Paeds · gastroenterology-hepatology-and-nutrition
Oesophagitis, caustic ingestion and oesophageal injury
Also known as Oesophagitis, caustic ingestion and oesophageal injury · Button battery ingestion · Caustic (corrosive) oesophageal injury · Eosinophilic oesophagitis · Reflux oesophagitis · Oesophageal foreign body
Fellowship guide to paediatric oesophagitis and oesophageal injury, built around the button-battery emergency: the reflux, eosinophilic, infective and pill causes of oesophagitis; the liquefactive alkali versus coagulative acid mechanism of caustic ingestion with the Zargar endoscopic grading; and the lithium coin-cell button battery that generates hydroxide at its negative pole and burns through the oesophageal wall within two hours, with honey and sucralfate as the pre-removal mitigations, emergent endoscopic removal, and the aorto-oesophageal fistula that can exsanguinate a child days after the battery is out.
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- A witnessed or suspected button battery in the oesophagus is a surgical emergency — a 20 mm lithium coin cell can burn through the mucosa within two hours, so it is removed endoscopically within two hours of ingestion, not observed
- Drooling, refusal to feed, chest or throat pain, stridor or a coin-like opacity with a halo (double-ring) sign on X-ray in a toddler is a button battery until proven otherwise — do not wait for symptoms to declare themselves
- New haematemesis, a sentinel bleed or massive bleeding in a child who has had an oesophageal button battery is an aorto-oesophageal fistula until proven otherwise and can exsanguinate within minutes — it occurs up to three weeks after the battery is removed
- After caustic ingestion, never induce vomiting, never give a neutralising acid or alkali, and never pass a blind nasogastric tube — each re-exposes the oesophagus to the corrosive or risks perforation
- Stridor, hoarseness or respiratory distress after caustic ingestion signals airway burn and impending obstruction — secure the airway early, before oedema makes intubation impossible
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- Oesophagitis, caustic ingestion and oesophageal injury
- Oesophagitis and oesophageal injury: causes, the button-battery emergency, and caustic ingestion management
- Button battery and caustic ingestion: recognition, emergency management, and complications
- Short case: the toddler with drooling and feed refusal after a witnessed ingestion
- Long case: the child with a caustic oesophageal stricture and recurrent dilatation
- Oesophagitis and oesophageal injury: classification, pathophysiology, and management
- Gastroenterology: the child with dysphagia and oesophageal injury
- Gastroenterology: oesophagitis and caustic oesophageal injury
- Patient Care: oesophagitis, caustic ingestion and oesophageal injury
- Medical Expert: oesophagitis, caustic ingestion and oesophageal injury
Overview & Definition
Oesophageal injury in a child spans two very different worlds that share one lumen. On one side is oesophagitis, the inflammation of the oesophageal lining from reflux, allergy, infection or medication — a chronic and usually treatable problem. On the other side is acute corrosive injury, where a swallowed caustic chemical or a lodged button battery burns the wall in real time. The whole skill lies in telling the slow inflammatory problem from the fast destructive one, because their timescales, dangers and management could not be more different. [7]
The single most important idea in this topic is that a lithium coin-cell button battery impacted in the oesophagus is a surgical emergency measured in hours, not days. Once lodged against the moist mucosa it completes an electrical circuit through the tissue, generates hydroxide at its negative pole, and produces a spreading liquefactive burn that begins within two hours. Everything else in this topic can wait for a clinic; a button battery in the oesophagus cannot. [1] [4]
References12ShowHide
- [1]Mubarak A; Benninga MA; Broekaert I; Dolinsek J; Homan M; Mas E; Miele E; Pienar C; et al Diagnosis, Management, and Prevention of Button Battery Ingestion in Childhood: A European Society for Paediatric Gastroenterology Hepatology and Nutrition Position Paper. J Pediatr Gastroenterol Nutr, 2021.PMID 33555169
- [2]Anfang RR; Jatana KR; Linn RL; Rhoades K; Fry J; Jacobs IN pH-neutralizing esophageal irrigations as a novel mitigation strategy for button battery injury. Laryngoscope, 2019.PMID 29889306
- [3]Jatana KR; Litovitz T; Reilly JS; Koltai PJ; Rider G; Jacobs IN Pediatric button battery injuries: 2013 task force update. Int J Pediatr Otorhinolaryngol, 2013.PMID 23896385
- [4]Litovitz T; Whitaker N; Clark L; White NC; Marsolek M Emerging battery-ingestion hazard: clinical implications. Pediatrics, 2010.PMID 20498173
- [5]Litovitz T; Whitaker N; Clark L Preventing battery ingestions: an analysis of 8648 cases. Pediatrics, 2010.PMID 20498172
- [6]Kramer RE; Lerner DG; Lin T; Manfredi M; Shah M; Stephen TC; Gibbons TE; Pall H; et al Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee. J Pediatr Gastroenterol Nutr, 2015.PMID 25611037
- [7]Contini S; Scarpignato C Caustic injury of the upper gastrointestinal tract: a comprehensive review. World J Gastroenterol, 2013.PMID 23840136
- [8]Hoffman RS; Burns MM; Gosselin S Ingestion of Caustic Substances. N Engl J Med, 2020.PMID 32348645
- [9]Zargar SA; Kochhar R; Mehta S; Mehta SK The role of fiberoptic endoscopy in the management of corrosive ingestion and modified endoscopic classification of burns. Gastrointest Endosc, 1991.PMID 2032601
- [10]Rosen R; Vandenplas Y; Singendonk M; Cabana M; DiLorenzo C; Gottrand F; Gupta S; Langendam M; et al Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr, 2018.PMID 29470322
- [11]Lucendo AJ; Molina-Infante J; Arias Á; von Arnim U; Bredenoord AJ; Bussmann C; Amil Dias J; Bove M; et al Guidelines on eosinophilic esophagitis: evidence-based statements and recommendations for diagnosis and management in children and adults. United European Gastroenterol J, 2017.PMID 28507746
- [12]Dellon ES; Liacouras CA; Molina-Infante J; Furuta GT; Spergel JM; Zevit N; Spechler SJ; Attwood SE; et al Updated International Consensus Diagnostic Criteria for Eosinophilic Esophagitis: Proceedings of the AGREE Conference. Gastroenterology, 2018.PMID 30009819