Oesophagitis, caustic ingestion and oesophageal injury — structured clinical encounter

Station brief (candidate)

You are the paediatric registrar in the emergency department. An 18-month-old girl presents with two hours of sudden drooling, refusal to feed and an intermittent cough. She was found next to her sibling's toy, which has an open battery compartment and a missing 20 mm lithium coin cell. She is alert and pink, is not stridulous, and her observations are stable. The team asks you to establish the diagnosis and the immediate plan, then proceed to imaging, the pre-removal measure, the definitive step, and the family counselling. You have 12 minutes with the team and 5 minutes for examiner discussion. [1]

Information available on request

• Well, thriving 18-month-old; up to date with immunisations; no medical problems. [1]
• Symptoms began abruptly two hours ago; the 20 mm lithium coin cell from the toy cannot be found. [4]
• Examination: drooling, reluctant to swallow, occasional cough; chest clear, no stridor, saturations 99 percent in air; abdomen soft and non-tender. [1]
• Plain radiograph (on request): a rounded radio-opaque disc in the proximal oesophagus with a halo or double-ring appearance on the frontal view and a step-off on the lateral view, consistent with a button battery, not a coin. [6]
• No haematemesis, no signs of perforation, and the airway is currently secure. [1]

Tasks

1. Give the diagnosis and explain why it is a time-critical emergency, stating the deadline for definitive action. [1]
2. State the imaging you order and the specific signs that confirm a battery rather than a coin. [6]
3. Outline your immediate management, including the pre-removal measure with its dose and eligibility, and the definitive step. [2]
4. State the delayed complications you will watch for and for how long, and the counselling you give the family. [1]

Marking anchors

Must-hit

• Diagnoses a suspected oesophageal button battery and explains that a lithium coin cell generates hydroxide at its negative pole and burns liquefactively through the wall within two hours, so the definitive action — emergent endoscopic removal — must occur within two hours of ingestion rather than by observation. [1] [4]
• Orders an urgent neck, chest and abdomen radiograph and identifies the halo or double-ring sign on the frontal view and the step-off on the lateral view that distinguish a battery from a coin, and reads the negative-pole orientation to predict the wall at risk. [6]
• Keeps the child nil by mouth, escalates immediately for removal within two hours, and gives honey 10 mL orally every 10 minutes for up to six doses because she is over twelve months, within twelve hours of ingestion and able to swallow, using sucralfate as the in-hospital alternative, without delaying removal and not if perforation, sepsis or airway compromise is present. [2]

Merit

• Anticipates the delayed aorto-oesophageal and tracheo-oesophageal fistula, perforation, mediastinitis, stricture and vocal cord palsy, states that the fistula bleed risk lasts up to about three weeks after removal, and counsels the family to return immediately for any haematemesis or bleeding. [1]

Fail

• Reads the disc as a coin and plans observation with a morning repeat film, or delays removal to complete honey dosing, so that the battery remains in the oesophagus beyond the two-hour window. [4]
• Induces vomiting, attempts to neutralise, or passes a blind nasogastric tube, or discharges the child after removal without warning the family about the delayed fistula bleeding risk. [1]