Keywords: Button battery; Foreign body ingestion; Meckel’s diverticulum

Introduction

Meckel’s diverticulum (MD) is identified in 1.2-3% of the population. It results from the failed involution of the Omphalomesenteric duct, which usually obliterates between 5^th and 7^th week of fetal life. Most of people with Meckel’s diverticulum remain asymptomatic. Around 5-10 % develop symptoms that prompt medical attention [1]. In pediatric age the most often symptoms are bleeding per rectum, intussusception, pain in lower abdomen. Very often, it mimics appendicitis. Foreign bodies (FB) ingestions are common in pediatric age group with wide varieties of size, shape and material of the FB. Most of children are toddler and the most vulnerable children are those with developmental delay. Approximately 3% of all FB ingestions are small button battery (BB). Probably the number of ingestions in children is bigger, as the production of sophisticated automated toys with BB increases drastically in the last decades. The Gastrointestinal tract is the most common place for FB retention but the MD appears the most uncommon place for (BB) lodgment. There are few previous reports of BB lodged in a MD but without characteristic sonographic diagnostic signs. We present a case with BB lodged in MD, complicated with perforation and sent to our institution with diagnosis acute appendicitis.

Case report

We present a case of 3 years old boy with lower abdominal pain, swallowing BB, sent to our institution to R/O Acute appendicitis. The conventional Radiographs of chest and abdomen supine position from previous hospital show two BB located in lower abdomen (Figure 1A), the bigger sized battery appears at level of ileo caecal valve, surrounded with soft tissue mass suggestive of attempting ileocolic intussusception or per appendicular mass. The erect position (Figure1B) shows air fluid levels suggestive of incomplete bowel obstruction. The lateral view (Figure1C) shows anterior location of the bigger BB raising the possibility of lodgment in MD and the patient was sent for abdominal sonography for precise localization of BB whether it is in the terminal ileum, appendix or MD. The abdominal sonography revealed normal size and echotexture of the appendix (diameter was 5 mm) with no BB in the lumen (Figure2A). The further scanning discovers a tubular structure with typical pseudo gestation sac sign, surrounded with redundant echoic omentum suggestive of inflamed MD probably perforated (Figure2B) With mild tilting of the transducer, the arching hyperechoic outlines of BB was visualized. The final diagnosis was BB lodged in MD and the patient was sent directly for surgical removal without any further investigations. The surgical specimen shows corroded BB out of the tip of perforated MD (Figure3).

Discussion

BB represent a distinct injury risk when ingested. Sodium hydroxide and hydrochloric acid appear at the cathode (negative) and anode (positive) ends respectively, leading to pH changes around the terminals. Such production leads to liquefaction necrosis and tissue injury [1] the age is an important predictor of severity. All fatalities and 85% of major effects are in children who are younger than 4 years. A major effect or death occurred in 12.6% of children who were younger than 6years and ingested 20-to 25-mm batteries [2]. The lithium alkaline battery produce more severe tissue damage compared with the BB because the lithium battery has higher voltage of 3V. The experiments with dogs show necrosis of esophageal epithelium 15 min. after fixation of battery deep to the inner muscular layer [3]. It is obvious how important is the timing management of MD with lodged BB. Time-consuming exams are not necessary. Our decade experience with sonographic diagnosis of MD using the sonographic pseudo gestation sac sign shows -sensitivity 87.1%, specificity82.1percentage, positive and negative predictive values for MD are 84.4 % and 85.2% respectively [4]. Our presented case proves once again the validity of sonographic pseudo gestation sac sign for precise diagnosis of MD. 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 advisable. If it is located in the stomach, extraction within 24 hrs is necessary. If the battery has passed distal to the stomach, the patient needs follow up with serial roentgenograms. When the battery location does not change and peritoneal irritation appear, an operation is the next step [5].

Conclusion

Timing management of MD with lodged BB (extremely rare) is essential for the outcome. Despite rarity, such combination is real and always should be considered in differential diagnosis. The sonographic pseudo gestation sac sign is reliable diagnostic tool for precise diagnosis of MD. It complies with international efforts for “Image Gently”.