#MiniTeach: A Dangerous Tummy Button
1. What Priority should she have at primary and secondary nurse assessment?
If the child is asymptomatic, she should be at a Priority 2. If there are any concerns regarding her airway, breathing or circulation she should be a Priority 1. The assessment should aim to establish how big the battery was; when it was ingested and whether the child has had any respiratory or GI symptoms.
2. What sort of X-ray should you request?
You should request a neck – abdomen X-ray: usually the radiographers will know to include the neck and upper abdomen in these cases if you request a straightforward CXR, but it’s always worth mentioning this on the form. You need to try and make sure you capture all the possible areas where the battery can be on one film.
3. What does the X-ray show?
The CXR shows that the button battery is more than likely in the stomach. You can tell it’s a button battery as it has a ‘double rim’.
The untrained eye may look at the film and believe that the battery has passed beyond the stomach and is in the small intestine, but close observation will show you that this is an erect film. In an erect film the stomach lies more inferiorly and centrally. It can be difficult for a non-radiologist to make this call as it relies on years of pattern recognition, so if you’re not sure – give the radiologists a call.
4. How should this patient be managed and what’s the evidence for this?
Batteries in the oesophagus should be urgently removed with endoscopy as they tend to cause the most damage if they get lodged here. There’s no good evidence base for the management of batteries in the stomach. We have a local guideline (see attachment) so follow this.
If the patient is symptomatic they need appropriate work up and referral to paediatric surgeons. If the patient is asymptomatic they will need a repeat X-ray in 8-12 hours to ensure that the battery has passed into the bowel where it is less likely to cause damage.
5. What are the most serious complications of button battery ingestion?
The most serious complication is aorto-oesophageal fistula, which can lead to rapid exsanguination.
A short time-lapse demonstrating the dangers button batteries pose infants when accidentally ingested. Watch the full talk by Dr Rachel Rowlands for NHS England here.
6. What’s the pathophysiology of button battery damage?
The battery produces an electric current that results in hydroxide production due to a chemical reaction with tissue fluid. This then causes necrosis.
Dr Rowlands and Dr Davies have written a paper on this subject. And here is another useful review worth reading. We've also produced an infographic (see below) as well as a related #LightningLearning on GI Bleeds that may indicate a button battery has been ingested.