The next confession slash disclosure is that this button battery I found at the weekend albeit on a high shelf but a high shelf in my three-year bedroom and Nobody in the house has got any idea how it got there. No idea whatsoever. He doesn't know I don't know his big brother doesn't know My husband doesn't know and then he doesn't know don't know fell from the sky the only things in his bedroom that have button batteries are Really secure. He's got one thing a remote for his bedside light and it is very secure, requiring a screwdriver to open it, but there you go. Another sort of similar anecdote, a friend of mine who's an ENT surgeon, when she woke one of her daughters up one morning she found no less than seven button batteries under the pillow where her daughter had been sleeping. So this is real, it happens, it happens to those of us, you know, I mean my children think that I spend half of my time at work removing batteries and magnets from naughty children that have swallowed them and the other half creating new bottom holes. They're not far wrong. There's a lot of ingrowing toenails, ingrownal hernias and orchid epexies and foreskin to deal with in between but I don't chat so much about those at home. So despite a lot of our chat at home being about the dangers of things like magnets and batteries, how they should be safely secured, stored safely, etc. I still found one this weekend terrifying. The other thing about this picture is that I don't know what anyone else thinks, but I'm not entirely sure that a bright red sticker on it that says harmful if swallowed is of any use to the children certainly and Really the adults should already know that if anything this red sticker makes the battery looks slightly more interesting and inviting than it did without it There's lots of different types of button batteries around I think there's about 85 different button batteries available either on the market or in use in toys, watches, hearing aids etc etc. In the UK these are just the ones that I could find at home. And you can see the sizes compared to a 10 pence coin and a 5 pence coin. In the batteries the active agent varies from lithium, alkaline, silver oxide, mercury, and all sorts of different things. They range in size from 2.8 to 30 millimeters, and in thickness from 1.2 to 16 millimeters. And the code on the battery, so the most common battery that is used button battery that's likely to cause problem, is the CR2032. The CR means that it's lithium manganese oxide and the 2032 means the diameter is 20mm and the thickness is 3.2mm. So how do ingested button batteries cause trouble? So you've seen the video of the battery that was inserted, just sort of wedged in that chicken breast and in a very, very, very short period of time, it's caused significant necrosis. The three N's stands for negative, narrow, and necrotic, which means that the negative battery pole is on the narrowest side, which you can see on the lateral X-ray, and causes the most severe necrotic injury. The larger the battery and the smaller the esophagus, the more likely the battery is to get stuck. And it's really, it's the batteries that are in the esophagus that we're worried about and that's because they stick against the mucosa of the esophagus, whereas if the button battery has passed through the esophagus down the rest of the GI tract, it's unlikely to be in contact with the mucosa for any prolonged period of time. It's moving around so it's much much much less likely to cause any significant injury whereas the esophagus has got three particularly narrow points at the level of thoracic inlets, the aortic arch and the gastroesophageal junction and those are the places where you're most likely to get the button battery stuck. And essentially what happens is the mucosa bridges the electrodes. The electrodes are like the circular kind of rim that you can see on the narrower side of the battery. And that allows generation of an electric current which causes hydrolysis of the tissue fluid. And that generates hydroxide at that negative pole. And that hydroxide is basically extraordinarily strong alkalites like pouring oven cleaner into the esophagus. So you very, very rapidly get this alkaline corrosive injury that causes tissue liquefaction and necrosis as you saw in that chicken breast video right at the beginning. And that happens really quickly. Within two hours, you've got significant injury. Later on there might be the risk of leakage of the battery contents, especially from the alkaline electrolyte. But that usually doesn't happen for at least two hours onwards. And in all of the studies that they've tried to do, there's been varying degrees of how much the battery has leaked or not. Obviously in the situation when you've already got the tissue necrosis, the liquefaction and you've got this fluid, the alkali fluid and the chronic necrotic tissue you're probably more likely to get some leakage but most of the injury is from the corrosive alkali effects of the hydroxide that is produced. So when might you suspect a battery ingestion? There's some really important things to think about here is that the vast majority of the time the button battery is ingestion is not witnessed. You don't have to have a child who's big enough to walk and get hold of a button battery to ingest it. We all know the dangers of having an older sibling and they will feed things to their younger siblings. I remember a child who presented with a magnet ingestion and their older sibling very proudly said, oh look mummy look what little Johnny can do and put a magnet on the outside of little Johnny and it stuck and the mum was like what's happened here? You know I realized that older sibling had fed the magnet to the baby. Great party trick but I don't recommend it. It may not be witnessed. It's unlikely that the child is going to offer up, oh yes, I've just swallowed a button battery because they probably don't even know what it is. It could be that parents thought that they've witnessed swallowing of a coin. We will talk in a moment about the signs to look for on an x-ray but they are not always there so if there is any hint of suspicion that this could possibly be a battery then treat it as a battery ingestion. They may present with airway obstruction, they may present withdrawing with swallowing, regurgitation. The history may be quite insidious and have been going on for several days. Some children have presented weeks after ingestion of a battery and still have a battery lodged somewhere in their esophagus. It may be that they're refusing to eat or drink and you've got no idea why. They may have chest pain, coughing, choking, gagging, lots of different things. Sometimes they present with recurrent upper respiratory tract infections but they're not so unwell as to warrant a chest x-ray for this presumed upper respiratory tract infection. I remember a patient who had presented daily to the local emergency department for seven days with cough and food refusal, low grade temperature, and generally not quite right. And it was only on the eighth day that somebody took a chest x-ray and saw the button battery lodged in the esophagus. And the patient was blue lighted to us in Leeds, this is many years ago, and on arrival, as they were wheeled in onto the ward with the with the paramedics she essentially just started to exsanguinate out of her mouth at huge high pressure because of an esophageal vascular fistula so she had been presenting repeatedly and nobody had thought about because there was no suggestive history and no one had thought about it so it's very very simple. What do you do when a button buttery ingestion is suspected, even the slightest bit of suspicion, get a chest X-ray? And then if you need to, a lateral to confirm, a double rim, a halo, or a step off. So a couple of X-rays here. So we'll go back to that one from earlier. You can see the, I've just highlighted there, the step-off sign, so you can see that drop down onto the negative electrode of the button battery and the double rim or halo sign. I've talked a little bit about magnets, I've mentioned them here and there, the talk is not about magnets, but beware the possibility of a battery plus magnet ingestion. With these batteries, we wouldn't be worried about one that's below the diaphragm. It's a little bit harder when you've got this many batteries in a patient, because who knows what's going to happen? Is that sort of more dangerous because you've got so many, you're going to be keeping a close eye on them, but it's not quite the same as if it's stuck in the esophagus. But you would want to think about what you're going to do and get your surgical colleagues involved if there are either this many or if there's any suspicion that there's a magnet in there as well, even if they are below the diaphragm. Continuing on the theme of what to do when a button battery ingestion is suspected, pre-arrival in hospital, the advice is over the age of one year to give honey a teaspoon every 10 minutes, and that can be repeated six times. If they're under the age of one, there's limited evidence that you can give jam. I mean, we don't want to worsen the situation of the button battery ingestion by giving them botulism and under the age of one from the honey, so we use jam instead. And in hospital, sucral fate, the suspension, a gram every 10 minutes, and you can do that three times. Neither of those things should delay the patient from getting to hospital, nor should those things delay the patient from getting to theatre. The key thing here is that we need to get the battery out as quickly as is possible, and who's going to do that is going to depend upon where you are, because it may be that you're in a tertiary center with pediatric surgical services and in which case somebody like Erica or myself will be around and will be able to get the patient to theatre and get the button battery out. But it may be that you're somewhere that doesn't have pediatric surgery but you might have an ENT surgeon who would be happy to get the battery out. There's usually this kind of if something's above the level of the clavicles, then ENT will remove it and if it's below, then pediatric surgery will. But if you ask your local ENT surgeons, even if it is below the level of the clavicles, they will appreciate that actually time saves lives in this situation. Even after you've removed the button battery, that alkali injury does continue to occur, so you do need to get that button battery out as quickly as possible. When they go for endoscopy to remove the battery, you're not just doing this to remove the battery, that is the key point. The other things you want to do is note the extent of the injury, see if there's any obvious evidence of perforation and document where the battery was lying, where the injury was, which side the negative pole was on. If there's no evidence of perforation, then we would irrigate with 150 ml of quarter percent acetic acid with the hope that that will neutralise some of the alkaline and prevent or reduce the amount of sort of ongoing consequences from the alkali burning. And we would also pass a nasogastric tube and a bridal which would allow enteral feeding to start early and also if they've got a significant injury, particularly if it looks circumferential, you're really worried about the risk of stricturing later down the line and that nasogastric tube is going to allow some patency or at least help you to find the esophagus and the way through the esophagus in the future should that be needed. As discussed, the injuries can continue for long after the button battery has been removed. So if the button battery has been removed in a DGH with by an ENT surgeon, that patient will need to be admitted and they almost certainly need to be transferred to a pediatric surgical center. The ingested button batteries can cause massive and wide and varying problems afterwards. So apart from the obvious sort of esophageal perforation, it can fistulate through into the trachea, into vessels, and perforation may present as late as 28 days down the line. Fistually have been reported to present as late as 48 days down the line. You can get recurrent laryngeal nerve injuries, trachea melation, medius dinitus and empyema, lung abscesses, strictures which present later on and may need you know multiple repeats general anaesthetic for dilatations and we've seen patients present with spondylodiscitis several weeks down the line as well and of course we all know about the risk of death. When death occurs in this situation it usually occurs because of a an esophagovascular fistula. It may be that there is a herald bleed and if that herald bleed occurs within hospital really all you can do is get that patient to theatre, get cardiothoracic surgeons, get the patient on bypass and then operate to see what you can do and if you can salvage. If the herald bleed happens outside of hospital then it's almost certain that the patient is not going to survive. What you do with the patient, you know, once they've been admitted, I mean I've kept patients like this in for three weeks and really if you're getting bored that's a good thing in this situation. You have to work out if you need to do any further imaging based upon their symptoms but how you interpret that imaging and what you do about it is really really difficult and know, whether a CT, whether an MRI is going to help what the degree of inflammation that you see means, it's very, very difficult to manage these patients until something happens and then you deal with it surgically, essentially. Thank you very much.