Pneumopericardium due to ingestion of button battery.

Mostly ingested button batteries passed through the gastrointestinal tract without any adverse effects. But button battery can lead to hazardous complications including tracheoesophageal fistula (TEF), especially when the battery is impacted in the esophagus. Urgent esophagoscopic removal of the battery is essential in all cases. Once the TEF is identified, conservative management is the initial treatment of choice. Delayed primary repair can be tried if spontaneous closure does not occur. Here in we want to report a rare case of air leak syndrome, pneumo-pericardium secondary to the corrosive effect of a button battery and child recovered completely with conservative management.

CLINICAL SUMMARY

A 3-year-old male child was admitted with complaints of fever off and on from the past 20 days. The child suddenly developed difficulty in breathing and pain in the abdomen. He was admitted to the district hospital for management and treated with parenteral antibiotics and oxygen inhalation, but his condition remained unchanged and was referred to the Medical College Hospital. On arrival at our institute, the child had fever, tachycardia, and tachypnea. There was marked intercostal retraction and pericardial rub present. His blood examination revealed polymorphonuclear leukocytosis. The first X-ray chest posterior-anterior view [Figure 1] revealed a foreign body at the lower end of the esophagus along with pneumopericardium. The patient was referred to the gastroenterologist for endoscopy. Under ketamine anesthesia, upper gastrointestinal (GI) endoscopy was done, and a rusted round button shape battery cell was removed. Endoscopy revealed necrotic patch at the site of impaction of the cell. Because of suspicion of esophago-pericardial fistula (EPF), local lesion was not further examined, as sealed lesion may open up and produce massive pneumopericardium. Repeat X-ray chest [Figure 2] done after endoscopy revealed little increase in pneumopericardium. Echocardiography showed minimal pericardial effusion with normal cardiac function. His blood culture had the growth of Gram-positive coagulase-negative staphylococci sensitive to vancomycin. The child was given injection vancomycin and ceftriaoxone and managed in the pediatric intensive care unit under strict cardiac and respiratory monitoring. The child did not require surgical drainage of the air leak as it resorbed gradually on its own and never assumed massive dimensions. The fistulous connection managed conservatively and healed on its own.

Figure 1

X-ray chest depicting battery cell and pneumopericardium

Figure 2

X-ray chest showing increase in pneumopericardium after endoscopic removal of battery cell from esophagus

DISCUSSION

Air leak syndromes are a group of clinically recognizable disorder produced either by alveolar rupture or due to GI perforation following which air escapes into the tissue, in which air is usually not normally present. EPF is an uncommon complication following impaction of a foreign body.[123] Pneumopericardium is a rare condition with a very high mortality. The majority of cases are due to perforation of either esophagus or bronchi into the pericardial cavity. The esophagus is in direct contact with the pericardium at the lower thoracic vertebrae level. Recorded causes of EPF include ingested foreign bodies such as fish bone, benign ulceration in association with hiatus hernia, esophageal carcinoma, and achalasia. Mostly, ingested button batteries passed through the GI tract without any adverse effects but can lead to hazardous complications including tracheoesophageal fistula (TEF), especially when the battery is impacted in the esophagus. Esophageal button battery impaction places the patient at high-risk for full-thickness damage to the esophagus and tracheal structures with fistula formation in as little as a few hours’ time.[4] Because of the complications associated with this disease (TEF) and subsequent difficulties associated with oxygenation and ventilation, these patients should be managed at an institution with the skilled capability of providing cardiopulmonary bypass quickly as a potentially lifesaving therapy.[5]

The key to successful therapy is prompt diagnosis and removal of foreign body, pericardial drainage, and appropriate antibiotic coverage along with elective operative closure of the fistula. Palliative therapy for patients with malignant TEFs is the endoscopic placement of covered self-expanding metallic stents, which allow closure of the fistula. Reeder et al. have reported mortality rates of 9% after early and 29% after late diagnosis among nonmalignant esophageal perforation.[6] Therefore, early diagnosis and treatment for EPF are essential for improving the clinical outcome. Our-patient though came late but recovered with conservative management.

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Conflicts of interest

There are no conflicts of interest.