Paeds SAQs · acute-care-resuscitation-and-toxicology
Oesophageal and gastrointestinal foreign-body ingestion — formative SAQs
Two MedVellum formative short-answer questions on paediatric foreign-body ingestion: emergency recognition and two-hour endoscopy for an oesophageal button battery, radiographic differentiation of battery from coin, the honey demulcent adjunct and its contraindications, and the observation strategy for an asymptomatic gastric coin. The marks and timing support transparent self-assessment. They are not an official board format or pass standard.
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Target exams
SAQ 1 — A toddler with a suspected oesophageal button battery
Question 1 — 10 formative marks; suggested time 15 minutes [3]
A three-year-old is brought to the emergency department thirty minutes after the family found a remote-control battery missing and the child drooling. The child is alert, drooling saliva, refusing drinks, and pointing to the front of the chest. A plain anteroposterior chest radiograph shows a 20-millimetre disc-shaped radiopacity at the thoracic inlet with a concentric ring appearance. [3] [10]
- State the radiographic diagnosis and the urgency tier. Justify your answer from the radiograph. (2 marks)
- Describe your immediate resuscitation and the time target for definitive management. Name who must be called in parallel. (3 marks)
- Endoscopy will be delayed by ninety minutes because the on-call team is in theatre. State whether you would give a temporising agent, name it, give the dose, and list the contraindications. (3 marks)
- The battery is removed and a deep oesophageal burn is noted. Describe your disposition and the written safety-net advice. (2 marks) [3] [5]
Full-credit answer — SAQ 1
Reveal full-credit answer for SAQ 1
1. Radiographic diagnosis and urgency tier
The combination of a disc-shaped radiopacity at the thoracic inlet with a concentric ring or halo (double-ring) sign on the anteroposterior view is diagnostic of a button battery lodged in the upper oesophagus. A lateral view should be obtained to confirm the step-off at the rim that distinguishes a battery from a stacked pair of coins. This is an emergency within two hours: endoscopic removal is required regardless of symptoms because alkaline necrosis is already underway. [10] [3]
2. Resuscitation, time target, and parallel calls
Keep the child nil by mouth and upright, suction oral secretions, and place the child on continuous monitoring. The definitive time target is endoscopic removal within two hours of presentation. In parallel, call the paediatric anaesthetic team, the paediatric gastroenterology or surgical endoscopist, and the paediatric intensive care or retrieval team if the local service cannot guarantee two-hour removal. A child who is drooling continuously and unable to handle secretions has a threatened airway and must not wait for further imaging. [1] [3]
3. Temporising agent
Because the child is over twelve months, has no evidence of perforation, and the battery is confirmed in the oesophagus with removal delayed beyond two hours, I would give honey by mouth at approximately 10 millilitres every ten minutes up to six doses while awaiting endoscopy, as endorsed by the ESPGHAN 2021 position paper. The contraindications are: infants under twelve months (botulism risk), suspected oesophageal perforation, inability to protect the airway, and a battery that has already passed the pylorus. Honey is an adjunct to, never a substitute for, emergency endoscopy. [3]
4. Disposition and safety net
A deep oesophageal burn mandates admission for inpatient observation because delayed perforation and fistula can declare days to weeks after removal. I schedule follow-up endoscopy to assess for stricture, involve the paediatric gastroenterology and surgical teams, and start a proton-pump inhibitor. The written safety net tells the family to return immediately with any haematemesis, coffee-ground vomit, melaena, chest pain, fever, dyspnoea or dysphagia, because a sentinel herald bleed is the presentation of aorto-oesophageal fistula and is a maximal emergency. [5] [3]
SAQ 2 — An asymptomatic gastric coin and a magnet concern
Question 2 — 10 formative marks; suggested time 15 minutes [1]
A four-year-old swallowed a coin four hours ago and is completely asymptomatic, eating and drinking normally. A plain radiograph shows a single round radiopacity in the stomach with a solid disc appearance and no step-off. A second child on the same day is reported to have swallowed several small spherical magnets from a toy, and is also asymptomatic. [1] [6]
- State the diagnosis for the first child and the management plan, including the threshold sizes that would change it. (3 marks)
- Describe the follow-up plan and the safety-net advice for the first child if managed conservatively. (2 marks)
- For the second child, explain why multiple magnets anywhere in the gastrointestinal tract are high-risk, and describe your assessment. (3 marks)
- Compare the management of a single gastric magnet with that of multiple gastric magnets. (2 marks) [1] [6]
Full-credit answer — SAQ 2
Reveal full-credit answer for SAQ 2
1. Diagnosis and management of the gastric coin
The first child has a coin in the stomach, confirmed by the solid disc appearance with no halo or step-off, and is appropriately managed by observation at home because he is asymptomatic, eating normally, and has no prior gastrointestinal surgery. The threshold sizes that would change management are objects longer than 6 centimetres or wider than 2.5 centimetres, which are unlikely to pass the duodenum and warrant endoscopic or surgical removal. A button battery in the stomach would also lower the threshold for removal, particularly if large or in a younger child. [1]
2. Follow-up and safety net
I ask the family to check the stools for the coin, to return urgently with abdominal pain, vomiting, fever or bleeding, and to attend for a repeat abdominal radiograph at four weeks if the coin has not been seen to pass. The safety net is written, names the symptoms to watch for, and gives the access route back to the emergency department. Most gastric coins pass spontaneously without intervention. [1]
3. Why multiple magnets are high-risk
Two or more magnets, or a magnet paired with a metal object, can attract across adjacent loops of bowel wall, trapping the intervening tissue and causing pressure necrosis, fistula, volvulus and perforation without any chemical burn. The first sign may be peritonitis from perforation, so any radiograph showing more than one radiopaque object that could be a magnet must be treated as high-risk until counted and located precisely. I obtain an anteroposterior and lateral chest and abdominal radiograph, examine the abdomen for tenderness or peritonism, keep the child nil by mouth if symptomatic, and involve paediatric surgery and gastroenterology from the outset. [6]
4. Single versus multiple gastric magnets
A single gastric magnet is followed closely with serial radiographs to confirm no second magnet exists and that it is progressing; endoscopic removal is reasonable if it is accessible and the family cannot guarantee follow-up. Multiple gastric magnets, or a magnet with a metal object, require endoscopic removal if reachable and surgical consultation if not, because the risk of inter-loop injury is high regardless of symptoms. Observation alone is not safe for multiple magnets anywhere in the tract. [6]
References
- [1]Kramer, Robert E Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee Journal of pediatric gastroenterology and nutrition, 2015.PMID 25611037
- [2]Oliva, Sara Foreign body and caustic ingestions in children: A clinical practice guideline Digestive and liver disease, 2020.PMID 32782094
- [3]Mubarak, Ahmed Diagnosis, Management, and Prevention of Button Battery Ingestion in Childhood: A European Society for Paediatric Gastroenterology Hepatology and Nutrition Position Paper Journal of pediatric gastroenterology and nutrition, 2021.PMID 33555169
- [5]Tran, Cat Complications of button battery ingestion or insertion in children: a systematic review and pooled analysis of individual patient-level data World journal of pediatrics, 2024.PMID 39168931
- [6]Quitadamo, Pierluigi Magnetic foreign body ingestion in pediatric age Digestive and liver disease, 2024.PMID 37985250
- [10]Whelan, Rebecca Button battery versus stacked coin ingestion: A conundrum for radiographic diagnosis International journal of pediatric otorhinolaryngology, 2019.PMID 31404782