A 3-year-old boy is brought to the emergency department 4 hours after his mother found him playing with a remote control. Chest X-ray shows a disc battery lodged in the esophagus with a characteristic double-ring halo sign on AP view and step-off appearance on lateral view, as marked **A** in the diagram. The child is currently asymptomatic with normal vital signs. What is the most appropriate immediate management?

Question

Accepted Answer

C. Emergent endoscopic removal within 2 hours. ## Why "Emergent endoscopic removal within 2 hours" is right

The structure marked **A** is a disc battery in the esophagus. According to NASPGHAN Button Battery Guidelines 2018 and Nelson Textbook of Pediatrics (22e, Ch 364), ANY disc battery in the esophagus is a TIME-CRITICAL EMERGENCY requiring emergent endoscopic removal regardless of symptoms. The critical mechanism of injury is electrolysis-induced hydroxide generation at the negative pole, causing alkaline burn and liquefactive necrosis within 2 hours. Waiting for asymptomatic presentation or clinic-hour endoscopy risks esophageal perforation, mediastinitis, tracheoesophageal fistula, and potentially fatal aortoesophageal fistula (which may occur even 28 days post-removal). The radiographic features (double-ring halo on AP, step-off on lateral) confirm battery identity and mandate immediate action.

## Why each distractor is wrong

- **Admit for observation and repeat imaging in 24 hours**: This violates the <2-hour emergency window. Observation delays removal and allows progressive alkaline injury; coins may be observed, but batteries never.
- **Administer honey 10 mL every 10 minutes and reassess in 6 hours**: Honey is a pre-endoscopy mitigation strategy only for asymptomatic ingestion <12 hours old when endoscopy is delayed; it does NOT replace emergent removal and is not a definitive treatment for esophageal battery.
- **Attempt blind advancement into the stomach with a bougie catheter**: Blind advancement risks perforation and is explicitly contraindicated in NASPGHAN guidelines; only experienced operators may attempt removal of smooth radiopaque coins in the ER when endoscopy is unavailable—never for batteries.

**High-Yield:** Disc battery in esophagus = emergency <2 hours, regardless of symptoms; coins can wait 24 hours; batteries cause hydroxide burn in 2 hours.

[cite: NASPGHAN Button Battery Guidelines 2018; Nelson 22e Ch 364]

Answer

A. Admit for observation and repeat imaging in 24 hours

Answer

B. Attempt blind advancement into the stomach with a bougie catheter

Answer

D. Administer honey 10 mL every 10 minutes and reassess in 6 hours

Explanation

Why "Emergent endoscopic removal within 2 hours" is right

Why each distractor is wrong

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