It’s a Pill, It’s a Coin, It’s a…Button Battery
Dr. Elizabeth Lehto
Case
A 1-year-old female presents with concern for refusing to eat and increased drooling. She had been doing well until earlier this afternoon when she was playing at a cousin’s house. She spit out most of her food during lunch and has refused to eat and drink since then. Since then, she has started drooling more, isn’t talking as much, and seems more restless than usual. Family initially thought she was tired from her usual routine being disrupted but grew concerned when she started developing an elevated temperature of 99°F.
On examination patient seems restless and is drooling. She is tachycardic with a slightly elevated blood pressure. Respiratory rate and oxygen saturations are normal. Imaging shows a round esophageal foreign body just below the clavicles.
Introduction
Button battery ingestion poses a significant health risk, especially in the pediatric population who are prone to putting small objects in their mouth. Button batteries are universally available and found in many small electronic devices, from toys to calculators. They range in size from 6 mm to 25 mm.
Over time, button batteries have become more powerful and physically larger, resulting in more profound injuries. Batteries larger than 12 mm in diameter are more likely to become lodged in the esophagus.
Worse outcomes are associated with younger children (<4 years old) and larger (>20 mm) lithium batteries.
Presentation
Some patients may present knowing they or their child swallowed a foreign body. Young children may swallow button batteries when exploring and putting non-food items in their mouth. Children may present after telling someone they swallowed a “coin,” it is important to have a high index of suspicion for button battery ingestion in these cases as batteries can cause far more damage than coins. Button batteries may be mistaken for pills and swallowed (for example, patients who wear hearing aids and keep their replacement batteries near their pills). Patients may also ingest button batteries when self-harming or attempting suicide.
Most button battery ingestions have a similar presentation as other ingested foreign bodies:
Coughing/gagging
Drooling/Dysphagia
Stridor, especially in the absence of associated viral symptoms
Increased work of breathing
Anorexia
Vomiting
Chest or abdominal pain
Patients may also present with signs of evolving tissue damage from an ingested button battery, especially those where the ingestion was unwitnessed. These include:
Fever
Irritability
Listlessness
Hemorrhagic shock with pallor, tachycardia, and hypotension
Subcutaneous emphysema with crepitus
Tension pneumothorax
Providers should include button battery ingestion in the differential for patients presenting with these symptoms as the most serious outcomes occur after unwitnessed ingestions, which can lead to a delay in recognition and diagnosis.
Tissue Damage
When the battery is placed in a moist environment, such as in saliva or against a mucous membrane, an electrical charge is generated. The discharged current hydrolyzes water, generating hydroxide ions and leading to alkaline injury.
The current generates hydroxide at the negative terminal of the battery, which is the narrower side of the battery when viewed laterally. The anatomic orientation of the battery an predict where the necrosis will be and the subsequent injury.
Lithium button batteries are especially dangerous because they can generate more current and even when they are used can still generate enough current to damage tissues.
The esophagus is highly suspectable to this injury. If the battery is moving freely, it does not generate enough hydroxide ions in one location to produce focal damage. However, if the battery becomes lodged in the esophagus, it can generate a collection of alkaline caustic material in a confined region that can cause tissue necrosis.
The severity of damage depends on the length of time that the battery is lodged in place, the amount of charge remaining in the battery, and the size of the battery. Serious damage can occur within two hours, with more sever damage after 8-12 hours. The longer the battery is in the esophagus, the more edematous the mucosa becomes and the more tightly the battery adheres to the mucosa.
Damage from button batteries may include:
Perforations
Tracheoesophageal fistula
Vocal cord damage and paralysis
Strictures
Spondylodiscitis
Massive hemorrhage
Death
Imaging
Button batteries are radio-opaque and can be seen on plane films. AP and lateral torso x-rays should be obtained to evaluate the location of the button battery.
Button batteries can be mistaken for coins on imaging, so it is important to be vigilant. When viewing imaging look out for:
The “double-ring” or “halo” sign
Look for a ring of radiolucency just inside the outer edge of the object
Seen when the button battery is viewed head-on
Seen due to the telescoping nature of the two ends of the battery housing
The “Step-off” sign
Look for a central bulge on one end of the object
Seen when the button battery is viewed on edge
Seen due to the two halves of the battery
Can be difficult to appreciate if the battery is in an oblique view or in newer, thinner batteries
Image adapted from: Eliason MJ, Ricca RL, Gallagher TQ. Button battery ingestion in children. Curr Opin Otolaryngol Head Neck Surg. 2017 Dec;25(6):520-526. doi: 10.1097/MOO.0000000000000410. PMID: 28858893.
Management
Button batteries in the esophagus:
Esophageal button batteries need to be removed immediately, ideally within 2 hours of the ingestion. Removal is done in the operating room via endoscopy
Early feeding with honey or sucralfate until the battery is removed may reduce the severity of esophageal burns and improve patient outcomes, but should not delay removal of the battery
Asymptomatic patients over 1 year of age with witnessed button battery ingestion or in which ingestion is likely to have occurred within 12 hours can be given 5-10 mL of pure honey at home by the care giver as soon as possible after the ingestion
Once in the emergency department a second dose of honey or a single dose of 500 mg sucralfate may be given prior to imaging
If the timing of ingestion is uncertain or patient has symptoms of esophageal injury or mediastinitis such as chest pain or fever DO NOT give honey or sucralfate; these patients should have no oral intake until the evaluation and management is complete
After removal, some advocate for a delayed second look endoscopy to ensure that there is no damage. Keeping in mind htat perforations and fistulas may develop up to 18 days after removal and strictures can develop moths after removal
Button batteries in the stomach or beyond:
Asymptomatic patients can be monitored, and the battery allowed to pass
Imaging should be repeated in 4 days if the child is under 6 or the battery is >15 mm, or in 10-14 days for older children/adults and smaller batteries. If the battery is still in the stomach at that time it should be removed endoscopically
Patients who are discharged should be instructed to return for evaluation if patient develops fever, vomiting, or abdominal pain
Bowel irrigation and repeat enemas are not recommended
Button batteries and magnets that are co-ingested need to be removed
For more information see: National Capital Poison Center Button Battery Ingestion Triage and Treatment Guideline
Prevention
Prevention efforts are being developed at many levels to help reduce the incidence of button battery ingestion. These include changes to packaging, public awareness campaigns, modification to battery designs, and legislative regulation.
Some manufactures have developed button batteries with a coating on the bottom that reacts with saliva to release a bitter taste, discouraging children from swallowing the battery.
Families are encouraged to check and secure battery compartments with tape, store batteries out of reach of children, and to not allow children to play with batteries.
Back to Our Case
Patient was taken to the operating room and a button battery covered in sloughed mucosal tissue was removed endoscopically. Esophageal mucosal tissue was found to be ulcerated. The patient was started on a proton pump inhibitor following battery removal. Following hospital discharge she did well without stricture formation or other complications.
Summary
Ingested button batteries can cause esophageal damage in as little as 2 hours
If the patient is greater than 1-year-old, asymptomatic, and ingestion occurred within 12 hours can give 5-10 mL of honey or 500 mg of sucralfate which may reduce injury from the battery
On imaging look for the double ring or halo sing (a ring of radiolucency just inside the edge of the object) or the step-off sign (a central bulge on one end of the object)
Batteries in the esophagus need to be immediately removed, ideally within 2 hours
For more information on button batteries:
National Capital Poison Center Button Battery Ingestion Triage and Treatment Guideline
Elizabeth Lehto, D.O.
University of Louisville | UL · Department of Pediatrics | Doctor of Pediatric Emergency Medicine
Dr. Elizabeth Lehto is a Pediatric Emergency Medicine Attending at Norton Womens and Children’s Hospital. Dr. Lehto attended Midwestern University Arizona College of Osteopathic Medicine and completed her residency and fellowship at the University of Louisville.
References:
Eliason MJ, Ricca RL, Gallagher TQ. Button battery ingestion in children. Curr Opin Otolaryngol Head Neck Surg. 2017 Dec;25(6):520-526. doi: 10.1097/MOO.0000000000000410. PMID: 28858893.
Kost KM, Shapiro RS. Button battery ingestion: a case report and review of the literature. J Otolaryngol. 1987 Aug;16(4):252-7. PMID: 3309361.
Macchini F, Vestri E, Ichino M, Morandi A, Fava G, Leva E. Button Battery Ingestion in Children: A Specific Clinical Issue. Clin Endosc. 2018;51(6):602-603. doi:10.5946/ce.2018.137
Mubarak A, Benninga MA, Broekaert I, Dolinsek J, Homan M, Mas E, Miele E, Pienar C, Thapar N, Thomson M, Tzivinikos C, de Ridder L. 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 Jul 1;73(1):129-136. doi: 10.1097/MPG.0000000000003048. PMID: 33555169.
