COMMENTARY

With Button Battery Ingestion, Watch for Gastric Injury

Digestive Disease Week (DDW) 2019

Alok S. Patel, MD; Racha T. Khalaf, MD

Disclosures

July 15, 2019

This transcript has been edited for clarity.

Alok S. Patel, MD: Hi, everyone. This is Dr Alok Patel with Medscape at Digestive Disease Week 2019. I'm joined by Dr Racha Khalaf, who is going to talk to me about gastric injury from button battery ingestions. We all know about esophageal injuries, but Dr Khalaf's study[1] looks at gastric injury, which is incredible. Thank you so much for talking with us.

Racha T. Khalaf, MD: Thank you for having me. It's a pleasure.

Patel: Can you tell me about the study and why you chose to look into this?

Khalaf: This is the first and largest pediatric study looking at gastric injury from button batteries. This started because we had a 9-year-old patient who presented to our center in Colorado, and had gastric injury and erosion and a perforation in his stomach after swallowing a button battery. We looked at the guidelines, and they did not recommend removal at the first presentation for this patient. He then came back, and we had to take the battery out because it was still in his stomach after several days.

We went to a national conference and chatted with some of our colleagues about the guidelines, and realized that we and other providers nationwide were seeing cases where there is gastric injury from these button batteries, but there is nothing reported in the literature. We formed a collaboration to get all of our data together and let other clinicians and the world know that button batteries are not as benign as we think.

Patel: The traditional thought is that if you take an x-ray and the battery is past the esophagus, we're kind of like, "We're okay. We can let it pass." But you're saying that may not be the case.

Khalaf: Yes. Our guidelines from the National Capital Poison Center and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition tell us that it's okay and it's safe to observe these patients, especially if they're older than 5 years and if the battery is < 2 cm. But in our study, we show that 60% of patients who had ingested button batteries had visible injury on endoscopy. There was a wide range of injury: mucosal erosions, ulcerations, and even deep burns to gastric mucosa.

Patel: When you were looking at these patients with gastric injuries, did you see any types of patterns in the age range or duration of how long the battery was in there before they presented?

Khalaf: Yes. There are two parts to that question. All centers who collected data are tertiary care centers. The average time of removal for these batteries was about 15 hours. We looked at the correlation between the time of how long the battery was in there and the injury, and we noticed that there was no correlation. We know from other studies that it only takes minutes to just a couple of hours for batteries to cause injury in the esophagus.

Patel: People think that these batteries leak, but that is not necessarily the case. They can cause an alkaline burn. You are saying that a burn can happen in the stomach just as easily as it can in the esophagus.

Khalaf: Yes.

Patel: Have you seen cases where the radiologist says, "This might be distal to the esophagus so we're okay," when in fact it was in the esophagus or vice versa?

Khalaf: Absolutely. We didn't ask that specific question in our study. However, I can tell you that for the patient who had the gastric perforation, the first x-ray obtained was read as distal to the stomach, but it was actually in the stomach, because when that patient came back again the battery was still lodged in the stomach and was now eroding into the lining of the stomach. Even an experienced radiologist can be fooled. We always advocate that every physician should look at their imaging themselves, and if you are in doubt, get multiple views.

Patel: Where are the batteries coming from? Where are kids finding them?

Khalaf: These batteries are everywhere. They are cheap and widely prevalent. They are in singing greeting cards; be cautious with those because if a child pulls, they can easily get that battery out. They are in remote controls, so if you have any products with remote controls, make sure that the battery is secured. A lot of them are not secured with screws. They are in watches. Sometimes parents replace an old [watch] battery and leave it sitting on a counter or in a jar somewhere because they think it's dead. It looks just like candy and a kid swallows it. Even old batteries can cause significant injury.

Patel: We know that batteries are present, and kids will get a hold of them. Based on your findings, we know that they can cause serious injury. What is your take-home point for all of the pediatricians, family doctors, emergency medicine doctors, and gastroenterologists seeing this? What do you want every doctor to know about your findings?

Khalaf: We want everybody to know that these batteries are not only harmful to the esophagus, causing bad damage including death, but they can be harmful to the stomach lining. We want them to know that harm and injury do not correlate with symptoms. In our study, only about 20% had symptoms but 60% had injury. We want providers to be aware of gastric damage, and we want providers to pull out these batteries from the stomach promptly.

Patel: The word is out. Dr Khalaf, thank you so much for your work. It's going to make a difference.

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