Batteries: Impact of Expert-Opinion Guideline Adoption and Continued Gaps in Care

BACKGROUND/OBJECTIVES

Esophageal button battery impactions (BBI) in children pose a significant danger to children. Although there are expert-opinion guidelines to help manage this population, few studies detail the impact of guidelines on the clinical care of these patients. With this study, we aimed to describe the care of these patients before and following adoption of guidelines at a single center.

METHODS

Retrospective cohort study of patients with esophageal BBI at a single center, large volume, urban academic pediatric hospital system before adoption of expert-opinion guidelines (2007-2017) and following adoption (2018-2020).

RESULTS

Cohort was comprised of 31 patients before adoption and 32 patients following adoption of guidelines. Patient characteristics did not differ between groups. After 2018, significantly more patients received acetic acid irrigation, initial cross-sectional imaging, and serial cross-sectional imaging. There was also an increase in intensive care unit (ICU) stays, number of intubations, nil per os time, and hospital length of stay. There was no difference in patient outcomes.

CONCLUSION

This study describes a large cohort of pediatric esophageal BBI before and following adoption of guidelines. Findings detail increased adherence to guidelines resulting in more cross-sectional imaging which led to ICU stays, longer length of stays, and more nil per os time. This study emphasizes the need for multi-disciplinary guidelines as well as further multi-institutional study.

Button Batteries and High-Powered Neodymium Magnet Ingestion in Children

BACKGROUND: Foreign body ingestions in pediatrics are present highly variably. For each case, it is important to consider the size of the child, the age of the child, the size of the object, and the inherently different risk of different objects ingested. It is important to note that regardless of the type of object, any foreign body should be removed from the esophagus. Over the past decade, the medical literature has particularly identified the potential for morbidity and mortality in cases of button battery and magnet ingestions. AIM: This study aims to describe the complications and how to avoid them in addition to studying the role of early endoscopic intervention in cases of button batteries (BB) and multiple magnets ingestion in children. METHODS: There were 151 children enrolled in the study, classified into two groups. The first group constitutes ninety children with BB, the other group sixty children with multiple magnets ingestion. In addition to one patient with both multiple magnets and battery ingestion, which are extracted endoscopically from the stomach without complication. BB detected in the upper gastrointestinal tract (GIT) in the esophagus, stomach, and duodenum in 70 patients were extracted endoscopically. Other 20 patients where the batteries were detected distal to duodenum were observed till the discharge of batteries was confirmed. In patients with multiple magnets, the magnets were in the upper GIT in 46 patients while found distal to the duodenum in 14 patients. RESULTS: There were 151 children enrolled in the study, classified into two groups. The first group constitutes ninety children with BB, the other group sixty children with multiple magnets ingestion. In addition to one patient with both multiple magnets and battery ingestion, which are extracted endoscopically from the stomach without complication. BB detected in the upper GIT in the esophagus, stomach, and duodenum in 70 patients were extracted endoscopically. Other 20 patients where the batteries were detected distal to duodenum were observed until the discharge of batteries was confirmed. In patients with multiple magnets, the magnets were in the upper GIT in 46 patients while found distal to the duodenum in 14 patients. CONCLUSION: This study put alarm that multiple magnets ingestion carries a high risk of gastrointestinal perforation compared to battery ingestion. Invitation to ban on the sale of products with high-powered neodymium magnets, such as Buckyballs and Buckycubes, and to keep BB difficult reachable by children. In addition to encouraging urgent endoscopic management of suspected BB or multiple magnets ingestion.

Battery Ingestion in Children, an Ongoing Challenge: Recent Experience of a Tertiary Center

INTRODUCTION

Morbidity related to childhood battery ingestions (BI) has increased recently due to the expanding use of larger lithium cells. A prompt endoscopic removal is vital to prevent severe complications in cases of esophageal batteries (EB).

MATERIALS AND METHODS

A retrospective, descriptive study of admissions for BI requiring endoscopic removal in a tertiary hospital's pediatric emergency department (Jan. 2011/Dec. 2020).

RESULTS

We had 35 cases, with an increasing incidence in the last 6 years; median age, 26 m (8 m-10 years), witnessed ingestion in 86%. On the X-ray: 14 (40%) had an EB, 21 (60%), a gastric battery (GB). Symptoms were present in 57% (100% EB/24% GB), and vomiting was the most frequent (50%). Endoscopy revealed: EB, 13 (37%); GB, 17 (49%); duodenal battery, 1 (3%); no battery, 4 (11%). Median time to removal: EB, 7 h (2 h-21days); GB, 12 h (2 h-3 days). All the patients with EB on the X-ray (14) had severe mucosal injury (Zargar classification): Grade IIIa, 7 (50%); IIIb, 5 (36%); IV, 2 (14%). CT-scan showed perforation in 2 patients (total, 4; 29% of EB). In patients with GB (21), 14 (67%) had mucosal damage; 13 (93%), mild (< Grade III, two esophageal erosions); 1 (7%) IIIa (esophageal ulceration). A statistically significant association between exposure time, younger age or battery size and severity of endoscopic lesions was found in EB location. There were no mortality cases. Acute complications occurred in 57% of EB: infection, 50%; perforation, 29%; pneumomediastinum/stridor, 14%; pneumothorax/subglottic stenosis/hemodynamic instability, 7 vs. 0% GB. Stenosis subsequently developed in 6 (43%) of EB: mild, 4 cases (29%); severe, 2 cases (14%, one resolved after endoscopic dilation; one needed a gastrostomy and esophagocoloplasty).

CONCLUSION

We verified recent increase in admissions due to battery ingestions and associated complications, despite the availability of an emergency pediatric endoscopy team. The patients with EB had more severe mucosal injury and poorer short/long-term outcomes. Children with GB had milder lesions, although the presence of a GB did not exclude esophageal injury. The availability of actual data from national referral centers will support advocacy efforts among stakeholders, including industry representatives and policy makers, in preventing worldwide button battery injury.

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.

Therapeutic dilemma and clinical issues in management of the button battery ingestion: a case report and literature review

The incidence of button battery ingestion in children less than 6 years, from year 1985 to 2019 was 59,000 and it is still a clinical challenge for pediatricians. Objects which are commonly ingested are large amounts of food, coins, toy parts, jewels, batteries, sharp materials and non-metallic sharp objects. It is an increased incidence of mortality and morbidity due to button battery ingestion, compared to accidental ingestion of other objects, due to its small size, and because of its potent source of energy. A literature search was carried out to evaluate the challenges in diagnosing, treatment, and follow-up of button battery ingested cases in children. A total of 36 original articles were included for the review.

Conclusions: Button batteries can quickly cause severe damage to the mucosal lining of the GI tract. Esophageal button batteries require emergency removal because they can cause serious complications leading to hemorrhage, and death. In children, where the button battery has passed the esophagus watchful management should be made. In the majority of cases, the button batteries with a diameter less than 2 cm lodged in the stomach will pass spontaneously with no complications. However, asymptomatic children may be followed up with X-rays to assess progression up to 10–14 days after ingestion. Endoscopic or surgical removal may be required to prevent intestinal perforation with peritonitis. Symptomatic children will always need a consultation with a pediatric surgeon for surgery no matter where the button battery is placed in the GI tract. Developing countries shall adopt surveillance and reporting systems for BBI ingestion and related complications and it is recommended as essential to have management protocols in place for button batteries ingestion.

Survival of Toddler with Aortoesophageal Fistula after Button Battery Ingestion

Button batteries (BBs) are found in many households and are a source of esophageal foreign body in the pediatric population. Upon ingestion, significant caustic injury can occur within 2 hours leading to tissue damage and severe, potentially fatal sequelae. Aortoesophageal fistula (AEF) is a rare complication that nearly always results in mortality. We report a rare case of a toddler who developed an AEF after BB ingestion and survived following staged aortic repair. There should be a high index of suspicion for this complication with the history of BB ingestion and presence of hematemesis, hemoptysis, or melena.

Management of broncho-esophageal fistula after button battery ingestion

Button battery ingestion can cause serious injury or death in young children who cannot communicate symptoms. An 18-month-old male presented after his mother noted drooling, nonbilious emesis and a metallic smell to his breath. He underwent rigid esophagoscopy and a 3-V 20-mm button battery was removed. Subsequent bronchoscopy after a 1-week interval revealed progression to a large broncho-esophageal fistula on the posterior wall of the right mainstem bronchus past the carina. A fenestrated nasogastric tube for local control of secretion and a feeding jejunostomy was placed. Six weeks later, the patient underwent a right thoracotomy for division and repair of the fistula and intercostal muscle flap interposition. Utilizing a well-placed fenestrated nasogastric tube to manage secretions can help reduce fistula size and improve conservative management results. When surgical repair is required, an intercostal muscle flap can reinforce fistula closure while simultaneously buttressing the bronchus and esophagus.

Foreign body ingestion and associated factors in pediatric patients at a tertiary care center

INTRODUCTION AND AIMS

Foreign body (FB) ingestion is a common problem in children under 5 years of age and is one of the main indications for endoscopy. The aim of the present study was to describe the clinical, radiographic, and endoscopic characteristics of patients with FB ingestion, as well as the factors associated with the anatomic location and the type of object ingested.

MATERIALS AND METHODS

An analytic cross-sectional study was conducted on all patients with FB ingestion seen at the gastroenterology service from January 2013 to December 2018. The data were analyzed using the SPSS program, obtaining frequencies, percentages, medians, and interquartile ranges. Associations were assessed through the chi-square test.

RESULTS

Eighty-five patients (52 males and 33 females) were included, with a median age of 4 years. The most common symptom was vomiting (29.4%). Two radiographic projections were carried out in 72.9% of the cases and the stomach was the site where the FB was most frequently visualized (32.9%). The objects most commonly ingested were coins (36%), with esophageal location (p<0.05), as well as objects with a diameter larger than 2cm (p<0.05). An endoscopic procedure was performed on 76 patients (89.4%) for FB extraction, with findings of erythema (28.9%), erosion (48.6%), ulcer (10.5%) and perforation (1.3%).

CONCLUSIONS

Numerous factors should be taken into account in the approach to FB ingestion in pediatric patients, including type and size of the FB, time interval from ingestion to hospital arrival, and patient clinical status and age.

Cylindrical and button battery ingestion in children: a single-center experience

PURPOSE

The purpose of our study was to perform a comparative analysis of the examination and treatment outcomes of children with cylindrical and button batteries (BB) ingestion depending on their size and anatomical locations.

METHODS

This study was a retrospective analysis of 124 children aged from 1 month to 18 years who ingested batteries and were treated in a tertiary care center from January 1, 2014 to March 31, 2019. The data studied included age, sex, presenting symptoms at the time of evaluation, type and size of battery and modality of management.

RESULTS

Twenty-three (18.5%) patients ingested cylindrical batteries (CBs), and 101 (81.5%) ingested BBs. The duration of hospital stay was significantly longer (p = 0.004) in the group of children who ingested BBs larger than 20 mm. Endoscopic removal was performed in 75 (60.5%) children, 46 (37.1%) were followed up and three (2.4%) underwent open surgeries. Children with CBs ingestion, in 55% of cases, had gastric mucosal injuries. Children with BBs impacted in the esophagus in 96% cases had visible severe mucosal damage, whereas patients with gastric BB ingestion 19.5% had superficial gastric mucosal damage.

CONCLUSION

Performing timely endoscopic retrieval in children who are admitted early to the hospital will reduce the risk of damage to the gastrointestinal mucosa, especially in the stomach. Unlike BBs, CBs, despite their large size, have advantageous shapes, uneventfully pass the esophagus and are more often retained in the stomach; thus, mucosal injuries are more often observed in the stomach. Consequently, endoscopic extraction is the treatment of choice for children with BB ingestion.

Magnetic resonance imaging findings following button battery ingestion

BACKGROUND

Lithium button battery ingestions have been increasing in frequency since the early 2000s and can develop severe and sometimes fatal complications from caustic injury even after rapid battery removal. To aid in clinical decision-making, we began obtaining magnetic resonance imaging (MRI)/MR angiography in these patients.

OBJECTIVE

Our goal was to review MRI/MR angiography imaging in button battery ingestion cases and compare with other imaging, clinical data and outcomes in these patients.

MATERIALS AND METHODS

In this retrospective institutional-review-board-approved study, we reviewed all button battery ingestion cases with MRI from April 2012 to September 2018. Clinical data, endoscopic findings and all imaging studies were rereviewed. MRIs were evaluated for inflammation, blooming artifact and complications including vascular injury, tracheoesophageal fistula, esophageal perforation and spondylodiscitis, and compared to endoscopy, esophagram and bronchoscopy.

RESULTS

Twenty-three patients with button battery ingestions had a total of 51 MRI/MR angiograms. Seventy percent of the cohort was male with a median age of 2 years (range: 0.94-17 years). Severe complications were found in 48% of patients (11/23), including esophageal perforation (n=11), tracheoesophageal fistula (n=3) and spondylodiscitis (n=1). No patients had vascular injury. Cervical location of the battery was significantly associated with severe complications (10/11 cases). The length of the blooming artifact was greater than 2 cm in those with severe complications and, in most cases, <2 cm in those without severe complications. All complications were seen on initial screening MR exam with serial exams showing decreased inflammation.

CONCLUSION

MRI/MR angiography can provide valuable information about complications, including esophageal perforation, tracheoesophageal fistula and spondylodiscitis. Decreasing inflammation surrounding the esophagus and vasculature is believed to be clinically reassuring and aids in managing button battery ingestion patients.

Endoscopic Evaluation for Stricture Formation Post Button Battery Ingestion

Every year, there are over 3300 ingestions of button batteries, mostly by young children. Initial presentation of button battery ingestion may be nonspecific, with a delay in diagnosis and removal resulting in increased risk of complications. We present the case of a five-year-old female who presented with vomiting following unwitnessed button battery ingestion. The battery was impacted in the middle esophagus for at least six hours. Endoscopy was performed for immediate removal and showed a Grade 2B erosion, warranting nasogastric tube placement. The patient remained asymptomatic following discharge and had a barium swallow that was read as normal. However, a repeat endoscopy one month later visualized stricture formation at the previous battery injury site. This case highlights the importance of both clinician and parent awareness of button battery ingestion and demonstrates that endoscopy provides the most accurate assessment of esophageal injury and complication development, even in asymptomatic patients.

A 2-Year-Old Boy Who Developed an Aortoesophageal Fistula After Swallowing a Button Battery, Managed Using a Novel Procedure with Vascular Plug Device as a Bridge to Definitive Surgical Repair

Patient: Male, 2-year-old

Final Diagnosis: Aortoesophageal fistula

Symptoms: Esophageal foreign body • gastrointestinal bleeding

Medication: —

Clinical Procedure: —

Specialty: Gastroenterology and Hepatology • Pediatrics and Neonatology

Successful management of an aorto-esophageal fistula following button battery ingestion: A case report and review of the literature

Foreign body ingestion is a common event among pediatric patients, especially in children less than 6 years of age. Although most cases are relatively benign, with the foreign body passing spontaneously or requiring a brief endoscopic procedure for removal, button battery ingestion is known to cause significant morbidity with the potential for mortality. Although aorto-esophageal fistula (AEF) is a rare complication following button battery ingestion, its clinical manifestations are significant and outcomes are poor. Early diagnosis and aggressive treatment are key in preventing fatal complications. We describe the successful management of an AEF which presented with hematemesis 8 days after removal of a button battery in a 17-month-old female. The literature regarding button battery ingestion and AEF is reviewed and treatment options including intraoperative anesthetic care discussed.