INGESTED CYLINDRICAL BATTERIES IN AN INCARCERATED MALE – A CAUSTIC TALE! L. Dunphy, M. Maatouk, R. O’ Hara. Department of Surgery, Milton Keynes Hospital. The Oxford Symposium, 3rd National Conference for Foundation Doctors.

CONTENTS Introduction Case Presentation Discussion Questions

INTRODUCTION Accidental ingestion – paediatrics ….. button batteries In adults, deliberate ingestion is common in the psychiatric population. Also common in prison inmates. Those with learning disabilities Intoxication Fig.1. Button Battery.

CASE PRESENTATION A 37 year old incarcerated male presented to A+E at 22.00 hrs Presenting Complaint: Generalised, mild abdominal pain Self-inflicted laceration to his left anti-cubital fossa History of Presenting Complaint: Fig.2. Cylindrical Batteries. Swallowed 8 intact cylindrical batteries 7 hours previously Inserted a razor blade wrapped in plastic in his rectum Fig.3. Razor Blade.

MEDICAL HISTORY Allergies: amitriptyline, diclofenac, chlorpromazine. Self-harm Emotionally unstable and paranoid personality disorder Emergency laparotomy 2013 Allergies: amitriptyline, diclofenac, chlorpromazine. Pregabalin 450 mgs od Fluoxetine 60 mgs od Clonazepam 2 mgs bd

CLINICAL EXAMINATION Baseline observations stable Soft tissue damage to antero-lateral aspect of left elbow Abdominal Examination Soft, non tender, mild distension Bowel sounds present Flatus PR: unable to retrieve the razor blade No clinical signs of small bowel obstruction or perforation. Fig.4. Midline laparotomy incision.

INVESTIGATIONS WCC 13.7 CRP <2 U+Es Hb 113 Glucose LFTs Plts Blood results Urine Dip negative Venous Blood Gas: lactate 2.4 mmol/l WCC 13.7 CRP <2 U+Es Hb 113 Glucose LFTs Plts Amylase

CHEST RADIOGRAPH Fig.5. A/P Chest Radiograph unremarkable.

ABDOMINAL RADIOGRAPH Fig.6. Radiopaque shadows beneath the left hemi-diaphragm.

MANAGEMENT Conservative IV fluids, analgesia, antibiotics Gastro-enterology review: endoscopic retrieval deemed futile GA: debridement and closure of laceration Removal of blade Fig.7. Laceration.

MANAGEMENT Failed conservative management Small Bowel Obstruction Naso-gastric tube and catheter Admitted removing the ends from the batteries prior to ingestion Emergency Laparotomy Fig.8. Nasogastric Tube.

EMERGENCY LAPAROTOMY Midline laparotomy incision via the old incision Clinical Findings: Multiple adhesions Not possible to palpate the batteries The stomach was mobilised A gastrostomy was performed Fig. 9. Fluoroscopy.

EMERGENCY LAPAROTOMY 6 x AA and 2 x AAA batteries were retrieved The ends had been removed Superficial mucosal necrosis Stomach wall viable Saline irrigation Fig.10. Batteries retrieved. Closure

OUTCOME IV pantoprazole 40 mgs od IV co-amoxiclav 1.2 g tds NG on free drainage Nil by mouth over night Hb 71 g/l: 2 units of PBCs transfused Tachycardic, Heart Rate 120 Fig.11. Blood Transfusion.

CT ABDOMEN AND PELVIS Repeat Hb 88g/l. He self discharged. Fig.12. No focal collection seen. The bowel was of normal calibre. Repeat Hb 88g/l. He self discharged.

Tracheo-oesophageal fistula Oesophageal Stricture DISCUSSION Ingestion of batteries is a well documented toxicological entity Accidental ingestion is common in the paediatric population Emergency endoscopy Oesophageal Ulceration Tracheo-oesophageal fistula Tracheal Stenosis Oesophageal Stricture Perforation

Special needs, alcohol intoxication Deliberate ingestion Accidental Ingestion Special needs, alcohol intoxication Deliberate ingestion Prison inmates: Personality disorder deliberate self harm Cases of biting the battery case prior to ingestion Erosions Ulceration Perforation

MANAGEMENT Limited data on outcome of cylindrical batteries History: encasement defect prior to ingestion Remove…. Signs of GI injury > 48 hours…..not passed per rectum

GUIDELINES American Society for Gastro-intestinal Endoscopy Emergency Endoscopy: airway compromise oesophageal obstruction perforation damage to the battery casing Complications from batteries Liquefaction necrosis Transmission of electrical current

MANAGEMENT Conservative Serial radiographs, provided the foreign body has traversed the oesophagus Spontaneous expulsion after a few days in the GIT [80%] Endoscopy is performed in 20% Surgery < 1% Foreign bodies >2.5cm wide are more likely to be retained in the stomach Impaction may occur at the ileo-caecal valve ..most common site of perforation

TOXBASE The National Poisons Information Service ….. TOXBASE www.toxbase.org

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