weekly_question 13/11/2022

[Admin]

A 16 month old asymptomatic boy presents to the emergency department approximately 4 hours after a suspected foreign body ingestion. The accompanying chest radiograph is obtained (below). The child is handling his salivary secretions. The on call endoscopist is notified and will be able to get the child into the OR for foreign body retrieval in about an hour.





The next step in management should be:

A Administration of IV antibiotics

B CT angiogram to exclude esophago-aortic fistula

C Esophagogram

D Administration of 10 ml of honey

E Intranasal budesonide

[Admin]

correct answer
D Administration of 10 ml of honey

Compiled National Poison Center data has confirmed a significant increase over time in morbidity and mortality associated with esophageal button battery impactions. This trend appears to be due to changes in the button battery market, including larger diameter batteries and a shift to lithium composition of the cells. The mechanism of injury is related to the generation of hydroxide free radicals in the esophageal mucosa which results in a caustic injurysecondary to the high generated pH. Experimental models of button battery injuries demonstrate that necrosis can occur within the lamina propria as early as 15 minutes post-ingestion, with extension to the outer muscularis within 30 minutes.

Diagnosis of a button battery ingestion is usually made immediately by an anteroposterior chest radiograph. The button battery has the characteristic “halo” sign, which differentiates it from a coin. Radiographic confirmation of an ingested button battery which has become lodged in the esophagus is considered an endoscopic emergency in a stable patient.

Recently, the National Button Battery Task Force was formed in a collaboration between the AAP and the American Broncho-Esophageal Association. One of the goals of this task force was to develop and advocate for mitigation strategies to reduce overall injury severity associated with button battery ingestions. The task force has recommended interventions to be undertaken before and after battery removal. Based on animal studies which confirmed the attenuating effects of both honey or sucralfate in reducing esophageal perforation, the task force recommends administration of either honey (10 ml every 10 min up to 6 doses) or sucralfate (10 ml every 10 min up to 3 doses) to stable patients older than 12 months who are awaiting either radiographic confirmation of a suspected button battery ingestion, or once confirmed, are awaiting endoscopic removal.

The task force also recommends post-removal irrigation of the exposed mucosa with 50 to 150 ml of 0.25% sterile acetic acid, assuming the clinical suspicion for perforation is low.

If there is a suspicion (based on injury proximity or suspected depth) of extension to adjacent major vasculature, consideration should be given to either CT angiography or MRI to evaluate for vascular injury, Such imaging should be done prior to battery removal in any unstable patient with active bleeding or obvious signs of mediastinitis.

[Gunduz Aghayev]

D

[Admin]

correct answer
D Administration of 10 ml of honey

Compiled National Poison Center data has confirmed a significant increase over time in morbidity and mortality associated with esophageal button battery impactions. This trend appears to be due to changes in the button battery market, including larger diameter batteries and a shift to lithium composition of the cells. The mechanism of injury is related to the generation of hydroxide free radicals in the esophageal mucosa which results in a caustic injurysecondary to the high generated pH. Experimental models of button battery injuries demonstrate that necrosis can occur within the lamina propria as early as 15 minutes post-ingestion, with extension to the outer muscularis within 30 minutes.

Diagnosis of a button battery ingestion is usually made immediately by an anteroposterior chest radiograph. The button battery has the characteristic “halo” sign, which differentiates it from a coin. Radiographic confirmation of an ingested button battery which has become lodged in the esophagus is considered an endoscopic emergency in a stable patient.

Recently, the National Button Battery Task Force was formed in a collaboration between the AAP and the American Broncho-Esophageal Association. One of the goals of this task force was to develop and advocate for mitigation strategies to reduce overall injury severity associated with button battery ingestions. The task force has recommended interventions to be undertaken before and after battery removal. Based on animal studies which confirmed the attenuating effects of both honey or sucralfate in reducing esophageal perforation, the task force recommends administration of either honey (10 ml every 10 min up to 6 doses) or sucralfate (10 ml every 10 min up to 3 doses) to stable patients older than 12 months who are awaiting either radiographic confirmation of a suspected button battery ingestion, or once confirmed, are awaiting endoscopic removal.

The task force also recommends post-removal irrigation of the exposed mucosa with 50 to 150 ml of 0.25% sterile acetic acid, assuming the clinical suspicion for perforation is low.

If there is a suspicion (based on injury proximity or suspected depth) of extension to adjacent major vasculature, consideration should be given to either CT angiography or MRI to evaluate for vascular injury, Such imaging should be done prior to battery removal in any unstable patient with active bleeding or obvious signs of mediastinitis.