Pediatric Emergency Medicine Board Review Course

A 3 yo female is seen in the ED after swallowing a shiny small foreign body yesterday. Her parents think it might have been a dime or nickel when they attempted to take it out of her mouth. She has not had any choking, difficulty breathing or drooling. Today she is complaining of abdominal pain with decreased fluid and solid intake. Her urine output is normal and she has not had a bowel movement since the ingestion. There is no history of fever, vomiting or diarrhea. Her T is 37.5ºC, HR 126, RR 28, BP 124/68, and pOx 100% on RA. On her abdominal exam, she is moderately tender to palpation in the epigastric and LUQ. Her abdominal radiograph is shown and shows a foreign body likely 20 mm in size.

What is the next best step in management?

 Give syrup of ipecac
 Give IV metoclopramide
 Give oral magnesium citrate
 Obtain Gastroenterology consult
 Discharge home with repeat KUB in 3 days

Correct Answer:

Obtain Gastroenterology consult

Explanation:

Obtain Gastroenterology consult. The abdominal radiograph reveals the child ingested a disc (button) battery, which has a distinctive double-rim appearance on plain radiographs, and it appears to be lodged in the stomach. Management of disc battery ingestions have changed over the past several years, with revised guidelines put forth from the National Battery Ingestion Hotline in 2010 and again in 2015. For the symptomatic patient in the vignette, the foreign body should be removed as quickly as possible by endoscopy. For disc batteries found in the stomach of asymptomatic patients, these can be watched and removed only if the foreign body persists 10-14 days post-ingestion or if the patient develops symptoms. However, patients with gastric batteries less than 5 years old and with a battery >20mm in diameter need removal within 24-48 hours. All disc batteries lodged in the esophagus should be removed immediately, regardless of symptoms. Syrup of ipecac is contraindicated in ingestions due to the risk of aspiration. GI motility agents, such as metoclopramide and magnesium citrate, have not been shown to be effective. Discharging home with a repeat KUB in 3 days would be considered for an asymptomatic patient younger than 6 years old with a battery < 15 mm in the stomach.

References:

Kramer RE, Lerner DG, et al. Management of Ingested Foreign Bodies in Children: a clinical report of NASPGHAN endoscopy committee. J. Ped. Gastroenterol. Nutr. 2015;60(4):562-74.

Kurowski, JA and Kay, M. Caustic Ingestions and Foreign Bodies Ingestions in Pediatric Patients. Ped. Clinics of North America. 2017;64(3): 507-524.

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