Oesophagitis, caustic ingestion and oesophageal injury — formative SAQs

SAQ 1 — The toddler with a suspected oesophageal button battery (20 marks, ~15 minutes)

A previously well 18-month-old girl is brought in with sudden drooling, refusal to feed and a fussy cough for two hours. Her older sibling's toy has an open battery compartment and a 20 mm lithium coin cell is missing. She is not in respiratory distress and her observations are stable. ^[1]

Questions

1. State the most likely diagnosis and why it is a time-critical emergency. (4 marks) ^[1]
2. Describe the first investigation and the specific radiological signs that confirm the diagnosis and distinguish it from a coin. (4 marks) ^[1]
3. Outline your immediate management, including any pre-removal measure and its eligibility, and the definitive step and its timing. (6 marks) ^[2]
4. State the delayed complications you must anticipate and how long the risk lasts. (3 marks) ^[1]
5. State the counselling you give the family at discharge. (3 marks) ^[1]

Model answer (must-hit)

1. The most likely diagnosis is an oesophageal button battery. It is a time-critical emergency because an intact lithium coin cell lodged against the moist mucosa completes an electrical circuit, generates hydroxide at its negative pole, and produces a liquefactive alkaline burn that begins within two hours; the injury can become transmural and erode into the trachea or aorta, so the battery is removed within two hours rather than observed. ^[1]
2. The first investigation is an urgent plain radiograph of the neck, chest and abdomen. A button battery shows a halo or double-ring sign on the frontal (anteroposterior) view and a step-off on the lateral view, which distinguishes it from a coin; the lateral view also shows the orientation of the narrow negative pole, which is the site of the deepest burn and the wall at greatest risk. ^[1]
3. Escalate immediately for emergent endoscopic removal within two hours of ingestion, keeping the child nil by mouth and calling the endoscopy and anaesthetic teams. While theatre is prepared, give a pre-removal mitigation because this child is eligible — older than twelve months, within twelve hours of ingestion, and able to swallow — with honey 10 mL orally every 10 minutes for up to six doses to buffer the alkaline burn; sucralfate suspension is the in-hospital alternative. Neither is given if there is suspected perforation, sepsis or airway compromise, and neither delays removal. ^[2]
4. Anticipate delayed complications: tracheo-oesophageal fistula, aorto-oesophageal fistula with catastrophic bleeding, oesophageal perforation and mediastinitis, stricture, vocal cord paralysis and spondylodiscitis. The aorto-oesophageal fistula can present with fatal bleeding up to about three weeks after the battery is removed, so the risk period extends well beyond the removal itself. ^[1]
5. Counsel the family that removal ends the burn but not the risk, and that they must return immediately if the child vomits blood or has any bleeding, because a sentinel bleed may herald a fatal aorto-oesophageal fistula for up to three weeks. Give injury-prevention advice about securing battery compartments and storing loose lithium cells out of reach, and arrange the planned follow-up. ^[1]