Today’s morning report is courtesy of Dr. Cioe.
Here’s the case:
A 3 year old female presents to ED with 3 day history of vomiting, throat pain, abdominal pain. On exam, the patient is febrile, tachycardic, and ill appearing. The patient has a clear pharynx, but pain on swallowing. A CXR is taken (shown below). What is the diagnosis and what are the keys to stabilization and treatment?
Diagnosis?
Esophageal Foreign Body = Button Battery
Continue reading below for the resolution of the case. . .
The patient was correctly identified by ED staff as having a swallowed button battery lodged in the esophagus. You can tell it is in the patient’s esophagus because the orientation of the battery is with the flat surface in the coronal plane, if it were displayed with the flat surface in the saggital plane, it would be more likely a foreign body in the trachea. One key to this case is that the double ridge on the object is a key feature of the button battery. A button battery in the esophagus is a surgical emergency. These batteries often leak and have highly alkaline contents which are corrosive. Also the direct contact of the battery with the mucosal surface forms and electric charge which further burns and injures the mucosa directly.
This child was taken emergently to the OR by ENT and was found to have a microperforation of her esophagus. Children with established mediastinitis from an esophageal perforation have a high mortality rate. Management is primary surgical removal of the foreign body, supportive care and in this case because the child was febrile and showed signs of infection, IV antibiotics covering GI and oral flora including anaerobes. Surgical consultation should be obtained prior to any additional workup, lab studies or CT scans which are not necessary to make the diagnosis.
That’s the case, feel free to leave your comments below!
Jay Khadpe MD
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