Perforation of Meckel's Diverticulum by a Button Battery: Report of a Case

Surg Today (2007) 37:1115–1116DOI 10.1007/s00595-007-3536-2

Reprint requests to: A. Karaman, Köylüler Sokak 15/2, 06590 Cebeci, Ankara, TurkeyReceived: January 11, 2007 / Accepted: March 30, 2007

Perforation of Meckel’s Diverticulum by a Button Battery: Report of a Case

AYSE KARAMAN, IBRAHIM KARAMAN, DERYA ERDOGAN, YUSUF HAKAN ÇAVUSOGLU, MUSTAFA KEMAL ASLAN, ONURSAL VARLIKLI, and ÖZDEN ÇAKMAK

Department of Pediatric Surgery, Dr. Sami Ulus Children’s Hospital, Ankara, Turkey

AbstractA perforation of Meckel’s diverticulum (MD) by foreign bodies is an extremely rare cause of acute abdomen in children. We herein present a rare case of perforation of Meckel’s diverticulum in a child after swallowing an alkaline button battery that contained lithium.

Key words Perforated Meckel’s diverticulum · Foreign body · Lithium

Introduction

Small foreign bodies are commonly ingested by children and most of them are excreted without causing any problem. Although the incidence of foreign body inges-tion is high, a perforation of Meckel’s diverticulum by an alkaline button battery is quite rare and only one such case has been previously reported.1

Case Report

A 1-year-old boy was admitted to our hospital with abdominal pain, vomiting, constipation, and a history of button battery ingestion 6 days before presentation. A physical examination revealed generalized abdominal tenderness. Laboratory data were normal except for leukocytosis of 16.2 × 103/µl and hyponatremia (133 mEq/l). The abdominal X-ray showed a round metallic foreign body in the lower abdomen (Fig. 1). A laparotomy was performed after preoperative preparation. The abdomen was entered through a right lower paramedian incision and some amount of serous fl uid was observed in the peritoneal cavity. During the examination of the small

bowel, perforated MD due to a button battery approxi-mately 60 cm proximal to the ileocecal valve was observed (Fig. 2). The perforation site adhered to the cecum and appendix, and resembled a plastron. Necro-sis and erosion were found in the cecum and appendix (Fig. 3). Wedge resection of the ileum, including per-forated diverticulum and segmental resection of the cecum, was performed. The removed battery, which contained lithium, measured approximately 1 cm in diameter and 3 mm in thickness. It appeared to be intact although its outer surface was pitted. The patient recov-ered uneventfully and was discharged on the seventh postoperative day.

Discussion

Meckel’s diverticulum is the most common congenital anomaly of the small intestine, found in 2% of the general population. Meckel’s diverticulum can be symp-tomatic with infection, bleeding, and intestinal obstruc-tion. Perforation of MD by foreign bodies is extremely rare and in a large review, the indication rate for a resection due to perforation by foreign body was reported to be 8% of all complicated diverticula.2 There are several case reports in the literature regarding per-forations caused by toothpicks, fi shbones, and needles.1,2 A perforation of MD caused by a button battery has been reported in one case in the literature.1 To the best of our knowledge our case is unique, because the perforation site in the MD due to battery adhered to the cecum and constituted a mass, thus resembling a plastron.

Although button battery ingestion is rare in child-hood, this ratio is increasing with technological develop-ments.3,4 Small disk batteries that are used in calculators, clocks, toys, and hearing aids may be swallowed by children. There are four main types of disk batteries: mercury, alkaline manganese, silver, and lithium.3,5 The

1116 A. Karaman et al.: Perforation of Meckel’s Diverticulum

caused by three mechanisms: pressure necrosis, direct corrosive action, and low voltage burns. In addition to the high risk of perforation following the ingestion of a mercury cell battery, acute mercury poisoning may also pose a life-threatening situation.3–5

Patients who ingest button batteries should have an initial roentgenogram to determine the location of the foreign body. If the battery is located in the esophagus, urgent extraction is recommended. If it is located in the stomach, extraction within 24 h is recommended. If the battery has passed distal to the stomach, the patient should be followed with serial roentgenograms. When the battery location does not change and peritoneal irritation is observed, an operation is indicated.

In conclusion, a conservative approach is indicated in an asymptomatic patient with a disk battery located in the gastrointestinal tract which had passed through the esophagus. However, if a patient manifests signs and symptoms indicative of injury to the gastrointestinal tract (abdominal pain, vomiting, fever, and generalized abdominal tenderness) such as in our case, then surgery is indicated.

References

1. Willis GA, Ho WC. Perforation of Meckel’s diverticulum by an alkaline hearing aid battery. Can Med Assoc J 1982;126:497–8.

2. Yagcı G, Çetiner S, Tufan T. Perforation of Meckel’s diverticulum by a chicken bone, a rare complication: report of a case. Surg Today 2004;34:606–8.

3. Litovitz T, Schmitz BF. Ingestion of cylindrical and button batteries: an analysis of 2382 cases. Pediatrics 1992;89(4):747–57.

4. Mack RB. Some light on the charge brigade-disk battery ingestion. N C Med J 1983;44:560–1.

5. Suita S, Ohgami H, Nagasaki A, Yakabe S. Management of pedi-atric patients who have swallowed foreign objects. Am Surg 1989;55:585–90.

Fig. 1. Abdominal X-ray shows a round metallic foreign body in the lower abdomen

Fig. 2. Perforated Meckel’s diverticulum due to a button battery

type, dimension, capacity of battery, ingestion time, and associated gastrointestinal pathology of the patient are important in the cases of ingestion of a disk battery.3 Following the ingestion of alkaline or mercury cell-type batteries, perforation of the gastrointestinal tract can be

Fig. 3. Necrosis and erosion were found in the cecum and appendix