Surprising cause of dysphagia in an elderly male

Abstract

A 73 year old man presented to his primary care physician with sudden onset dysphagia to solids and liquids. He urgently completed a barium swallow study showing what was believed to be a coin. Endoscopic removal subsequently revealed it was a lithium battery. Consequences and management of lithium battery ingestion are discussed.

A 73-year-old male with a medical history of GERD on proton pump inhibitor therapy complained to his physician of sudden onset dysphagia to solids and liquids with regurgitation of undigested foods. Urgent barium swallow was ordered, which showed a 3 cm disc-like foreign body lodged within his distal esophagus thought to be a coin (Fig. 1). Removal of the foreign body by emergent endoscopy revealed a surprising finding. The coin was actually a circular 20 mm Energizer 2032 lithium button battery commonly used to power small household appliances. He had extensive focal esophagitis at the site of impaction and later admitted to accidentally ingesting a lithium battery. The patient remained on proton pump inhibitor therapy post ingestion and 6 weeks later had a repeat EGD that showed complete resolution of the focal esophagitis.

Fig. 1.

Barium video swallow.

Button battery ingestion is an uncommon event with 11.1 cases per million reported in 2009, however with the increased use of lithium button batteries, a trend in fatal and disabling outcomes is on the rise (1). Twenty millimeter lithium batteries are attractive products to power many household items, including hearing aids, watches, remote controls, toys, and so on, due to the longer battery life, higher voltage, and portable size. A button cell is a small single-cell battery shaped as a cylinder typically ranging from 5 to 20 mm in diameter and 1–6 mm in height. This small size makes it easy to mistake as a pill, a common cause in accidental adult ingestion. Lithium coin batteries are 3-V cells generating a higher current than other batteries, consequently producing more hydroxide. Hydroxide is a caustic agent to esophageal tissue resulting in local esophagitis, perforation, tracheoesophageal fistula, esophageal stricture, vocal cord palsy, aspiration pneumonia, and even cardiopulmonary arrest (1, 2).

Prompt identification of a lithium battery ingestion is imperative to prevent poor outcomes since time to removal is directly related to the extent of damage. Removal of the batteries within 2 hours of ingestion ensures minimal disability (3). Unfortunately, 15.5% of lithium battery ingestions are mistaken for pills and often the patient is unaware of the mistake (1). Therefore, a thorough history with inquiry into pill habits is important to discover the potential etiology and uncover the time of ingestion. Dysphagia, chest pain, abdominal pain, melena, hematemesis, or nausea after suspected or known ingestion should be confirmed by imaging to assess placement of the battery. Button batteries may be identified on anteroposterior and lateral chest x-rays or barium swallow study (4–6). Currently, there is no consensus for the treatment. If it has passed through the esophagus, watchful waiting or exploratory laparotomy is the approach. If the lithium battery is in the esophagus, most clinicians recommend for removal by therapeutic endoscopic procedure to avoid permanent or fatal damage (2).

Lithium button battery ingestion is a potentially life-threatening event that requires a high clinical suspicion as most elderly patients are unaware of the ingestion due to mistaking the small battery for a medication. Imaging to assess for battery placement and prompt endoscopic removal (within 2 hours) is imperative if within the esophagus to minimize permanent disability or death.