Abstract
Objectives:
Given the potential for devastating complications associated with esophageal impaction of a button battery, there is a need to distinguish between a button battery and look-alike stacked coins at the time of presentation. Given there have been no studies analyzing differences in radiographic density between these two entities, the study objective was to determine if a difference exists between esophageal coin and button battery radiographic density on plain radiograph and to describe the operative and treatment course following these two distinct entities of ingestion.
Methods:
Retrospective case series following button battery or stacked coin ingestion in a tertiary care pediatric hospital from 2003 to present. Radiographic density of each button battery and stacked coin was calculated by dividing the foreign body radiographic density by the mean density of two background radiographic sections. Radiographic density of coins versus batteries was compared using t-tests.
Results:
There were 22 patients identified with button battery ingestion and 47 with stacked coins. Median (range) radiographic density of button batteries on anteroposterior view was 1.16 (0.37– 2.19) x background compared to 1.13 (0.09–2.65) x background of stacked coins, p=0.198. There was similarly no statistically significant difference in lateral views, p=0.622.
Conclusion:
Our study suggests that radiographic density measured on diagnostic x-ray does not prove a reliable adjunctive measure to distinguish an innocuous stacked coin ingestion from the far more ominous button battery and highlights the need for prompt operative evaluation for any suspected button battery ingestion.
Keywords: button battery, battery ingestion, esophageal battery, esophageal foreign body, esophageal coin
1.1. Introduction
In recent years, the devastating complications associated with esophageal button battery ingestion in pediatric patients have been well described in the literature. Due to the risk of serious sequelae including esophageal stricture, perforation, tracheoesophageal fistula, or even erosion into the aorta with subsequent hemorrhage that can occur within hours of ingestion, standard of care requires emergent removal of all suspected button batteries lodged in the esophagus1–3. Radiographically, button batteries are described as having a characteristic two-layer appearance when visualized on-end, or a circle-within-a-circle appearance when seen front-to-back4,5. Interestingly, two coins layered against one another can mimic this radiographic appearance and thus become managed as a button battery with emergent removal4,6.
While the radiographic similarities have been qualitatively described4,6, there have been no studies analyzing differences in the radiographic density between coins and button batteries in order to distinguish between the two entities. As such, the goal of our study was to determine if a significant difference exists between esophageal coin and button battery radiographic density on plain radiograph in order to help guide management algorithms for pediatric patients presenting after unwitnessed foreign body ingestion.
1.2. Materials and Methods
Following approval of the Institutional Review Board (PRO17090816, PRO18070274), a patient list was generated using a database available within our tertiary care pediatric hospital that includes all patients who underwent removal of an esophageal foreign body using the Text Information Extraction System (TIES). All patients with documented button battery or multiple coin ingestion from January 1, 2003 through December 31, 2018 were included in retrospective analysis. Patients were excluded if the foreign body was in a location other than the esophagus. Patients with single penny ingestion were included as an additional reference group.
Patient demographics, operative findings including documented esophageal appearance (normal, mild mucosal ulceration/eschar, esophageal necrosis, or perforation), intraoperative placement of a nasogastric tube, and post-operative measures including performance of a gastrograffin esophagram and use of a proton pump inhibitor were collected.
For each pre-operative radiograph, a region of interest was drawn around the foreign body and mean radiographic density was measured. Due to variability in exposure settings, values were normalized to those taken from regions of interest (ROI) encompassing adjacent bone. For anteroposterior radiographs, circular ROIs from the left and right clavicle were used. Normalized radiographic density was then calculated as: mean density foreign body / mean ROI density from left and right clavicle. For lateral radiographs, circular ROIs were drawn from the second and third ribs and the normalized radiographic density was calculated as: mean density foreign body / mean density of second and third rib. The final radiology interpretation was reviewed with respect to whether a button battery was documented as a possible diagnosis, definitive diagnosis, or neither.
Using a p value < 0.05 to determine statistical significance, age at time of presentation and radiographic density in patients with ingestion of stacked coins or button batteries were compared using Wilcoxon rank-sum tests with Bonferroni correction in order to account for non-normal distribution. These were compared to ingestion of a single penny to provide an additional reference group. Patient characteristics were compared between the groups using Chi-squared tests and all analyses were performed using Stata 13.1/SE (StataCorp, College Station, TX).
1.3. Results
Overall, there were 22 patients with button battery ingestion and 47 patients with stacked coin ingestion who met inclusion criteria. An equal number of patients (47) with single penny ingestion were randomly selected to comprise a control group for comparison. Median age at time of presentation was 2.6 years (range 1.0–8.1 years) for button battery ingestion, 3.3 years (range 0.4–11.0 years) for stacked coins, and 2.2 years (range 0.6–10.1 years) for single penny. There was a documented history of witnessed ingestion in 6 patients (27.3%) with button battery ingestion, 20 patients (42.6%) with stacked coin ingestion, and 10 patients (21.3%) with single penny ingestion.
On anteroposterior radiograph, median normalized radiographic density of button batteries was 1.16 (range 0.37–2.19) compared with 1.13 (range 0.09–2.65) for stacked coins and 1.19 (range 0.09–2.47) for single penny (button battery vs. stacked coin p=0.198, button battery vs. penny p=0.690). On lateral radiograph, median normalized radiographic density of button battery was 0.81 (range 0.09–2.03) compared with 0.69 (range 0.21–2.78) for stacked coin and 0.83 (range 0.13–6.30) for single penny (button battery vs. stacked coin p=0.622, button battery vs. penny p=0.970). In assessing final radiology interpretation of the plain radiograph, all button batteries were accurately identified as such. Interestingly, 12 (25.5%) stacked coins were interpreted as either suspected or definite button battery by final radiology read and 11 patients (23.4%) with stacked coins compared with 21 (95.5%) patients with button battery were taken emergently to the operating room for removal of suspected button battery based upon radiographic appearance, p<0.001.
Following button battery ingestion, 1 patient (4.6%) had normal mucosal appearance on esophagoscopy at the time of removal, 7 patients (31.8%) had evidence of mild ulceration or eschar, 13 patients (59.1%) had evidence of more advanced esophageal necrosis, and 1 patient (4.6%) had an esophageal perforation. All patients with stacked coins had mild ulceration/eschar (31 patients, 73.8%) or findings within normal limits (11 patients, 26.2%). No patients with stacked coins received a nasogastric tube, while a nasogastric tube was placed intraoperatively in 12 patients (54.6%) following button battery ingestion. Twenty-one patients (95.5%) with button battery ingestion compared with 6 patients (12.8%) with stacked coins underwent an esophagram prior to resumption of a per oral diet. Proton pump inhibitors were prescribed in 16 patients (72.7%) after button battery ingestion and 1 (2.1%) patient with stacked coins. No patients required gastrostomy tube placement and there were no deaths related to foreign body ingestion.
1.4. Discussion
As estimates of at least 40% of all pediatric foreign body ingestions are unwitnessed and thus represent an unknown entity7, clinicians generally rely upon radiographic appearance to guide triage and subsequent timing of foreign body removal. While the classic characteristic two-layer appearance when visualized on-end, or a circle-within-a-circle appearance when seen front-to-back is well described with respect to identification of button batteries radiographically4, stacked coins oftentimes mimic this appearance. To date, the similar radiographic appearance of stacked coins compared to button batteries has been described in several isolated case studies6,8,9 however our study is the first to compare these distinct clinical entities in a case series approach. Additionally, no studies to date have analyzed differences in radiographic density as was performed in our study.
In keeping with previously published reports2,3, the inability to definitively distinguish between stacked coins and button batteries on radiograph was demonstrated in our series, as almost half of all patients (45.5%) presenting with stacked coin ingestion were believed to represent a button battery on final radiology read and 36% were subsequently taken emergently to the operating room for foreign body removal. The one patient with coin ingestion interpreted as likely button battery on radiograph who was not taken urgently for removal had a history of witnessed ingestion and therefore removal was appropriately delayed until later in the day.
In our series, normalized radiographic density was not significantly different between stacked coins and button batteries on plain radiograph. Given very similar diameters between the most common commercially sold button battery in the United States and most coins (Table 1), diameter similarly fails to provide a sound distinction between the two entities. Moreover, subgroup analysis between different stacked coin types (pennies versus quarters) also failed to show a difference with respect to radiographic density. While radiographic appearance can generally be utilized to help guide decision-making and distinguish between a single coin and a button battery, a low threshold for urgent removal of any potential button battery must remain the standard of care.
Table 1:
Comparative dimensions of most common coins and most common lithium battery in United States.
| Foreign body | Dimensions (width x height (mm)) |
|---|---|
| Dime | 17.9 × 1.4 |
| Penny | 19.5 × 1.6 |
| Nickel | 21.2 × 2.0 |
| Quarter | 24.3 × 1.8 |
| CR2032 lithium battery | 20.0 × 3.2 |
Following button battery ingestion, post-operative management is largely determined based upon intraoperative esophageal appearance. At our institution, there exists a low threshold to place a nasogastric tube under direct visualization intraoperatively as esophageal necrosis, perforation, and/or stricture can occur in a delayed fashion. Similarly, all patients are placed on a 2-to 4-week course of a proton pump inhibitor, as was demonstrated in our patient cohort. An esophagram is then obtained prior to resumption of a per oral diet to ensure there are no luminal irregularities. In our series, one patient had evidence of a small area of luminal outpouching on post-ingestion esophagram for which the patient was kept nothing by mouth for an additional 3 days; interval esophagram at that time showed resolution of the area in question and oral diet was then safety initiated.
As we move towards limiting or eliminating radiation exposure particularly in the pediatric setting, further studies examining radiographic as well as ultrasonographic diagnostic imaging modalities are needed to continue to optimize management algorithms following unwitnessed ingestion in pediatric patients.
1.5. Conclusions
Given the potential for devastating complications associated with esophageal impaction of a button battery, there is a need to distinguish between a button battery and all other clinical entities at the time of presentation. Our study is the first to compare radiographic density of stacked coins versus button batteries and suggests that radiographic density on plain radiograph is not a reliable adjunctive measure in the management algorithm of patients presenting after unwitnessed foreign body ingestion in order to distinguish button batteries from less harmful stacked coins. Given the possibility of any unwitnessed ingestion posing a potential risk of button battery ingestion, management algorithms should continue to recommend prompt operative evaluation in all potential cases following suspected button battery ingestion as well as any foreign body that radiographically mimics button battery appearance.
Figure 1:
While the circle-within-a-circle appearance classically describes the anteroposterior radiographic appearance after button battery ingestion (left), this is easily mimicked after stacked coin ingestion (right).
Figure 2:
The step-off classically described in lateral radiographic view after button battery ingestion (left) is again easily mimicked after stacked coin ingestion (right).
Acknowledgements
The project described was supported by the National Institutes of Health through Grant Number UL1 TR001857. The TIES system is supported by Grant Number U24 CA180921 from the National Cancer Institute (NCI).
Footnotes
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Oral presentation information: Presented at podium at the ASPO Summer Meeting: Frontiers in Pediatric Otolaryngology in Vail, CO on July 18, 2018.
There are no financial disclosures.
The authors have no conflict of interest to disclose.
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