[Downloaded free from http://www.annalspc.com on Friday, December 25, 2020, IP: 36.65.6.

115]

IMAGES

Pneumopericardium due to ingestion of button battery

Jai Prakash Soni, Sandeep Choudhary, Pramod Sharma, Mohan Makwana
Department of Pediatrics, Dr. S. N. Medical College, Jodhpur, Rajasthan, India

ABSTRACT
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.

Keywords: Air leak syndrome, button battery, corrosive, esophageal-pericardial foreign body,
pneumopericardium

produce massive pneumopericardium. Repeat X-ray

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
Access this article online
Quick Response Code:
Website:
www.annalspc.com
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.
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.[1-3] Pneumopericardium is a rare condition
This is an open access article distributed under the terms of the
Creative Commons Attribution-NonCommercial-ShareAlike 3.0
License, which allows others to remix, tweak, and build upon the
work non-commercially, as long as the author is credited and the
new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com

DOI: How to cite this article: Soni JP, Choudhary S, Sharma P, Makwana
10.4103/0974-2069.171387 M. Pneumopericardium due to ingestion of button battery. Ann Pediatr
Card 2016;9:94-5.

Address for correspondence: Dr. Sandeep Choudhary, Department of Pediatrics, Dr. S. N. Medical College, Jodhpur, Rajasthan, India.
E-mail: sandeepbugasara@gmail.com

94 © 2016 Annals of Pediatric Cardiology | Published by Wolters Kluwer - Medknow

[Downloaded free from http://www.annalspc.com on Friday, December 25, 2020, IP: 36.65.6.115]
Figure 1: X-ray chest depicting battery cell and pneumopericardium
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
Annals of Pediatric Cardiology 2016 Vol 9 Issue 1
Soni, et al.: Pneumopericardium: A rare cause
Figure 2: X-ray chest showing increase in pneumopericardium after
endoscopic removal of battery cell from esophagus
essential for improving the clinical outcome. Our-patient
though came late but recovered with conservative
management.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Abdulkareem I, Sabir OM, Elamin A. Button battery
induced traumatic tracheoesophageal fistula: Case
report and review of literature. Sudan J Paediatr
2011;11:43-9.
2. Alkan M, Büyükyavuz I, Dogru D, Yalçin E, Karnak I.
Tracheoesophageal fistula due to disc-battery ingestion.
Eur J Pediatr Surg 2004;14:274-8.
3. Chan YL, Chang SS, Kao KL, Liao HC, Liaw SJ, Chiu TF,
et al. Clinical analysis of disc battery ingestion in
children. Chang Gung Med J 2004;27:673-7.
4. Slamon NB, Hertzog JH, Penfil SH, Raphaely RC, Pizarro C,
Derby CD. An unusual case of button battery-induced
traumatic tracheoesophageal fistula. Pediatr Emerg Care
2008;24:313-6.
5. Han Y, Lu Q, Zhang T, Wang X. Pneumopericardium and
esophagopericardial fistula presenting as pericarditis in a
1-year-old boy. Eur J Cardiothorac Surg 2008;34:1120-2.
6. Reeder LB, DeFilippi VJ, Ferguson MK. Current results
of therapy for esophageal perforation. Am J Surg
1995;169:615-7.
95