Button battery ingestion

Background

  • Button batteries (disc/coin batteries) are small, round batteries found in household electronics, toys, hearing aids, watches, key fobs, light-up shoes, remote controls, and musical greeting cards
  • Button battery ingestion (BBI) is a life-threatening emergency — a battery lodged in the esophagus can cause severe tissue necrosis in as little as 2 hours[1]
  • The rate of severe complications and death from BBI has increased almost 7-fold since the mid-1990s, corresponding to the widespread adoption of larger-diameter (≥ 20 mm), higher-voltage 3V lithium cells (CR2032, CR2025)[2]
  • Between 2011–2021, the CPSC documented 27 deaths and ~54,300 ED visits related to ingested or inserted button batteries in the US[3]
  • Mechanism of injury:
    • Generates an external electrolytic current at the negative pole (anode) when in contact with moist tissue
    • This produces hydroxide ions (alkali) at the tissue-battery interface → liquefactive necrosis (same mechanism as alkali caustic injury)[4]
    • Injury continues even after battery removal because residual alkali persists in tissue
    • Pressure necrosis and heavy metal leakage (rare) contribute to injury but are minor compared to the electrolytic mechanism
  • Peak incidence: children < 6 years (especially ages 1–3); boys slightly more than girls
  • Most dangerous scenario: 20 mm lithium cell lodged in the esophagus of a child < 5 years

Clinical Features

  • Presentation is highly variable and often mimics common childhood illnesses, leading to delayed diagnosis
  • May be completely asymptomatic initially — symptoms can develop insidiously over hours
  • Symptoms depend on battery location and degree of injury:

Esophageal Impaction (Highest Risk)

  • Dysphagia, odynophagia, drooling, refusal to eat or drink
  • Chest pain, back pain, epigastric pain
  • Vomiting (may be bloody)
  • Cough, stridor, wheezing (from tracheoesophageal compression or fistula)
  • Fever, irritability, poor feeding (nonspecific — often mistaken for viral illness)

Airway (Nasal/Tracheal Insertion or Aspiration)

  • Stridor, wheezing, respiratory distress
  • Nasal discharge (unilateral — if lodged in nasal cavity)

Post-Esophageal (Stomach/Intestine)

  • Usually asymptomatic
  • Abdominal pain, vomiting if complications develop (rare beyond the esophagus)

Catastrophic Complications

  • Aortoesophageal fistula → fatal exsanguinating hemorrhage (may present with sentinel bleed followed by massive hematemesis — the most feared complication)[2]
  • Tracheoesophageal fistula
  • Esophageal perforation → mediastinitis
  • Vocal cord paralysis (recurrent laryngeal nerve injury)
  • Esophageal stricture (weeks to months post-ingestion)
  • Complications can present days to weeks after battery removal because alkali tissue damage continues after the battery is removed[4]

Differential Diagnosis

Evaluation

Workup

  • Urgent AP and lateral radiographs of the upper airway, chest, and abdomen (if ingestion location uncertain) — do NOT delay imaging[5]
  • If any suspicion of BBI, imaging should be performed immediately upon ED arrival — do not wait for full triage or registration
  • Labs (for symptomatic patients or esophageal impaction):
    • CBC, BMP, type and screen/crossmatch
    • Coagulation studies
    • VBG/ABG with lactate if concern for perforation or sepsis
  • CT angiography: Consider if concern for vascular injury (aortoesophageal fistula) or in any patient with hematemesis after known BBI[2]

Diagnosis

  • Radiographic identification: Button battery vs. coin on X-ray
Feature Button Battery Coin
AP view "Double ring" or "halo" sign (bilaminar structure creates a step-off between anode and cathode) Single uniform density; no double ring
Lateral view Step-off between the two layers of the battery (one side is slightly wider) Uniform thin disc
  • The double ring/halo sign on AP view is the key distinguishing feature[1]
  • If a round radiopaque foreign body is seen in the esophagus and cannot be clearly identified as a coin, treat as a button battery until proven otherwise
  • Battery location determines urgency:
    • Esophagus: EMERGENT removal — do NOT observe
    • Stomach: Risk-stratified management (see Management)
    • Beyond the stomach: Usually passes spontaneously; observation
  • Nasal/aural cavity: If battery is lodged in the nose or ear, this also requires urgent removal

Management

Pre-Hospital / En Route to ED

  • Honey (for children ≥ 12 months old ONLY): 10 mL PO every 10 minutes, up to 6 doses, from the time of suspected ingestion until arrival in ED[6]
    • Honey creates a viscous protective barrier and has been shown to slow esophageal injury in animal models
    • Do NOT give honey to infants < 12 months (botulism risk)
    • Do NOT give honey if battery has been in place > 12 hours
    • Honey is NOT a substitute for emergent removal — it is a temporizing measure only
  • Do NOT induce emesis
  • NPO otherwise (anticipate endoscopy)

Esophageal Battery — EMERGENT REMOVAL

  • This is a surgical/endoscopic emergency — goal is removal within 2 hours of confirmed or suspected esophageal impaction[1]
  • Endoscopic removal is preferred (allows direct visualization of tissue injury)[5]
  • Activate GI/surgery/ENT for emergent endoscopy immediately
  • Sucralfate (Carafate suspension): 10 mL PO every 10 minutes (up to 3 doses) from the time esophageal impaction is confirmed on X-ray until sedation for endoscopy[7]
    • Honey (10 mL q10min, ≥ 12 months) can substitute for sucralfate
    • Do NOT give sucralfate or honey if battery has been in esophagus > 12 hours
    • Do NOT delay battery removal for oral agents or because patient recently ate
  • After removal, the endoscopist should examine for depth and extent of injury
  • Consider post-removal irrigation of the esophageal injury site with 50–150 mL of 0.25% acetic acid (sterile vinegar) to neutralize residual alkali[4]

Gastric Battery — Risk-Stratified

  • High risk (child < 5 years OR battery ≥ 15 mm):
    • If battery remains in stomach at 48 hours → endoscopic removal[8]
    • Some experts recommend earlier endoscopic assessment (within 24 hours) for children < 5 years with ≥ 20 mm batteries due to risk of unrecognized esophageal injury during passage
  • Lower risk (child ≥ 5 years AND battery < 15 mm AND asymptomatic):
    • Outpatient observation
    • Repeat radiograph in 10–14 days to confirm passage[8]
  • Symptomatic at any point → endoscopy

Post-Esophageal (Intestinal) Battery

  • Usually passes spontaneously without complication
  • Monitor for passage in stools
  • Return precautions for abdominal pain, vomiting, bloody stool, fever

General Supportive Care

  • NPO until scope/removal completed and injury graded
  • IV access, fluid resuscitation
  • Pain management
  • Type and crossmatch blood for all esophageal impactions (massive hemorrhage from aortoesophageal fistula can be sudden and fatal)
  • Do NOT use whole bowel irrigation, activated charcoal, or nasogastric tubes to attempt removal

Disposition

  • Admit (ICU level) after esophageal battery removal:
    • All patients after endoscopic removal of an esophageal battery
    • NPO, IV fluids, serial monitoring for delayed complications
    • Delayed vascular erosion (aortoesophageal fistula) can present days to weeks after removal — patients and families must be counseled on this risk[2]
    • CT angiography if hematemesis develops or if injury is in proximity to great vessels
    • GI/surgery and possibly vascular surgery or interventional radiology on standby
  • Admit for observation:
    • Symptomatic patients with gastric or intestinal batteries
    • Any patient with abnormal labs, signs of perforation, or hemodynamic instability
  • Discharge with follow-up:
    • Asymptomatic patients with battery confirmed beyond the esophagus AND low-risk criteria (≥ 5 years, battery < 15 mm)
    • Provide written return precautions: abdominal pain, vomiting, bloody stool, bloody vomit, fever, refusal to eat
    • Repeat radiograph per guidelines (48 hours to 10–14 days depending on risk)
  • Family education: Secure battery compartments, discard old batteries, childproof storage
  • National Battery Ingestion Hotline: 1-800-498-8666
  • Poison Control: 1-800-222-1222

See Also

External Links

References

  1. ↑ 1.0 1.1 1.2 Litovitz T, Whitaker N, Clark L, White NC, Marsolek M. Emerging battery-ingestion hazard: clinical implications. Pediatrics. 2010;125(6):1168-1177. PMID 20498173.
  2. ↑ 2.0 2.1 2.2 2.3 Kramer RE, Lerner DG, Lin T, et al. Button battery ingestion in children: a paradigm for management of severe pediatric foreign body ingestions. Gastrointest Endosc. 2015;81(1):9-16. PMID 25440678.
  3. ↑ U.S. Consumer Product Safety Commission. Making Families Safer from Button Cell or Coin Battery Dangers: Reese's Law. September 2023.
  4. ↑ 4.0 4.1 4.2 Jatana KR, Rhoades K, Milkovich S, Jacobs IN. Basic mechanism of button battery ingestion injuries and novel mitigation strategies after diagnosis and removal. Laryngoscope. 2017;127(6):1276-1282. PMID 27861945.
  5. ↑ 5.0 5.1 Mubarak A, Benninga MA, Broekaert I, et al. Diagnosis, management, and prevention of button battery ingestion in childhood: a European Society for Paediatric Gastroenterology Hepatology and Nutrition position paper. J Pediatr Gastroenterol Nutr. 2021;73(1):129-136. PMID 33853108.
  6. ↑ Anfang RR, Jatana KR, Linn RL, Rhoades K, Fry J, Jacobs IN. pH-neutralizing esophageal irrigations as a novel mitigation strategy for button battery injury. Laryngoscope. 2019;129(1):49-57. PMID 29889308.
  7. ↑ National Capital Poison Center. Button Battery Ingestion Triage and Treatment Guideline. 2023. Available at: https://www.poison.org/battery/guideline
  8. ↑ 8.0 8.1 Newman RK, Dijkstra B, Gibson J. Disk Battery Ingestion. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023. PMID 29261985.
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