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Button and cylindrical battery ingestion: Clinical features, diagnosis, and initial management

Button and cylindrical battery ingestion: Clinical features, diagnosis, and initial management
Literature review current through: Jan 2024.
This topic last updated: Jun 02, 2022.

INTRODUCTION — The evaluation and management of button and cylindrical battery ingestion will be presented here.

The management of button batteries in the ear or nose, esophageal foreign bodies other than button batteries, and corrosive esophageal injury are discussed separately as follows:

(See "Foreign bodies of the outer ear (pinna [auricle] and external auditory canal): Diagnosis and management", section on 'Foreign bodies of the external auditory canal'.)

(See "Diagnosis and management of intranasal foreign bodies", section on 'Foreign body removal'.)

(See "Foreign bodies of the esophagus and gastrointestinal tract in children" and "Ingested foreign bodies and food impactions in adults".)

(See "Caustic esophageal injury in children" and "Caustic esophageal injury in adults".)

BUTTON BATTERY INGESTION

Epidemiology — The National Battery Ingestion Hotline (NBIH) was created in 1982 and collects data, provides consultation, and promulgates recommendations for battery ingestions [1]. As of 2015, up to 1.5 battery ingestion cases per 10,000 children occur each year in the United States [2]. The incidence has increased with expanded use of button batteries in household and recreational products [1-10].

From 2007 to 2009, serious sequelae (eg, esophageal burn, perforation, or fistula) occurred in 2.7 percent of all button battery ingestions reported to the National Poison Data System, which compiles all calls to United States regional poison control centers [3]. Ingestion of large diameter (≥20 mm) lithium cell batteries was strongly associated with these major outcomes and death. (See 'Complications' below.)

Battery ingestion has been described in several retrospective case series [1,4-6,11]. The largest series, from the NBIH, describes 8648 battery ingestions, 94 percent of which involved button batteries and 6 percent of which involved cylindrical batteries (eg, AA, AAA, C, N) [11].

In this series, battery ingestions had the following characteristics:

The majority of ingestions occurred in children younger than six years of age, with the peak frequency between one and two years of age.

Among children, over half of the batteries were ingested immediately after removal from a product.

Ingested batteries were obtained from a variety of devices including (in decreasing order of frequency) hearing aids, games and toys, watches, calculators, lighting devices (eg, flashlights, light/laser pointer, penlight), and remote control devices (eg, television, garage door, key fob).

By 2008, 18 percent of ingested batteries were ≥20 mm, and most of these large diameter batteries were lithium cells. (See 'Battery description' below.)

Patients with hearing aid battery ingestions were the user of the hearing aid in a large majority of cases.

In a significant number of ingestions, the hearing aid battery was mistaken for a pill. A common scenario involved storage of hearing aid batteries near medications. In some instances, the patient swallowed the battery and then realized their mistake when they tried to put their pill into the hearing aid and found it did not fit.

Other reasons for ingestion included placement on the tongue to "test" the battery, holding the battery in the mouth, and suicidal intent.

These findings suggest that parents/caregivers and users of hearing aids should be made aware of the danger of button battery ingestion. In addition, measures by the manufacturer to secure the battery compartment of devices using button batteries could prevent over half of pediatric button battery ingestions. (See 'Prevention' below.)

Battery description — Between 30 and 60 percent of each battery contains inert components [5]. The active portion of the battery consists of a negative terminal and a positive terminal (figure 1) [12]. The negative terminal of the battery is typically made of zinc or lithium, and the positive terminal of one of the following substances [3,5]:

Lithium manganese (3 volts, most common)

Manganese dioxide (1.5 volts)

Oxygen (zinc-air cells, 1.5 volts)

Silver oxide (1.5 volts)

Mercuric oxide (1.5 volts)

The negative terminal is the narrow portion of the battery where the electric current flows into the tissue and usually creates the most damage.

The negative and positive terminals are typically separated by a disc that is embedded with potassium hydroxide, sodium hydroxide, or an organic solution with varying concentrations [13]. The terminals and salt solution are encased in steel and/or nickel (figure 1).

Battery identification — Button batteries range in diameter from 6 to 25 mm, a range that closely approximates that of pills. Lithium batteries are preferred by manufacturers because they maintain a longer charge, provide a higher voltage, and are lighter than other cell types [14]. Batteries that are larger than 12 mm in diameter are most likely to become lodged in the esophagus, especially in young children.

The chemical content, diameter, and height of the battery can be determined from the imprinted code found on the battery case as determined by the International Electrotechnical Commission [15]. The first letter gives the chemical identification of the positive terminal as follows:

L: Manganese dioxide

S: Silver oxide

P: Oxygen

C: Manganese dioxide

B: Carbon monofluoride

G: Copper oxide

LR (or AG): Alkaline

SR: Silver oxide

CR: Lithium/manganese dioxide

BR: Lithium carbon monofluoride

A battery with a three number code has the diameter given by the first number (eg, SR516 is 5 mm in diameter).

A battery with a four number code has the diameter given by the first two numbers (eg, CR2032 is 20 mm in diameter).

The last two numbers give the battery height in tenths of millimeters (eg, CR2032 is 3.2 mm in height).

The package code also corresponds to the battery diameter in millimeters. For example, a battery with a package code of 23 has a diameter of 23 mm.

The type of device from which the battery was removed or for which it was intended may also help in identification as indicated below [12]:

Calculator – HgO, AgO

Camera – HgO, MnO2

Computer game – HgO, AgO

Hearing aid – HgO, AgO, zinc-air

Watch – AgO, HgO, MnO2, lithium

Remote control – lithium

Pathogenesis — Button batteries that become lodged in the mucosa of the gastrointestinal (GI) tract cause caustic injury, mucosal ulceration, and, if impacted long enough, perforation. Although injury may occur at any site, the esophagus is most prone to impaction. The severity of esophageal damage after button battery ingestion depends upon the length of time that the battery is lodged in place, the amount of electrical charge remaining, and the size of the battery [16-18]. Damage to the esophagus may be seen as early as two hours after ingestion, with more severe damage after 8 to 12 hours [5,16,19]. As the duration of impaction increases, the mucosa becomes edematous and the battery adheres tightly to the mucosa. If the battery remains in place, ulceration and perforation can occur [18,20].

Electrical discharge appears to be the most prominent mechanism for mucosal injury after button battery ingestion in most clinically significant cases. Mechanisms of injury from battery ingestion include electrical discharge, pressure necrosis, and leakage of battery contents [3,5,6], each of which contribute to corrosive damage when the battery is in contact with a mucosal surface for a sufficient period of time as follows:

Electrical discharge – The flow of electric current from the battery through the surrounding tissue occurs near the negative pole and can cause local hydrolysis, hydroxide accumulation, and corrosive tissue injury [4,16,20-22]. Discharged batteries still retain enough voltage and storage capability to generate an external current. Thus, ingestion of "dead" button batteries is still a major concern.

The corrosive injury caused by electrical discharge cannot be differentiated from that caused by leakage of battery contents. However, this mechanism appears of primary importance for the following reasons:

In an in vitro study, after less than one minute, the electric discharge from a battery generated enough sodium hydroxide at and near the anode to raise the pH to 11 [21].

Several case reports describe increased severity of mucosal injury near the negative pole of batteries removed from the esophagus [21].

Major complications (eg, esophageal burns, fistula, or perforation) and deaths are associated with lithium batteries, which contain higher voltage (3 volts) and capacitance than most other button batteries [3]. (See 'Battery description' above.)

Among patients who ingested large (≥20 mm in diameter) button batteries, clinically significant esophageal injury was significantly associated with new batteries [3].

Significant esophageal mucosal injury has been documented in patients with intact batteries lodged for less than two hours, an insufficient amount of time for pressure necrosis [3].

Leakage of contents – In an acidic environment such as the stomach, the seal or crimp of the battery may erode, potentially releasing chemical contents, including sodium or potassium hydroxide [19,23,24]. In vitro experiments and examination of ingested batteries after passage through the gastrointestinal (GI) tract provide information about the likelihood of dissolution of the battery seal [1,24].

In the large series of cases from the NBIH, 1809 batteries were available for examination after transit through the GI tract [3]. Two percent of the batteries fragmented within the GI tract and 13 percent had severe crimp dissolution or extensive perforations. Severe outcomes were significantly more likely in patients with severe crimp dissolution or battery fragmentation (4 versus 1 percent).

In an in vitro experiment, button batteries were placed into a 0.1 N hydrochloric acid solution to mimic the pH of the stomach [24]. The percent erosion of the crimp seal after 24 hours was directly related to the amount of charge remaining in the battery, with complete crimp dissolution in fully charged cells, 50 to 60 percent dissolution in 50 percent discharged cells, 10 to 20 percent dissolution in 75 percent discharged cells, and only minor pitting in the fully discharged cells [24].

Alkaline solutions – As the alkaline solutions (potassium and/or sodium hydroxide) react with the exposed proteins on the mucosal surface of the GI tract, they may cause liquefaction necrosis and saponification of lipid membranes [25]. (See "Caustic esophageal injury in children".)

The dissolution process is slowed somewhat when the battery enters the intestines, where the pH is higher than in the stomach [4].

Heavy metals – Absorption of heavy metals from broken or fragmented batteries is another potential mechanism of injury. However, cases of heavy metal poisoning from disc battery ingestion are quite rare. In one case, a five-year-old boy's serum lithium concentration peaked at 0.7 mEq/L after swallowing a button battery [26].

Mercury batteries are the most concerning in this regard because they are the most likely to fragment [1], and because of the potential severity of mercury poisoning. However, mercury toxicity from battery ingestions is extremely rare. There are several case reports describing elevated serum or urine levels of mercury after battery ingestion with radiologic evidence of battery fragmentation and radiopaque droplets in the intestines [1,4,5,19,27-30]. However, none of the involved patients had clinical signs or symptoms of mercury toxicity. In the one possible case where symptoms of mercury poisoning (malaise and lethargy) were present, mercury levels were not obtained [31].

The absence of symptomatic cases of mercury poisoning among battery ingestion victims is thought to be related to the conversion of mercuric oxide to the less easily absorbed elemental mercury in the presence of soluble iron (released from the corrosion of the steel casing), according to the following reactions [32]:

HgO + 2HCl –> HgCl2 + H2O

HgCl2 + Fe –> FeCl2 + Hg

Pressure necrosis – When an ingested foreign body, such as a button battery, lodges at a single site, it can place pressure on the surrounding tissue and cause irritation, inflammation, and ischemia. This series of events may lead to tissue necrosis [6,25,33]. The magnitude of the contribution of pressure necrosis to the overall mucosal damage in patients after button battery ingestions is less certain [4,5].

Clinical features

History — In most instances, battery ingestions are witnessed or the child tells the caregiver about the ingestion. The clinician should obtain the following information:

Battery type – The battery type may be known by the patient or caregiver, available from the code on an identical battery, or determined based upon descriptions of the battery or the device it operates [34]. (See 'Battery identification' above.)

Most large diameter (≥20 mm) batteries are lithium cells and are associated with the most severe sequelae, including death [3]. For comparison, a dime is 18 mm, a nickel 21 mm, and a quarter 24 mm in diameter [3,27]. (See 'Complications' below.)

Battery charge state – The charge state of the battery is important because new batteries are associated with a greater potential for tissue damage if they are ≥20 mm in diameter [3]. However, "dead" batteries still have significant potential for tissue damage. (See 'Pathogenesis' above.)

Time of ingestion – The time elapsed since ingestion can indicate the severity of damage, particularly when it exceeds two to four hours.

Number of batteries ingested – Ingestion of multiple button batteries is associated with more severe clinically significant outcomes [3].

Magnet coingestion – Although rare, ingestion of a button battery and a magnet may lead to bowel necrosis and perforation should the intestinal wall be trapped between the battery and the magnet [3,35].

History of esophageal anomaly, stricture, or surgery – These patients are at greater risk for esophageal impaction after button battery ingestion. Furthermore, the site of impaction may differ from what is seen in patients with normal anatomy (figure 2).

Signs and symptoms — Most patients are asymptomatic although one or more of the following symptoms may be present [1,3-5,12]:

Chest pain

Cough

Anorexia

Nausea/vomiting

Hematemesis

Diarrhea

Epigastric pain

Abdominal pain

Fever

Many of these symptoms are caused by the battery's lodging within the esophagus, where it can cause corrosive tissue damage. (See "Foreign bodies of the esophagus and gastrointestinal tract in children".)

Additional clinical features include dysphagia, drooling, and black flecks in the saliva [27].

Symptoms of esophageal perforation or tracheo-esophageal fistula in children with button battery ingestion include hematemesis, drooling, refusal of oral intake, and/or respiratory distress [36]. Physical findings in these patients can include:

Fever

Hemorrhagic shock with pallor, tachycardia, and hypotension

Subcutaneous emphysema with crepitus

Tension pneumothorax with tracheal deviation, decreased chest wall excursion, hyperresonance on the side of the pneumothorax, distended neck veins, tachycardia, and/or hypotension [37]

The clinician should also maintain a high level of suspicion for an esophageal button battery or other foreign body, despite a negative history of ingestion, in young children who are refusing oral intake. In a case series of 13 deaths after button battery ingestion, misdiagnosis occurred in seven patients because of a lack of ingestion history combined with nonspecific presenting symptoms, such as fever, vomiting, lethargy, poor appetite, irritability, cough, wheezing, and/or dehydration [3].

Diagnosis — Most patients or caretakers provide a history of button battery ingestion at initial evaluation and many patients are asymptomatic. However, especially in young children, ingestion should be included in the differential diagnosis of patients with abrupt onset of any one of the following symptoms [3,38] (see 'Clinical features' above):

Airway obstruction

Wheezing (without typical prodrome of viral illness or history of atopy)

Stridor (without typical prodrome of viral croup)

Drooling

Chest pain

Difficulty swallowing

Symptoms (eg, coughing, choking, or gagging) with oral intake

Refusal of oral intake

Hematemesis

Abdominal pain

Demonstration of the battery on plain radiographs confirms ingestion. Radiographic location also determines appropriate management. The radiographs should cover the area from the nasopharynx to the anus. (See 'Radiographic localization' below.)

Management — The National Battery Ingestion Hotline (NBIH; 1-800-498-8666) or a regional Poison Control Center are available to provide guidance for the management of patients with button battery ingestions. If available, the clinician should try to determine the battery identification code, which is typically located on the package or on a matching battery. (See 'Regional poison control centers' below.)  

Approach — Our approach is largely consistent with guidelines developed by the National Capital Poison Center and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Endoscopy Committee (NASPGHAN). The Battery Ingestion Hotline (1-800-498-8666) or a regional Poison Control Center are available to provide guidance for the management of patients with battery ingestions. The NASPGHAN guideline is found in the reference [14]. Since the publication of the NASPGHAN guidelines, in vitro and in vivo animal models of esophageal battery impaction indicate that early feeding with either honey or sucralfate until the battery is removed may reduce the severity of esophageal burns and improve patient outcomes [39].

These guidelines emphasize timely recognition, radiographic localization, and emergency endoscopic removal of esophageal button batteries and, in symptomatic patients, emergency endoscopic or surgical removal of button batteries regardless of location.

Important differences between the guidelines do exist for management of asymptomatic young children with button batteries in the stomach, as summarized below. (See 'Gastric location' below.)

First aid — For asymptomatic children with acute button battery ingestions (eg, witnessed or likely to have occurred within 12 hours) who are older than one year of age and without allergies to honey or its components, we suggest one oral dose of pure honey (eg, 5 to 10 mL) given by the caregiver at home as soon as possible after ingestion. Once in the emergency department, the child may receive another dose of honey or, if no history of allergy, a single dose of sucralfate 500 mg prior to confirmation of esophageal impaction by radiography and emergency battery removal.

Although this approach runs counter to the usual approach of no oral intake until operative removal, the benefit of neutralization and reduction in burn injury to the esophagus appears to outweigh the potential increased risk of aspiration. This recommendation is derived from animal studies that demonstrate a marked reduction of esophageal injury after button battery impaction when honey or sucralfate are given [39]. By contrast, the National Battery Ingestion Hotline guidelines advise more frequent and greater volume of honey administration (ie, 10 mL of honey every 10 minutes up to six doses) [40]. No human studies are available to guide optimal dosing for honey or sucralfate.

Children with a delayed recognition of a button battery ingestion (eg, uncertain timing of ingestion or symptoms of serious esophageal injury or mediastinitis such as chest pain or fever) should not receive honey or sucralfate and should have no oral intake until the evaluation and management is complete.

Stabilization — As with all acute ingestions, stabilization of the cardiorespiratory status is the first priority. However, most patients with button battery ingestion are asymptomatic or present in stable condition, and localization of the battery is typically the first step.

Asymptomatic, stable patients with acute battery ingestion (eg, witnessed or likely to have occurred within 12 hours of presentation) should receive honey or oral sucralfate as described above [39]. (See 'First aid' above.)

Symptomatic children with a delayed diagnosis of battery impaction (eg, uncertain timing of ingestion or symptoms of serious esophageal injury or mediastinitis, such as fever or chest pain) should have no oral intake prior to battery removal.

Radiographic localization — We recommend emergency evaluation and plain radiography after ingestion of a button battery for patients who meet any one of the following criteria [3,40]:

All children ≤12 years of age

All patients who have ingested a button battery that is ≥12 mm in diameter

All patients for whom the diameter of the battery is not known

Because approximately 10 percent of cases involve ingestion of multiple items, the radiographs should cover the area from the nasopharynx to the anus [17,20].

In asymptomatic, healthy patients older than 12 years of age with confirmed ingestion of a solitary, small (≤12 mm in diameter) battery and without coingestion of a magnet, radiography may be deferred [3,40]. These patients may undergo observation for battery passage at home without initial radiographs as long as the patient or caregiver is reliable and able to promptly seek treatment should symptoms develop. Radiographic localization is warranted if battery passage is not confirmed in 10 to 14 days.

Important radiographic features of button batteries that have lodged in the esophagus include:

Anatomic site of impaction – In otherwise healthy patients, esophageal foreign bodies tend to lodge in areas of physiologic narrowing, such as the cricopharyngeus muscle (upper esophageal sphincter), the level of the aortic arch, and the lower esophageal sphincter (figure 2). Patients with a history of esophageal anomalies, strictures, esophagitis (particularly eosinophilic esophagitis), or surgery may have impactions at sites that do not correspond to physiologic narrowing. (See "Foreign bodies of the esophagus and gastrointestinal tract in children".)

Differentiating a button battery from a coin – Patients with button battery ingestions usually present with a chief complaint of button battery ingestion. When the ingestion is an incidental finding on plain radiograph, it may be difficult to differentiate between a button battery and a coin. This distinction is essential to proper management, especially when the foreign body is in the esophagus, because batteries require emergency removal whereas coins may or may not. (See "Foreign bodies of the esophagus and gastrointestinal tract in children", section on 'Coins'.)

The characteristic features of button batteries versus coins are as follows:

Button batteries have a bilaminar structure, making them appear as a double-ring or halo on plain radiographs. The double-ring shadow helps to differentiate battery from coin ingestions (image 1).

On lateral view of the foreign body, the button battery has a step-off at the separation between the anode and cathode (image 2) [41]. By contrast, the coin has a sharp, crisp edge (image 2).

Enlargement of the radiograph may help to demonstrate these differences when interpreting the image. Misidentifying the foreign body as a coin when it is actually a battery can have significant adverse consequences. As an example, an 11-month-old infant incurred bilateral vocal cord paralysis when a button battery was misread as a coin on plain radiographs; she remained intubated for six days [42].

Estimation of battery size – Although size of an object cannot be reliably predicted based upon radiographs, objects greater than 50 mm in length or 20 mm in diameter are less likely to pass into the stomach [43].

Findings of esophageal perforation – Although rarely seen in children with esophageal button battery impaction, findings suggestive of an esophageal perforation on chest radiograph include mediastinal or free peritoneal air or subcutaneous emphysema. With cervical esophageal perforations, plain films of the neck may show air in the soft tissues of the prevertebral space. Other findings suggestive of an esophageal perforation include pleural effusions, mediastinal widening, hydrothorax, hydropneumothorax, or subdiaphragmatic air. However, plain radiographs are an insensitive means for establishing the presence of esophageal perforation [37].

Esophageal impaction — For patients with button batteries that are lodged in the esophagus, we recommend emergency removal with direct endoscopic visualization by an appropriate specialist (eg, in children, a pediatric gastroenterologist, otolaryngologist, or surgeon). For patients with early diagnosis of an impacted button battery (<12 hours after ingestion), we suggest administration of honey or sucralfate suspension to neutralize esophageal pH until the battery is removed [39]. Patients with a delayed diagnosis (eg, ≥12 hours after ingestion) should receive nothing by mouth until the battery is removed. (See 'First aid' above.)

General anesthesia with endotracheal intubation usually is recommended to protect the airway during performance of this procedure.

Airway compromise from esophageal edema has been reported as early as three hours post-ingestion, and esophageal injury has occurred in patients with a battery lodged for less than 2 hours [4,16,27]. Thus, every effort should be made to expedite removal once esophageal impaction has been identified.

The determination of which specialist to perform button battery removal depends upon the presence and type of symptoms as follows:

Asymptomatic – In asymptomatic patients, removal by any of the above specialists is reasonable and the choice should be based upon who can accomplish removal in the timeliest fashion. In many institutions, specific guidelines determine which specialty manages esophageal foreign bodies based upon a variety of factors including anatomic location and provider expertise.

Symptomatic with no bleeding – Symptomatic patients without hematemesis have a higher likelihood of esophageal perforation with complications and warrant involvement of a pediatric surgeon. Patients with symptoms of upper airway compromise (eg, drooling, stridor, or respiratory distress) also warrant consultation with an otolaryngologist who can assess and address any airway damage.

Symptomatic with bleeding – Patients with hematemesis require stabilization and battery removal in conjunction with a surgeon with cardiothoracic expertise as follows [14,44]:

Patients with a low-volume sentinel bleed in association with an impacted esophageal button battery warrant rapid hemodynamic stabilization and emergency removal in the operating room with surgeons present and prepared to perform a thoracotomy.

Patients with active bleeding warrant endotracheal intubation, hemodynamic stabilization, and emergency thoracotomy by a surgeon with cardiothoracic expertise in the operating room. Placement of a Sengstaken-Blakemore tube designed to tamponade esophageal sites of bleeding may be a temporizing measure if the tube and clinicians knowledgeable with its use are available.

The disposition after button battery removal is based upon mucosal findings as follows:

Normal – Patients with normal esophageal mucosa may be discharged home from the post-operative care area.

Esophageal caustic injury – Based upon expert consensus, hospitalization is warranted in patients with any esophageal injury [3,14]. Additional specialty guidance for ongoing management of these patients is provided in the reference [14]. Esophageal perforation and tracheoesophageal fistula (TEF) with erosion into the aorta or other arteries are rare complications, described in case reports and case series [44-47]. Although these injuries are not necessarily apparent at the time of endoscopy, they have occurred in children with moderate to severe esophageal injury at the time of battery removal. Fatal complications have been described 1 to 18 days after battery removal. (See 'Complications' below.)

Patients with severe injury (grade 2B or 3 [deep ulcers or necrosis]) warrant evaluation for stricture formation. The typical approach is to perform a barium esophagogram four to six weeks after the ingestion or sooner if the patient develops dysphagia (difficulty swallowing). Patients with mild to moderate injury are also at risk for stricture formation and warrant repeat clinical evaluation and imaging if symptoms develop. The peak incidence of dysphagia after corrosive esophageal injury is two months, although it can occur as early as two weeks or as late as years after ingestion. (See "Caustic esophageal injury in children", section on 'Stricture formation' and "Caustic esophageal injury in adults", section on 'Esophageal strictures'.)

Before endoscopy became a standard technique for removal of esophageal batteries, other techniques were used with some regularity. The two most common were Foley catheter removal [5] and retrieval of the battery via insertion of an orogastric tube with a magnet attached to the distal end [48-50]. However, such "blind" techniques do not permit evaluation of the esophageal mucosa surrounding the battery, and may have increased risk for airway compromise, emesis, lodging of the battery in the esophagus, and esophageal perforation compared with endoscopy. These techniques are not recommended [3-5,20,33,51].

Gastric location — The approach to children who have a button battery localized to the stomach is as follows:

Symptomatic patients – For patients who have a button battery in the stomach and who have signs or symptoms of esophageal or gastric injury at initial presentation, even if minor, we suggest emergency endoscopy and removal [3,14,40,52,53]. (See 'Signs and symptoms' above.)

Although evidence is limited, symptomatic children have a high risk of mucosal injury to the stomach [52-54]. For example, in a multicenter, retrospective cohort of 68 children with button batteries in the stomach, 76 percent of the 17 symptomatic children who underwent endoscopy (median time nine hours after ingestion) had gastric mucosal damage [52].

Asymptomatic patients – For asymptomatic patients who have a button battery in the stomach, we suggest urgent endoscopy and removal within 12 hours of ingestion rather than at a later time [52,55]. Young children who have ingested a battery ≥20 mm appear to be at highest risk of injury. More timely endoscopy in these patients also permits earlier detection of potential esophageal injury.

In the previously mentioned retrospective cohort of 68 children with button batteries in the stomach, 54 percent of the 51 asymptomatic patients who underwent endoscopy had mucosal damage [52]. Injury was more likely in children who had battery removal >12 hours after ingestion (adjusted OR 4.4, 95% CI 1.4-14.3). Most of the children in this cohort were younger than five years of age.

Our approach to asymptomatic children with gastric button batteries differs from several national consensus guidelines that suggest longer waiting periods of varying length prior to endoscopic removal, including the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Endoscopy Committee (NASPGHAN) [14], the Battery Ingestion Hotline [40], and the European Society for Paediatric Gastroenterology Hepatology and Nutrition [56]. Although the overall risk of gastric injury in selected patients with a button battery in the stomach may be low, serious mucosal injury has been described [52]. Until more evidence is available to demonstrate characteristics that better identify patients with a gastric button battery who can safely undergo observation rather than endoscopy, early removal seems prudent.

Successful endoscopic removal of button batteries from the stomach is less likely than from the esophagus (33 to 82 percent versus 90 percent, respectively) [1,5,6,52]. Although there appears to be a lower risk of damage from the battery once it has cleared the esophagus, serious injury (including gastric perforation) has been described, even relatively soon after ingestion [52,55].

Intestinal location — Button batteries that have cleared the stomach usually pass through the gastrointestinal tract within one week without complication [3]. Prolonged battery transit is more common in patients older than 65 years of age.

Patients and their caretakers should be counseled to seek immediate medical attention for emergency radiography if abdominal pain, hematochezia, or fever develops before battery passage in the stool is confirmed. Such symptoms may indicate intestinal perforation or lodging of the battery in the appendix. Although not reported after button battery ingestion, appendiceal impaction of a wide variety of ingested foreign bodies, including smooth foreign bodies, has been described. Prompt surgical consultation for removal is indicated in symptomatic patients with radiographic documentation of a retained intestinal button battery. (See "Foreign bodies of the esophagus and gastrointestinal tract in children", section on 'Clinical manifestations'.)

Follow-up radiographs should be performed in asymptomatic patients who have not passed the battery by 10 to 14 days, regardless of size. In almost all patients, the battery will have passed by this time. If the battery still remains in the intestine, then further evaluation is warranted to determine if the lack of passage reflects a dysfunction of motility or an abnormality of anatomy (eg, intestinal duplication or stricture). Consultation with appropriate specialists (eg, gastroenterologist or surgeon) is warranted.

Increasing GI motility, bowel irrigation, and repeated enemas in patients with an intestinal button battery have been performed in the past with the goal of hastening passage [5,28,57]. However, given the inconsistent benefit of these measures and the limited risk of heavy metal toxicity or intestinal caustic injury, these measures are not recommended.

Mercury toxicity — Although elevated blood mercury levels have occurred after mercuric button battery ingestion, symptomatic mercury toxicity has not been reported and is unlikely [1]. Furthermore, most button batteries in use contain lithium and significant absorption of lithium is also unlikely.

However, because of the potential severity of mercury poisoning, patients with ingestion of batteries containing mercury that have fragmented or who demonstrate radiopaque droplets in the intestines on follow-up radiographs warrant evaluation for toxicity and consultation with a medical toxicologist and/or a poison control center [1]. (See 'Additional resources' below.)

Signs and symptoms of mercury toxicity include intention tremor, ataxia, psychiatric disturbances, anorexia, weakness, hyperreflexia, and paresthesias. Mercury also can impair kidney function, leading to a nephrotic-like syndrome and/or tubular injury with tubular dysfunction. The recognition and management of mercury toxicity is discussed separately. (See "Mercury toxicity", section on 'Treatment' and "Mercury toxicity".)

Complications — Complications from button battery ingestion are a significant concern, especially when the battery is impacted in the esophagus. In addition to esophageal burns, severe complications include [3,16,19,33,58-65]:

Tracheoesophageal fistula

Vocal cord paralysis

Subglottic or tracheal stenosis

Tracheomalacia

Aortic arch perforation

Esophageal perforation

Esophageal stenosis

Mediastinitis

Spondylodiscitis

Aspiration pneumonia

Gastric hemorrhage and perforation

Intestinal perforation

Severe complications are associated with ingestion of large (≥20 mm) lithium cell button batteries [3,63,64] and prolonged button battery impaction [3,66]. Young age (<4 years), ingestion of more than one button battery, and co-ingestion of a magnet are additional risk factors for severe outcomes such as esophageal burns, perforations, or fistulas) [3]. In these patients, tracheoesophageal fistula or esophageal stricture may not be symptomatic for many days after battery removal. Vascular injuries, especially aortoesophageal fistulae are the most common cause of death after button battery ingestion [66]. In one case, fatal bleeding from an aortoesophageal fistula occurred 18 days after battery retrieval [3].

Esophageal stenosis is a late complication of button battery ingestion (image 3). When it occurs, it typically does so weeks to months after endoscopic removal [1,45]. Thus, patients with esophageal injury after button battery ingestion warrant evaluation, as determined by the degree of injury, as described above. (See 'Esophageal impaction' above.)

The diagnosis and treatment of esophageal stricture after corrosive esophageal injury is discussed separately. (See "Caustic esophageal injury in children", section on 'Stricture formation' and "Caustic esophageal injury in adults", section on 'Esophageal strictures'.)

Prevention — As with other ingestions, primary prevention of ingestion is preferable to treatment. Children and their caregivers should be educated about the dangers of button battery ingestion, proper disposal of batteries, and avoidance of the use of one's mouth as a "third hand" while changing batteries.

Other measures that caregivers may consider include the following [11]:

Check and secure (with tape) battery compartments on household products

Store batteries out of reach and sight of children

Do not allow children to play with batteries

In addition, changes in the design of button batteries and/or the products they power could prevent morbidity from ingestion. These include [1,4,11,20,67]:

Developing child-resistant, unit-of-use battery packaging.

Providing package warnings regarding the potential for serious injury or death if a button battery is ingested.

Securing the battery compartment of devices using button batteries so that a tool is required to open them.

Altering the design of hearing aids and other battery-containing products that are used by children to make the battery less accessible.

Improving the integrity of the seal and crimp area of button batteries.

Eliminating button batteries greater than 15 mm in diameter (since these are more likely to lodge in the esophagus).

CYLINDRICAL BATTERY INGESTION — The National Battery Ingestion Hotline (NBIH; 1-800-498-8666) or a regional Poison Control Center are available to provide guidance for the management of patients with cylindrical battery ingestions. (See 'Regional poison control centers' below.)

Most cylindrical battery ingestions occur in patients between 6 and 39 years of age and are intentional [3,11]. Intact cylindrical batteries (eg, AA, AAA, C type batteries) pose a low threat for caustic damage after ingestion but because of their length (>2.5 cm) may become entrapped in the stomach in both children and adults. (See "Ingested foreign bodies and food impactions in adults", section on 'Blunt objects'.)

Leaking batteries do have the potential to cause corrosive injury. As an example, sucking on the fluid from a leaking cylindrical alkaline battery has caused esophageal burns in a child [68].

All patients who ingest cylindrical batteries warrant prompt localization with plain radiography that includes anterior-posterior (AP) and lateral views from the mouth to the anus, and urgent endoscopic removal of batteries located in the esophagus [14]. Depending upon the specific type of cylindrical battery (eg, larger C or D type battery), the presence of leakage, concern that follow-up will be difficult, and/or the age of the patient (eg, young child), some specialists may also choose to remove batteries localized to the stomach at initial evaluation. An alternative approach is to re-evaluate the patient with a radiograph 48 hours after ingestion and remove batteries that remain in the stomach at that time.

Patients with batteries that have exited the stomach may be observed with follow-up radiographs at weekly intervals or until passage in the stool is confirmed. Endoscopic or surgical removal (depending upon the location of the object) is warranted if the battery remains in the same location for more than one week. Patients should immediately seek medical attention for surgical removal if symptoms of perforation and peritonitis (eg, fever, vomiting, and abdominal pain) develop. (See "Ingested foreign bodies and food impactions in adults", section on 'Blunt objects'.)

ADDITIONAL RESOURCES

Regional poison control centers — Regional poison control centers in the United States are available at all times for consultation on patients with known or suspected poisoning, and who may be critically ill, require admission, or have clinical pictures that are unclear (1-800-222-1222). In addition, some hospitals have medical toxicologists available for bedside consultation. Whenever available, these are invaluable resources to help in the diagnosis and management of ingestions or overdoses. Contact information for poison centers around the world is provided separately. (See "Society guideline links: Regional poison control centers".)

Information specific to button battery exposure and expert guidance on management of serious cases is available at the National Battery Ingestion Hotline (NBIH; 1-800-498-8666) and at its website.

Society guideline links — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Battery ingestion" and "Society guideline links: Esophageal strictures, foreign bodies, and caustic injury".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Swallowed objects (The Basics)")

SUMMARY AND RECOMMENDATIONS

Epidemiology – Button battery ingestion by children requires rapid recognition. Lithium batteries that are ≥20 mm in diameter are associated with esophageal impaction in children and can cause serious complications. (See 'Epidemiology' above.)

Clinical features and diagnosis – Most button battery ingestions are witnessed, and most children are asymptomatic at the time of presentation. The clinician should also maintain a high level of suspicion for an esophageal button battery, despite a negative history of ingestion, in young children with abrupt onset of any one of the following:

Refusal of oral intake

Difficulty swallowing

Chest pain

Drooling

Hematemesis

Demonstration of the button battery on plain radiographs confirms ingestion (image 1 and image 2). (See 'Clinical features' above and 'Diagnosis' above.)

Approach – Our approach is largely consistent with guidelines developed by the National Capital Poison Center and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Endoscopy Committee. The Battery Ingestion Hotline (1-800-498-8666) or a regional Poison Control Center are available to provide guidance for the management of patients with battery ingestions. (See 'Approach' above and 'Additional resources' above.)

First aid – For asymptomatic children with acute button battery ingestions (eg, witnessed or likely to have occurred within 12 hours) who are >1 year old and without allergies to honey or its components, we suggest one oral dose of pure honey (eg, 5 to 10 mL) be given at home by the caregiver as soon as possible after ingestion (Grade 2C). Once in the emergency department, the child may receive another dose of honey or, if no history of allergy, a single dose of sucralfate 500 mg prior to radiography. (See 'First aid' above.)

Children with a delayed recognition of a button battery ingestion (eg, uncertain timing of ingestion, ≥12 hours after ingestion, or symptoms of serious esophageal or vascular injury or mediastinitis such as hematemesis, chest pain, or fever) should not receive honey or sucralfate and have no oral intake until the evaluation is complete. (See 'First aid' above.)

Emergency evaluation – We recommend emergency evaluation and plain radiography for patients who meet any one of the following criteria:

-All children under 12 years of age who ingest button batteries

-All patients who have ingested a button battery that is ≥12 mm in diameter

-All patients for whom the diameter of the button battery is not known

Plain radiographs should include anteroposterior (AP) and lateral views from the nasopharynx to the anus. (See 'Radiographic localization' above.)

Management – Management of ingested button batteries depends on its location, symptoms, and size:

Esophageal impaction – For patients with button batteries that are lodged in the esophagus, we recommend emergency removal with direct endoscopic visualization by an appropriate specialist as determined by location (figure 2), presence of symptoms, and signs of hemorrhage (Grade 1B). Further management is determined by the presence and degree of injury at endoscopy. (See 'Esophageal impaction' above.)

Gastric location – For patients who have a button battery in the stomach and who have signs or symptoms of esophageal or gastric injury at initial presentation, even if minor, we suggest emergency endoscopy and removal (Grade 2C). (See 'Gastric location' above.)

For asymptomatic patients who have a button battery in the stomach, we suggest urgent endoscopy and removal within 12 hours of ingestion rather than at a later time (Grade 2C). (See 'Gastric location' above.)

Intestinal location – Button batteries that have cleared the stomach typically exit the gastrointestinal tract within one week. Patients with symptoms of abdominal pain, hematochezia, or fever without confirmed battery passage warrant urgent evaluation, emergency radiography, and, if radiographs demonstrate a retained intestinal button battery, prompt surgical consultation for removal. (See 'Intestinal location' above.)

Follow-up radiographs should be performed in asymptomatic patients with an intestinal button battery who have not passed the battery by 10 to 14 days, regardless of size. (See 'Intestinal location' above.)

Asymptomatic ingestion of small button battery – Asymptomatic, healthy patients >12 years of age with confirmed ingestion of a solitary button battery that is ≤12 mm in diameter and without co-ingestion of a magnet may undergo observation for battery passage at home without initial radiographs as long as the patient or caregiver is reliable and able to promptly seek treatment should symptoms develop. Radiographic localization is warranted if battery passage is not confirmed in 10 to 14 days. (See 'Radiographic localization' above.)

Cylindrical battery ingestion – Cylindrical batteries (eg, AA, AAA, C type batteries) pose a lower threat for caustic damage after ingestion than button batteries but may become entrapped in the stomach. They require prompt radiographic localization and urgent endoscopic removal if located in the esophagus. Depending upon the specific situation, cylindrical batteries located in the stomach may be removed at initial evaluation or only if they remain in the stomach at 48 hours after ingestion. (See 'Cylindrical battery ingestion' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Ivor D Hill, MD, who contributed to earlier versions of this topic review.

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References

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