Congenital Colonic Stenosis Manifested after Foreign-Body (Button Battery) Ingestion in a Child.

Sir,

With few exceptions, swallowed foreign bodies in children are passed spontaneously once they cross the cricopharynx (the narrowest portion of the gastrointestinal tract). A preexisting narrowing (congenital/acquired) is likely to be the cause if the foreign body gets arrested beyond the cricopharynx. A rare case of swallowed foreign body reaching the colon, and causing obstruction, revealed a preexisting congenital colonic stenosis (CCS) on exploration.

One and a half year old boy presented with features of intestinal obstruction for 8 days. The child was well at birth with the first passage of meconium within 24 hours. He had a history of constipation for 6 months and always had a protuberant abdomen. He had ingested a “button battery” a day before the onset of symptoms. Clinically, the child had intestinal obstruction which was confirmed on abdominal X-rays. The position of the circular foreign body was unchanged as compared to the X-ray done 8 days ago. A presumptive diagnosis of intestinal obstruction secondary to battery injury was considered, though a preexisting obstructive pathology was a kept as a differential diagnosis.

On abdominal exploration through a right lower quadrant sub-umbilical transverse incision, a 6 cm segment of the narrowed colon [Figure 1] was evident. The colon proximal to stenosis was dilated with a foreign body within. The colon and rectum distal to stenosis was of normal calibre. A colotomy with retrieval of foreign body, resection of stenosed colonic segment, and primary end-to-end anastomosis were performed. Postoperatively, the child had prolonged ileus and superficial wound infection, but he recovered well on follow-up. Histopathology was consistent with CCS with normal ganglion cells.

Figure 1

(a) Abdominal X-ray, showing intestinal obstruction with a radiopaque foreign body (? button battery on X ray) in the left lower abdomen. (b) Stenosed segment of the colon with, (c) foreign body within the dilated segment, which caused complete obstruction to, (d) narrow lumen admitting a small mosquito forceps

Colonic atresia affects 1 in 20,000 live births and makes up 1.5%–1.8% of intestinal atresias.[1] CCS is considered as part of atresia with <20 cases reported in the world literature. Clinical manifestations are of subacute bowel obstruction, but patients may remain asymptomatic for varying periods of time. Age at diagnosis varies from 2 days after birth to 10 years. The baby may be asymptomatic at birth, but the progression of feeds from milk to solids would initiate obstructive symptoms, and in our index patient, the foreign body precipitated complete obstruction.

CCS needs to be differentiated from other causes of colonic obstructions such as Hirschsprung's disease and meconium ileus. Hirschsprung's disease is present in around 2% of colonic atresias; and a rectal biopsy is advocated during surgery for CCS. The most important differential is an acquired colonic stricture secondary to necrotising enterocolitis (NEC), as the appearance may be similar and is more common than CCS.[2] In CCS, there is no intrinsic obstruction, but a length of the colon is narrowed with small lumen [Figure 1] and the length of the segment involved can range from 3 to 16.5 cm.[2] In children with stricture colon secondary to NEC, laparotomy usually reveals generalized interloop adhesions. While intestinal strictures are common following surgically treated NEC, colonic localization of the strictures is more frequent in medically treated patients compared to surgically treated ones (87% vs. 50%), and the median time interval for diagnosis of intestinal stricture is 34 days (range: 27.5–62 days).[3] Our patient was born at term, had no prolonged stay in neonatal intensive care, and presented at 1.5 years of age. Delayed presentations[4] of colonic atresia Type 1 are likely due to a perforate membrane, and atypical presentations such as rectal prolapse, recurrent melena, and constipation are known. There are no reports of foreign body itself precipitating an obstruction in CCS, as in our case. This case report also emphasizes the importance of educating parents regarding the dangers of foreign-body ingestion.[5]

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