Button battery or sharp object

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Button battery

Sharp/pointed object

In human ingestions, these effects can be seen clinically, although only approximately 0.5% of ingestions result in major complications.$^{40}$ A systematic review of 24 case reports and 7 articles demonstrated that complications are most commonly seen with lithium-ion BBs, larger BBs (>2 cm) and BBs that are new or unused.$^{46}$ Complications include ulceration (22%), perforation (18%), and stricture (13%). A devastating complication of BB ingestion, an aorto-esophageal fistula, can present up to 18 days after BB removal, due to ulcerative healing leading to fistula formation and massive GI hemorrhage.$^{47}$  A systematic review found vascular hemorrhage to be the most common cause of death from BB ingestion; only 18% of vascular hemorrhage cases from the National Poison Center registry were deemed survivable.$^{48}$

Treatment

Button batteries in the esophagus should be removed endoscopically as quickly as possible—ideally within 2 hours—regardless of symptoms, battery type, or size. There is more controversy surrounding the treatment of gastric and intestinal button batteries (see below). The National Button Battery Hotline at 1-800-498-8666, based out of the Rocky Mountain Poison Center in Denver, CO, can be a resource in complicated cases and provides 24/7 guidance to clinicians.

If the patient is older than 12 months, honey is one measure that can be taken while awaiting endoscopy. (Honey for infants <12 months is not recommended due to the risk for infant botulism.) Animal studies have shown that honey and sucralfate neutralize the elevated tissue pH that results from alkaline batteries, and decreases the thickness and size of burns in vivo.$^{88}$ Exceptions to the pre-endoscopy nil per os (NPO) rule can be made in the ED in order to give 5 to 10 mL of pure honey or sucralfate to patients who are able to tolerate it if the ingestion was within 12 hours. The National Capital Poison Center recommends up to 6 doses, given every 10 minutes.$^{89}$

While even sharp objects can pass uneventfully through the GI tract, all sharp or pointed objects within endoscopic reach should be removed, due to the increased risk for perforation. Those in the esophagus should be removed emergently within 2 to 6 hours, and sharp objects in the stomach or duodenum within 24 hours, based on American Society for Gastrointestinal Endoscopy guidelines.$^9$ If sharp objects pass beyond endoscopic intervention, surgical management may be necessary if complications occur. Most objects, even sharp ones, that make it to the small intestines will pass spontaneously without intervention, and the literature suggests a conservative approach is appropriate if sharp objects have progressed beyond reach. Weiland and Schurr reviewed cases of sharp or pointed FBIs, many of which were multiple or recurrent ingestions in the same patient, and 23 objects were beyond endoscopic intervention and were managed conservatively with admission and observation. Of those, 22 (97%) passed spontaneously, and one patient went to the OR after developing an acute abdomen.$^{18}$ While distal sharp objects can be managed expectantly in this way, all patients should have consultation with a surgical specialist, as surgeon preference will inform management and observation strategy.

For fish or chicken bones found in the hypopharynx or proximal esophagus, ENT may be the most appropriate specialist to consult. They can often remove proximal, sharp bones by trans-nasal flexible esophagoscopy or laryngoscopy, with very little sedation. Bones found more distally should be managed as other sharp foreign bodies and removed if within endoscopic reach. The challenge comes in patients with suspected fish or chicken bone ingestion, but no findings on CT scan. Numerous case reports exist that describe perforated fishbones found on laparoscopy in patients with initially negative CTs.$^{96}$ Therefore, in cases of suspected animal bone ingestions with persistent symptoms (foreign body sensation, dysphagia, odynophagia, or abdominal pain) gastroenterology or surgery should be consulted. For a patient with suspected animal bone ingestion, negative imaging, and who remains asymptomatic, outpatient follow-up in 1 to 2 weeks is appropriate.$^{97}$