Endoscopic Retrieval vs Observation in Cylindrical Battery Ingestion

Background: Battery ingestion, particularly in the pediatric population, has become more common since the development of button batteries. Consequently, formal recommendations regarding the management of this battery type have been developed. Larger cylindrical battery ingestion is less common, with fewer cases reported. As such, no clear practice guidelines have been developed for the management of cylindrical battery ingestion. Case Report: We present a case of an incarcerated adult who ingested 2 AA batteries. One battery was retrieved endoscopically, but the second passed into the distal small bowel beyond endoscopic means of retrieval. The second battery passed spontaneously via the rectum after administration of laxatives and supportive care. Conclusion: Our case and review of the literature demonstrate that nonsurgical, conservative management with close clinical monitoring is possible in a hospital setting after cylindrical battery ingestion. Cases with concerning clinical symptoms or a history of damage to the battery casing warrant endoscopic or surgical intervention.


INTRODUCTION
Battery ingestion, particularly in the pediatric population, has become more common since the development of button batteries. Consequently, formal recommendations regarding the management of this battery type have been developed. 1 Larger cylindrical battery ingestion is less common, with fewer cases reported. As such, no clear practice guidelines have been developed for management of cylindrical battery ingestion. We present a case of an adult prison inmate who ingested 2 AA batteries in a suicide attempt, review the available literature and associated sequelae, and propose an approach to the management of patients presenting after the intentional ingestion of cylindrical batteries.

CASE REPORT
A 36-year-old male was transferred to our facility from prison after reporting that he had ingested 2 AA batteries 2 days prior to admission. He had a history of schizophrenia and a previously reported suicide attempt by ingestion of AA batteries that were endoscopically retrieved. The patient had no complaints on admission; he denied abdominal pain, nausea, vomiting, and other gastrointestinal (GI) symptoms. His physical examination was without significant findings, including a nontender, nondistended abdomen and regular bowel sounds. Laboratory data were unremarkable. Abdominal x-rays revealed 2 cylindrical structures superimposed on the mid upper abdomen consistent with the reported battery ingestion ( Figure 1A).
Approximately 2 hours after the patient's presentation, upper GI endoscopy revealed one AA battery in the gastric fundus ( Figure 1B). The second battery was not seen on endoscopic examination up to the third portion of the duodenum, and no mucosal damage was apparent. An overtube was placed. The first battery was captured with a snare and retrieved through the overtube. After retrieval of the first battery, a second examination with a pediatric colonoscope was conducted. The pediatric colonoscope was advanced deep into the jejunum, at least 80 cm from the ligament of Treitz, without success in locating the second battery.
Repeat abdominal x-rays revealed the second battery in the distal ileum or proximal colon ( Figure 1C). Meanwhile, the patient's psychiatric medications were adjusted, and he was started on a regular diet that he tolerated well. Daily abdominal x-rays ( Figure 2) demonstrated the battery progressing from the proximal colon to the descending colon. He was administered a 10-ounce bottle of magnesium citrate and started on 17 g daily of polyethylene glycol 3350 on hospital day 4, resulting in regular bowel movements the following day. The patient defecated the battery on hospital day 7. His hospital course was otherwise unremarkable, and he was discharged back to the correctional facility.

DISCUSSION
Ingestion of batteries has been well documented in the medical literature and at poison control centers for decades. However, the majority of the literature concerning battery ingestion deals with button batteries rather than with cylindrical batteries. In a 7-year study from the National Capital Poison Center in Washington, DC, individuals swallowing button batteries greatly outnumbered those ingesting cylindrical batteries (2,320 vs 62). 2 Button batteries are more likely to be swallowed either by accident or by a curious child. 3 Button batteries may cause liquefactive necrosis, and perforation can occur rapidly when the battery lodges in the esophagus, leading to severe and potentially fatal complications. As such, formal guidelines have been developed and emphasize emergent removal of button batteries from the esophagus. 1 On the other hand, given the larger size of cylindrical batteries, they are commonly ingested deliberately in the psychiatric population and by prison inmates. 4,5 Most ingestions occur in patients 6-39 years of age. 6 Cylindrical cells are typically alkaline-manganese or nickel-cadmium (rechargeable) and when ingested can cause corrosive and toxic damage. Such damage can occur if the integrity of the battery casing is deliberately damaged and can also occur from sustained acid attack from gastric contents for a period of weeks, rather than days, or as a result of battery leakage. Untersweg et al reported the case of a 4-year-old boy who sustained grade II-III esophageal burns from putting a leaking cylindrical battery to his mouth and sucking the caustic solution. 7 The burns resulted in an esophageal stricture, necessitating frequent bouginages and placement of a jejunal tube for feeding.
The most comprehensive studies on battery-related exposures are based on cases reported to the National Battery Ingestion Hotline and US poison control centers. Litovitz conducted an 11-month review of the National Capital Poison Center at Georgetown University Hospital where 125 battery ingestions were reported. 8 Only 6 of the ingested batteries were cylindrical; all passed through the GI tract spontaneously. Two cylindrical batteries were ingested by a 6-year-old and a 12-year-old child. Both children remained asymptomatic and passed the batteries in 36-38 hours. The other 4 batteries were ingested by a 30-year-old male convict who swallowed the batteries to avoid incarceration and subsequently reswallowed 3 of the excreted batteries with no reported adverse events. Litovitz and Schmitz next conducted a 7-year review. 2 Of the 2,383 reported battery ingestion cases, only 62 were reported as cylindrical battery ingestions: 33 patients ingested AA batteries, 26 patients ingested AAA batteries, 2 patients ingested N batteries, and 1 patient ingested a C battery. No other characteristics were reported. The Litovitz et al 18.25-year review reviewed 8,648 battery ingestion cases, 487 of which were cylindrical ingestions. 9 The researchers did not report individual characteristics of the cylindrical battery ingestions, but statistics showed that at least 43% of them were intentional, suicidal, or associated with a neuropsychiatric disorder; another 6% were by incarcerated individuals. Additionally, 37.8% of cylindrical cell ingestions involved multiple cells compared with 8.7% of button cell ingestions.
We conducted a literature search in PubMed, Scopus, and Cochrane Library for the terms cylindrical, battery, and ingestion from database inception until September 17, 2017 and identified 15 case reports and 1 case series (a case written in the Spanish language was not included). We summarize these cases in the Table. [10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25] Most reported cases involved patients who were asymptotic after ingestion. If symptoms did occur, they usually manifested as upper GI complaints or abdominal pain. Unusual presentations include ST segment abnormalities on electrocardiogram and a grand mal seizure. 10,18 All but one patient 19 with a history of prior abdominal surgery required either surgical or endoscopic intervention for battery retrieval, possibly related to adhesions or dysmotility preventing the passage of the batteries. 11  Several patients spontaneously passed the cylindrical batteries via the rectum. In the Hindley et al case series, 3 psychiatric patients swallowed cylindrical batteries and passed them with conservative management within 1-2 weeks, a fourth patient passed ingested batteries within 3-4 months, and a fifth patient required surgical extraction. However, the patient who required surgery, unlike the other 4, had developed acute upper GI pain. 13 Our review revealed that in all cases with evidence of corrosive changes, leakage, or damage to the battery casing, patients were symptomatic or had evidence of mucosal damage. 10,11,13,14,21,22 In 2017, Tien and Tanwar reported a case of a 3-battery ingestion that resulted in gastric ulcers and gastritis within 14 hours, despite the patient denying destruction of the battery cases. 24 Our review of the abdominal x-rays provided with the case suggested distortion of the battery casing that would have explained the gastric find-ings. Two batteries were removed urgently from the stomach; the third had passed to the small bowel. Despite conservative management for 2 days with a laxative, urgent colonoscopy with planned terminal ileum intubation was attempted because of concern that the third battery would be impacted at the ileocecal (IC) valve. On endoscopy, the battery had passed the IC valve and was retrieved from the proximal right colon. Urgent colonoscopy may not have been indicated in this case, as the battery had passed the IC valve and therefore would have likely been passed without complication.
In a case from 2015, Hammad et al reported the case of a patient whose ingestion of 7 cylindrical batteries resulted in severe gastric ulcerations and erosions caused by the corrosive alkaline spilling from the eroded batteries, despite the patient being asymptomatic and the batteries being in his stomach for less than 12 hours. 21

NR
• Swallowed drug packets and 2 pairs of batteries to push drug packets down the GI tract; all drug packets and one pair of batteries expelled within several days; 6 years later, patient presented with intermittent diffuse abdominal discomfort and heartburn of several months • Abdominal x-ray showed radiopaque mass in the stomach; attempt to retrieve batteries with forceps failed because plastic began to tear and leakage was a concern; batteries removed laparoscopically; gastric biopsy revealed mild chronic inflammation In an interesting report of delayed symptom presentation after battery ingestion, an individual who intentionally ingested 2 pairs of batteries wrapped in plastic to help move drug packets along the GI tract sought medical attention 6 years later because he was setting off alarms at the airport and had started having heartburn and intermittent abdominal pain. 15 He had expelled all drug packets and 1 pair of batteries a few days after ingestion, but 1 battery packet was not expelled. Upper endoscopy revealed a pair of batteries wrapped in plastic in the stomach, no sign of leakage was seen, and the stomach looked intact. Endoscopic retrieval was unsuccessful because the plastic began to tear, but the batteries were retrieved laparoscopically.
Current guidelines only briefly address cylindrical battery ingestion. Overall, intact cylindrical batteries pose a low threat for caustic damage after ingestion, but because of their length (>2.5 cm) they may become entrapped in the stomach in children and adults. The recommendation for retrieval of this battery type includes situations in which (1) the battery has remained in the stomach more than 48 hours, (2) the patient develops signs of injury to the GI tract, or (3) evidence indicates that the battery had an encasement defect prior to ingestion. 1 In our case, the batteries were in the patient's stomach beyond the recommended 48-hour observation period. However, he remained asymptomatic, and no evidence indicated that the batteries were damaged or eroded. Based on our case and review of the literature, we conclude that if cylindrical battery swallowing is not accompanied by abdominal symptoms or abnormal physical examination findings, the battery cases were not damaged prior to ingestion, and the batteries are beyond retrieval with esophagogastroduodenoscopy, cylindrical battery ingestion can be managed conservatively with the aid of radiologic imaging, regardless of the timing of the observation period. Our case demonstrates that conservative management with close clinical monitoring is possible in a hospital setting.
Nonurgent upper endoscopy may be considered if the batteries are within reach of an upper endoscope. If upper endoscopic retrieval is not feasible, clinical monitoring and following battery progression through the GI tract with serial abdominal radiographs until batteries are discharged via the rectum can be achieved. However, in cases of prior abdominal surgery, history or evidence of damage to the battery, or any clinical symptoms, prompt endoscopy and battery retrieval are indicated. If retrieval fails, surgical consultation should be done for those cases.
Given the complexity of cylindrical battery ingestion, the lack of data on this subject, and the large variety of cylindrical batteries available, more reviews and specific guidelines on this topic seem indicated. In our review of the cases, most ingested cylindrical batteries were the AA and AAA type. However, other cylindrical battery shapes and sizes (ie, N, C, and AAAA, some of which resemble button batteries) may warrant different guidelines.

CONCLUSION
Cylindrical battery ingestions are less common than button batteries, and data on the outcomes of these ingestions are limited. Based on our case and review of the literature, we conclude that if cylindrical battery swallowing is not accompanied by abdominal symptoms or abnormal physical exam-ination findings, the battery cases were not damaged prior to ingestion, and the batteries are beyond retrieval with esophagogastroduodenoscopy, cylindrical battery ingestion can be managed conservatively with the aid of radiologic imaging. However, in the presence of prior abdominal surgery, history or evidence of damage to the battery, or any clinical symptoms, prompt endoscopy and battery retrieval should be done. If this is not possible, then surgical consultation should be done for those cases.