Development and repair of aorto-esophageal fistula following esophageal button battery impaction: A case report

Abstract

Background: Complications from esophageal button battery impactions remain a real fear for practicing pediatric gastroenterologists and surgeons. This case describes a child who developed an aorto-esophageal fistula 25 days after initial battery ingestion and survived due to prompt placement of an aortic stent via minimally invasive surgery, avoiding an open procedure.

Case presentation: A 6-year-old female presented acutely with a mid-esophageal button battery impaction witnessed by her parents. Presenting symptoms included chest pain and emesis. Button battery location and size were confirmed on X-ray. She underwent removal with flexible esophagogastroduodenoscopy (EGD) and rigid esophagoscopy. She was admitted to the hospital and received conservative medical management, with serial cross-sectional imaging via chest MRIs to assess the evolution of her injury according to available national guidelines, and was discharged after 12 days of close inpatient monitoring. Despite these measures the patient represented 25 days post-ingestion with hematemesis from a new aorto-esophageal fistula, requiring emergent cardiac catheterization with successful, life-saving aortic stent placement. She remained admitted for an additional 12 days of monitoring as her diet was advanced slowly post-catheterization. Since this second hospitalization she continues to do well, with outpatient follow-up by multiple subspecialists.

Conclusions: This case highlights the continued uncertainty regarding the risk of developing this complication, as well as gaps in the current literature and guidelines for managing these patients following ingestion and esophageal injury. It also details the unique course following development of this complication and its surgical repair.

Keywords: Aorto-esophageal fistula; Button battery ingestion; Case report; Foreign body.

Fig. 1.

A-B: Initial Chest X-ray demonstrates approximately 21mm button battery in the mid esophagus (T7–8) with negative pole oriented posterior on lateral view.

Fig. 2.

A-F (color image): Endoscopic images of impacted button battery demonstrating corrosion of the battery and bleeding (A–C) and injury after removal showing erythema and ulceration (D–F).

Fig. 3.

A-I: Initial MRI (A, B, C) demonstrates esophageal wall irregularity (=>) and enhancement of posterior mediastinal fat (→) abutting and surrounding thoracic aorta (a); Second MRI (D, E, F) demonstrates little change; Esophagus (=>) is improved on Third MRI (G, H, I), however enhancement abutting thoracic aorta (a) is minimally changed.

Fig. 4.

A-C: Imaging from the catheterization lab showing outpouching of the anterior descending aorta consistent with intimal injury (A,B) and repair with stent placement(C).

Fig. 5.

A-B: Sagittal reformat (A) and 3D rendering (B) from CTA performed 2 months following aortic stenting demonstrates stable position of stent in descending thoracic aorta. No contrast leak seen, however evaluation of prior intimal aortic injury is limited due to metallic streak artifact.