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Complicated Cases of Lithium Battery Ingestion: Delay can be Deadly

Authors:
  • Indira Gandhi Institute of Medical Sciences, Patna, India
  • Regency hospital, lucknow

Abstract

Increasing use of button battery (BB) in household products and toys is responsible for the growing incidence of button battery ingestion (BBI). The BBI may cause life-threatening complications. We present a series of three cases of complicated BBI (lithium cell) with delayed presentation; one of them could not survive due to tracheoesophageal fistula and sepsis. Here, we highlight the importance of early endoscopic intervention and careful follow-up in children with lithium battery ingestion.
184184 © 2019 Journal of Digestive Endoscopy | Published by Wolters Kluwer - Medknow
Increasinguseofbuttonbattery(BB)inhouseholdproductsandtoysisresponsible
for the growing incidence of button battery ingestion (BBI). The BBI may cause
life-threatening complications. We present a series of three cases of complicated
BBI (lithium cell) with delayed presentation; one of them could not survive due
totracheoesophagealstulaand sepsis. Here, we highlight the importance of early
endoscopic intervention and careful follow-up in children with lithium battery
ingestion.
 Button battery, disc battery, esophageal stricture, lithium cell,
tracheoesophageal stula

Arya Suchismita, Ravish Ranjan1, Ashish Kumar Jha1, Praveen Jha1, Madhur Choudhary1, Vishwa Mohan Dayal1,
Kuldeep Sehrawat1
2.5 kg loss of weight. Clinical examination showed
poor nutritional status, tachycardia, tachypnea, pallor,
fever, and bilateral chest crackles (left > right). Blood
investigations showed hemoglobin of 10 g/dL and
leukocytecount of 16,000/mm≥ (polymorphs88%); the
restofthe parameters werenormal.ChestX-rayshowed
bilateral upper zone opacity suggestive of pneumonia.
Endoscopyrevealed anopening (about1 cm) at the left
esophageal wall just distal to cricopharynx suggestive
ofTEF[Figure 1b].Anasogastric tubewas placed.The
stulawas repaired viaa lateral neck incision ofstula
after 1 week of antibiotics and nutrition support. The
stulous tract was divided, and repair of both trachea
and esophagus was performed with placement of a
muscle ap between them. The patient succumbed to
death on the 4th postoperative day due to uncontrolled
sepsisandshock.
Case 2
An 11-year-old boy presented to the pediatrician
with recurrent vomiting. The symptom was gradually
progressive, and the patients did not improve after
3monthsof symptomatic treatment.Threemonths later,
thepatient developed dysphagia. ChestX-ray showed a
coin-likeobjectintheesophagus[Figure2a].Endoscopy

Children constitute around 80% of patients presenting
with foreign body ingestion. Foreign body ingestion
is common in toddler, especially between 6 months and
3 years of age.[1] About one-third of these patients remain
asymptomatic after ingestion of foreign body.[2] Increasing
use of button battery (BB) in household products and
toys is responsible for the growing incidence of button
battery ingestion (BBI).[3] BBI may cause life-threatening
complications.Wepresentaseriesofthreecomplicatedcases
of BBI with delayed presentation; one of them could not
surviveduetotracheoesophagealstula(TEF)andsepsis.

Case 1
An 11-month-old boy with normal developmental
milestones presented to secondary health care center
with a history of BBI a few hours back, while he was
playingwithamusicaltoy.Thechildwasasymptomatic.
Chest X-ray showed a disc-shaped radio-opaque
shadow at the level of T4 vertebra [Figure 1a]. Serial
radiographs conrmed that the battery migrated to the
lower abdomen near the pelvic brim. One week later,
the child passed battery in the stool. Repeat radiograph
showedno radio-opaque shadow.Atreatment document
didnotshowthefollow-updetails.
Onemonthlater,thepatientreferredtous with2weeks
history of fever, cough, vomiting after feeding, and
Departmentsof Pediatrics
and1Gastroenterology,Indira
GandhiInstitute ofMedical
Sciences,Patna, Bihar,India

Access this article online
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Website: www.jdeonline.in
DOI: 10.4103/jde.JDE_86_17
Address for correspondence: Dr. Ashish Kumar Jha,
Department of Gastroenterology, Indira Gandhi Institute of
Medical Sciences, Patna, Bihar, India.
E‑mail: ashishjhabn@yahoo.co.in
How to cite this article: Suchismita A, Ranjan R, Jha AK, Jha P, Choudhary M,
Dayal VM, et al. Complicated cases of lithium battery ingestion: Delay can
be deadly. J Dig Endosc 2018;9:184-7.
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Suchismita, et al.: Complicated cases of lithium battery ingestion: Delay can be deadly
Journal of Digestive Endoscopy ¦ Volume XX ¦ Issue XX ¦ Month 2018 185
Journal of Digestive Endoscopy ¦ Volume 9 ¦ Issue 4 ¦ October-December 2018
showed a BB in the mid-esophagus. The patient was
referred to us for its removal. We retrieved a lithium
battery (size 20 mm) impacted in the mid-esophagus.
Endoscopy after retrieval revealed a short-segment
mid-esophageal stricture with irregularly thickened
mucosa [Figure 2b]. Endoscopic dilatation of stricture
was performed. The patient was able to swallow
satisfactorilyondischarge.
Case 3
A 3-year-old boy presented to us with a history of
BBI 4 days ago, and dysphagia. The patient was
managed conservatively for 3 days before being
referred to us. An urgent endoscopy was performed
which showed a BB embedded in the mucosa of the
upper esophagus. BB (lithium battery, size 20 mm)
was gently retrieved with the use of the foreign body
forceps [Figure 3a and c]. Repeat endoscopy after
retrieval showed a deep esophageal ulcer and mucosal
burn [Figure 3b]. The patient was kept orally for 48 h;
intravenous uids and antibiotics were prescribed. The
patientwas dischargedon postproceduralday 3. During
a month of follow-up, the patient showed no further
complication.

BB containing lithium is being increasingly used in
various electronic devices. Various types of BB can be
recognized by their imprint codes (CR2032: lithium,
20 mm diameter, 3.2 mm height; SR516: silver,
5.8 mm diameter, 1.6 mm height; LR1154/SR1154:
alkaline/silver, 11.6 mm diameter, 5.4 mm height). In
two of the three cases of current case series, lithium
body (LB) was identied by their imprint codes.
However, Case 1 presented to us after the passage of
thebatteryinthestool;therefore,theparentswereasked
tobring the musicaltoy for conrmationof the typeof
battery.
Studies showed worsening outcomes for BBIs,
paralleling the increase in ingestion of 20 mm LB.
Nearly all severe complications of BBI are associated
with lithium cells. In a study, major complications
were noted in 13% of children (<6 years of age) with
LB (>20 mm) ingestion.[4] In a study by Lahmar etal.,
allchildren(<15yearsofage)presentingwithBBIwith
esophagealimpactionrequiringemergencyremovalwere
analyzed. Twenty-ve of the 26 batteries had diameters
of ≥20 mm. Esophageal impaction time ranged from
2to72h.Thecomplicationsratewas23%.[5]Inanother
studybyLitovitzetal.,complicationsinmajoroutcome
cases were TEF, esophageal perforations, esophageal
strictures, and vocal cord paralysis in 48%, 23%,
38%, and 10% of patients, respectively.[3] Study of 13
severe cases of BBI showed esophageal perforation,
esophageal stricture, and mortality in 31%, 23%,
and 23% of cases, respectively.[6] In a study from the
United States, 12 patients with BBI (all aged <4 years)
expiredmainlybecauseof gastroesophagealhemorrhage
due to aortic-esophageal stula, TEF, and esophageal
perforation.[7] Other complication includes mediastinitis,
aspiration pneumonia, empyema, lung abscess,
pneumothorax, pneumoperitoneum, tracheal stenosis or
tracheomalacia,andspondylodiscitis.[3,8]
Predisposing factors for severe complications include
battery containing lithium, larger battery (>20 mm),
younger age (<4 years), location in the esophagus, and
delayed endoscopy. Ingestion of multiple batteries,
unnoticed ingestion, unknown ingestion time, the
absenceofendoscopyfacility,andmisdiagnosisareother
riskfactorsfor serious complications.[3,9]Theabsenceof
endoscopy facility and the migration of battery toward
 (a)A button battery ona lateral viewof chest X-ray,
(b)short-segmentesophagealstricturewithirregularthickenedmucosa
atthesiteofimpactedlithiumbattery(endoscopy)
b
a
 Endoscopicimages showing impactedlithium battery (a),
esophagealulcerwithmucosalburn(b),andretrieved lithium battery
withimprintcode(c)
c
b
a
 (a) Button battery at level of T4vertebrae (chest X-ray),
(b)tracheo-esophagealstulaafter1monthofbatteryingestion(endoscopy)
b
a
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Suchismita, et al.: Complicated cases of lithium battery ingestion: Delay can be deadly
186186 Journal of Digestive Endoscopy ¦ Volume 9 ¦ Issue 4 ¦ October-December 2018
the lower abdomen on serial radiographs were the
possible reasons for the failure to order endoscopy in
case1ofthe present caseseries.BBIwent unnoticed in
Case2.
The following mechanisms are responsible for the
battery-relatedinjury:(a)electricaldischargehydrolyzes
tissue uids and produces sodium hydroxide at the
battery’s negative pole, (b) leakage of hydroxide ion,
and (c) local pressure effect. Hydroxide is the main
factor for mucosal injury. Hydroxide accumulation
causescontinuedinjurydespitetheremovaloftheBB.In
comparisontootherBB(1.5V),LBislarger(≥20mm),
have a higher voltage (3 V), generate more current
and therefore produces more hydroxide. LB can cause
seriousmucosalinjurywithin2hofingestion.[3,5]
Ina childwith foreignbody ingestion,a carefulhistory
is required to diagnose BBI. The physician should
consider BBI if a toddler presented with symptoms
such as vomiting, dysphagia, coughing, fever, airway
obstruction or wheezing, drooling, chest discomfort,
refusalto eat, choking, or gaggingwith feeding.In two
newstudies fromEurope, vomiting(31.3%), dysphagia/
feeding difculties (31.3%), fever (31.3%), and
fever with a cough (26.42%) were the most common
presenting symptoms; however, 18.8% of the patients
were asymptomatic. In these studies, the batteries were
removed by endoscopic (87.5%) or surgical (12.5%)
methods.[8,10] All patients with suspicion of BBI require
immediate radiograph, except asymptomatic ingestions
of<12-mm sizebatteries inpatients who are more than
12 years of age. Radiographs should be analyzed for
battery’s double-rim or halo effect on anteroposterior
view or step-off on the lateral view, to rule out the
“coin”or“coin-likeobjects.”[4,11]
 Endoscopy is indicated to conrm the diagnosis, assess
theseverityofinjury and toremovethe battery.Current
guideline indicates immediate endoscopy and removal
of esophageal ingested batteries >12 mm in size and in
all patients under 12 years of age.[12] Serious mucosal
injuries can occur without esophageal impaction and
symptoms can be observed even after the passage of
battery.[13] The rst case presented with TEF after a
week of passage of battery. North American society
for pediatric gastroenterology, hepatology, and nutrition
endoscopy committee advocates endoscopic retrieval
of all esophageal as well as gastric ingestions of disc
batteries>20 mm and/orin children <5 years of age.[14]
Smaller batteries lodged in the stomach or beyond in
an asymptomatic patient of an older age should be left
to pass spontaneously. Inspection of the stool or repeat
radiograph in 10–14 days is warranted to conrm
passage.
Several issues are still not clear such as
frequency of endoscopy or imaging, duration
of hospitalization/observation, duration of
esophageal/gastricrest,anduseofantibiotics.Therefore,
the clinician’s individual decision is very important for
themanagementofBBI.
Fistulaformation maybe delayedup to 9–18 days after
batteryremoval;therefore,follow-upisrequired even in
the absence of stula at the time of endoscopy. In our
rstcase,thepatientbecamesymptomaticafter2weeks
of BBI. Children with unnoticed BBI may present
several months later with delayed complications such
asesophageal stricture andtracheal stenosis.One of the
three cases of the current case series presented after 3
monthsofunnoticedBBI.

Lithium battery ingestion can lead to life-threatening
complications. Early endoscopic retrieval of the battery
is required to avoid severe complication in young
children with lithium battery ingestion. Young children
with ingestion of lithium battery of larger size should
receive careful follow-up for early detection of delayed
complication. The patients with unnoticed ingestion of
a BB may present several months later with delayed
complicationssuchasesophagealstricture.
Declaration of patient consent
The authors certify that they have obtained all
appropriate patient consent forms. In the form, the
patient has given his consent for his images and other
clinical information to be reported in the journal. The
patient understands that name and initials will not be
published and due efforts will be made to conceal
identity,butanonymitycannotbeguaranteed.
Financial support and sponsorship
Nil.
Conicts of interest
Therearenoconictsofinterest.

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