1. 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.

2. CONTENTS
Introduction
Case Presentation
Discussion
Questions

3. 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.

4. CASE PRESENTATION
A 37 year old incarcerated male presented to A+E at 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.

5. 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

6. 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.

7. 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
CRP <2
U+Es Hb
Glucose
LFTs
Plts
Amylase

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

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

10. 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.

11. 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.

12. 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.

13. 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

14. 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.

15. 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.

16. 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

17. 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

18. 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

19. 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

20. 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

21. TOXBASE The National Poisons Information Service ….. TOXBASE

22. REFERENCES
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 2. Salinger L, Francis OS, Bayer MJ. “Freedom” by intentional ingestion of batteries: A Case Report. Clinical Toxicology, August 2014, vol. 52 (7), (755), 1556 – 3650.
3. Gitlin DF, Caplan JP, Rogers MP, Avni-Barron O, Braun I, Barsky AJ. Foreign body ingestion in patients with personality disorders. Psychosomatics 2007, 48:
 4. Eisen GM, Baron TH, Dominitz JA, Feigel DO, Goldstein JL, Johanson JF et al. American Society for Gastrointestinal Endoscopy. Guideline for the management of ingested foreign bodies. Gastrointest Endosc. 2002;55(7):802–6.
 5. Gurler M, Pehlivan S, Altuntas A, Karapirli M. Evaluation of a battery ingestion case with the results of ICP / MS. Clinical Chemistry and Laboratory Medicine. July 2014, vol. 52 (S212),
6. Hindley N. The management of cylindrical battery ingestion in psychiatric settings. Psychiatr Bull 1999; 23;
7. Gullbrand III E, Rideman ED, Nguyen J, Vankawala III S. Foreign body removal: A completely laparoscopic approach for aa batteries advancing to the small bowel. Surgical Endoscopy and other Interventional techniques, April 2013, vol. 27 (S449).

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