Tracheo-oesophageal fistula by ingestion of a lithium battery

A 1-year-old boy presented to the paediatric emergency department due to vomiting for 2 hours. His mother noticed that a lithium button battery in the drawer was missing 1 hour before the presentation. X-ray revealed a double ring sign in the oesophagus (Fig. 1). It was removed by forceps fluoroscopically under general anaesthesia 5 hours after onset. On day 7, perforation was not detected by upper gastrointestinal endoscopy; however, his respiratory condition worsened by enteral feeding on day 9. On day 11, upper gastrointestinal imaging visualized the respiratory tract (Fig. 2). Hence, a nasoduodenal tube was placed fluoroscopically to improve his respiratory condition. Upper gastrointestinal endoscopy revealed a tracheooesophageal fistula on days 35 and 52 (Fig. 3). It finally resolved on day 73.

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FIG 1.

Chest X-ray showing a double ring sign in the oesophagus

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FIG 2.

Upper gastrointestinal contrast imaging indicated an opening between the oesophagus and the trachea

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FIG 3.

Upper gastrointestinal endoscopy showed a tracheooesophageal fistula. The intubation tube (black arrow) and the feeding tube (white arrow) were visible through the fistula

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The incidence of accidental button battery ingestion is increasing in Japan. Eight cases occurred in the 1990s, and 23 in the 2010s.¹ A button battery located in the oesophagus must be removed within 2 hours to avoid serious and delayed complications, including death.² Therefore, the location of the button battery should be ascertained by X-ray if the patient is <12 years old.³

The likelihood of oesophageal perforation is low within 12 hours after ingestion, and perforation in two-thirds of patients was evident after 9 days.³ Tracheo-oesophageal fistula was found several days later because of worsening respiratory condition. Therefore, oesophageal perforation must be considered in patients who have ingested a button battery and show worsening respiratory condition.