A 2-year-old boy is brought to the emergency room by his mother, who states that her son has been coughing uncontrollably for 3 hours. The child has a medical history of obesity and atopic dermatitis and uses topical steroid cream. His birth history is unremarkable. His family history is notable for asthma in his older sister and irritable bowel syndrome in his father. His temperature is 98.5°F (36.9°C), pulse is 120/min, blood pressure is 90/52 mmHg, and respirations are 32/min. On exam, he appears uncomfortable, is coughing continuously, and is drooling. Cardiopulmonary and abdominal exams are unremarkable. A chest radiograph is performed and the results are shown in Figures A and B. Which of the following is the most appropriate next step in management?
Observation
Balloon catheter removal
Surgical extraction
Endoscopic removal
Endoscopic removal
This child presents with foreign body ingestion with a button battery seen in the esophagus on radiography. The most appropriate next step in management is urgent endoscopic removal of the battery.

Button batteries are commonly used in watches and small electronic devices. If these objects are ingested (usually by children), they can become lodged in the esophagus. Coughing, drooling, and chest discomfort are classic symptoms but a lack of symptoms does not negate the need for evaluation if suspicion is high. The location of the battery can be confirmed by radiograph and orthogonal views can localize the object in the esophagus versus the trachea. Endoscopy is the preferred method of removal as direct visualization of any associated esophageal injury is possible. The battery can cause ulceration or perforation if left in the esophagus due to chemical extravasation.

Baharudin et al. review a number of cases of pediatric ingestions resulting in esophageal lodging. They discuss how a stack of coins can mimic the appearance of a battery. They recommend urgent intervention in cases of suspected battery ingestion.

Figure/Illustration A is a chest radiograph depicting a round object lodged in the esophagus, with a “double halo” sign (red circle). This sign is an indication that this object is a battery rather than a coin. Figure/Illustration B is a lateral chest radiograph demonstrating that the battery is posterior to the trachea (red circle). This view confirms that the location of the battery is in the esophagus.

Incorrect Answers:
Answer A: Balloon catheter removal can be attempted for ingested button batteries but is typically used only if endoscopy is not available. There is more potential for tissue damage without direct visualization, so ingestion time greater than 2 hours is generally a contraindication for this method.

Answer B: Ipecac administration can induce emesis and is rarely used for toxic ingestions. Vomiting can cause further lodging in the esophagus and even more tissue damage. Ipecac is therefore not recommended in the modern management of toxic ingestions.

Answer D: Observation would be appropriate if there is an ingested object that has already traveled further into the gastrointestinal tract (if they are small and smooth), as these objects would likely pass on their own. A classic example would be a coin ingestion that would appear as a single round object rather than a double ring appearance. A button battery in the esophagus is an emergency and should be removed urgently.

Answer E: Surgical extraction of a battery with associated repair may be required if there is suspicion of an esophageal-vascular fistula, mediastinitis, or other such complications. It may also be necessary if a magnet was simultaneously ingested. In the absence of these complications, endoscopic removal should be attempted first.

Bullet Summary:
Button batteries lodged in the esophagus require urgent endoscopic removal.