AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 10  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
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• References

Background

Disk batteries are small, coin-shaped batteries used in watches, calculators, and hearing aids. The vast majority of disk battery ingestions occur when curious children explore their environment.

Early published case reports of ingestion of disk batteries were concerned with serious sequelae (eg, esophageal perforation, aortic perforation with exsanguination, tracheoesophageal fistulae). From these reports, recommendations were made for aggressive management, including surgical removal. Information gained from the National Button Battery Investigation Study combined with more recent case reports and series involving successful conservative management has shown that these ingestions usually are benign.

Disk batteries

Disk batteries are formed by compacting metals and metal oxides on either side of an electrolyte-soaked separator. The unit is then placed in a 2-part metal casing held together by a plastic grommet (see Media file 1). The grommet electrically insulates the anode from the cathode. The metal undergoes oxidation on one side of the separator, while the metal oxide is reduced to the metal on the other side, producing a current when a conductive path is provided.

Disk batteries contain mercury, silver, zinc, manganese, cadmium, lithium, sulfur oxide, copper, brass, or steel. These are the components of the anode, cathode, and case containing the battery. Disk batteries also contain sodium hydroxide or potassium hydroxide to facilitate the electrochemical reaction through the separator. In a series of 2382 battery ingestions in 1589 patients in which the type of battery was known, 30% were manganese dioxide, 29% were zinc/air, 25% were mercuric oxide, 17% were silver oxide, and fewer than 1% were lithium.¹

Disk batteries vary in diameter from 7.9-23 mm and in weight from 1-10 g. The diameter of ingested disk batteries is less than 15 mm in 97% of cases. Most frequently ingested sizes are 11.6 mm (63%) and 7.9 mm (30%).

Pathophysiology

Disk batteries do not usually cause problems unless they become lodged in the gastrointestinal (GI) tract. The most common place disk batteries become lodged, resulting in clinical sequelae, is the esophagus. Batteries that successfully traverse the esophagus are unlikely to lodge at any other location.

Batteries pass through the GI tract in a relatively short period of time: 23% within 24 hours, 61% within 48 hours, 78% within 72 hours, and 86% within 96 hours. Only 1% of batteries take more than 2 weeks.

The likelihood that a disk battery will lodge in the esophagus is a function of the patient's age and the size of the battery. Disk batteries of 16 mm have become lodged in the esophagi of 2 children younger than 1 year. Older children do not have problems with batteries smaller than 21-23 mm. For comparison, a dime is 18 mm, a nickel is 21 mm, and a quarter is 24 mm.

Esophageal damage can occur in a relatively short period of time when a disk battery is lodged in the esophagus. Liquefaction necrosis may occur because sodium hydroxide is generated by the current produced by the battery (usually at the anode). Perforation has occurred as rapidly as 6 hours after ingestion.

Frequency

United States

An estimated minimum of 2100 cases of disk battery ingestion occur per year (see Media file 2).

Sex

Male predominance (59%) is observed in disk battery ingestions.

Age

• Children younger than 6 years account for 66% of ingestions, with a peak incidence in those aged 1 and 2 years.
• A second peak is observed in adults older than 60 years, with 10.3% of cases occurring in patients aged 60-89 years. Elderly patients are more likely to have batteries lodged in the small or large bowels. Patients older than 79 years account for only 4.6% of ingestions; in 31% of those cases, the battery lodges in the bowels.

CLINICAL

Section 3 of 10  

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History

• Occasionally, the ingestion of a disk battery is observed. More than one half of disk battery ingestions (53%) occur immediately following removal from a product. Another 41% involve batteries that are loose, either sitting out or discarded. More than one battery is ingested in 8.5% of the episodes.
• Powering hearing aids is the most common intended use of the ingested batteries (44.6%). In 32.8% of the cases, the child removed the battery from his or her own hearing aid. Watch batteries account for 16% of ingestions. Other sources of disk batteries that are ingested include games and toys, calculators, cameras, lighted key chains, fishing bobs, flashing jewelry, musical greeting cards or books, and thermometers.
• Most children who ingest a disk battery remain asymptomatic and pass the battery in their stool within 2-7 days. Only 10% of patients who ingest disk batteries report symptoms, which are predominantly minor GI problems.
• Rashes following disk battery ingestion have been reported infrequently and may be a manifestation of nickel hypersensitivity, as many disk batteries are nickel-plated.
• Lodging of lithium cells is associated with disproportionately more adverse effects than lodging of other types of batteries. Symptoms reportedly associated with the lodging of the battery in the GI tract include the following:  
• • Coughing or gagging
  • Dysphagia
  • Retrosternal discomfort
  • Vomiting, diarrhea, constipation, green stools, melena
  • Hematemesis (occasionally)
  • Abdominal pain
  • Fever
  • Anorexia
  • Increased salivation (often with black flecks in the saliva)

Physical

• No physical examination findings are specific for patients who ingest disk batteries.
• Children with a battery lodged in the esophagus typically present with the following:
• • Refusal to take fluids
  • Increased salivation (often with black flecks in the saliva)
  • Dysphagia
  • Vomiting
  • Hematemesis occasionally
• Patients may have airway compromise following disk battery ingestion.
• Hematochezia or abdominal tenderness suggests GI injury, possibly due to battery rupture.
• In one study, 9 of 25 patients (36%) with batteries in the esophagus were asymptomatic; therefore, do not rely on the lack of symptoms as an indicator to rule out esophageal lodgment.

Causes

• When a disk battery is in an acid environment, an electrochemical reaction occurs that leads to dissolution of the cathode, primarily in the crimp area. Not surprisingly, batteries that become lodged in the stomach corrode and fragment more frequently than other ingested batteries. Corrosion and fragmentation are most common in batteries that lodge in the stomach for more than 48 hours.
• Approximately 2-3% of ingested batteries fragment within the GI tract, and 10.7% demonstrate severe crimp dissolution.
• Mercuric oxide cells are substantially more likely to fragment than batteries of other chemical compositions.

DIFFERENTIALS

Section 4 of 10  

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Other Problems to be Considered

Caustic ingestions

WORKUP

Section 5 of 10  

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• Miscellaneous
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• References

Lab Studies

• Obtain blood and urine mercury levels only if the mercury-containing cell has been observed to fragment in the GI tract or radiopaque droplets are observed in the gut on radiographs.

Imaging Studies

• Radiography  
• • Radiography is indicated to confirm the ingestion and to establish the location of ingested disk batteries.
  • Disk batteries have a relatively characteristic appearance on radiograph. When viewed from above, they appear much like a coin; however, a double density is often present. When viewed on edge, a much more rounded edge with a step off at the junction of the cathode and anode is seen (see Media file 3).
• Batteries located in the esophagus on initial radiograph frequently (28%) pass into the stomach spontaneously.
• Radiopaque droplets in the gut may be found on radiograph in patients with fragmented mercuric oxide cells.

TREATMENT

Section 6 of 10  

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Emergency Department Care

The recommended management algorithm for dealing with the ingestion of disk batteries is shown in Media file 4.

• Secure the ABCs, and resuscitate the patient as necessary.
• Obtain an initial radiograph of the chest and abdomen to determine the battery location.
• Remove batteries located in the esophagus emergently because of the risk of esophageal burns and resultant complications. The procedure of choice is flexible fiberoptic endoscopy. If an endoscopist is not available within 2 hours and the history of ingestion less than 2 hours earlier is reliable, consider attempting the Foley balloon catheter technique for removal, which is performed as follows:  
• • A 10-16 Fr Foley catheter is passed orally, as the patient sits upright on the fluoroscopy table. Some sedation may be required for small children.
  • After the Foley catheter is inserted, place the patient in the lateral decubitus or Trendelenburg position, and fluoroscopically confirm the distal catheter tip position by introducing contrast into the balloon. Slowly inflate the balloon with 3-5 mL, and slowly withdraw the catheter under fluoroscopic guidance.
  • With the operator's thumb on the syringe plunger, the syringe remains in contact with the balloon. Filling adjustments can be made as the operator senses subtle pressure changes in the balloon as the catheter is withdrawn.
  • Use constant, moderate traction to withdraw the balloon, while avoiding hesitation at the hypopharynx; there the balloon meets and pushes the battery into the oral pharynx, where it can be removed with McGill forceps or expelled by the patient.
  • Batteries localized beyond the esophagus rarely need to be retrieved unless the patient manifests signs or symptoms of GI tract injury (eg, hematochezia, abdominal pain, tenderness) or a large-diameter battery fails to pass beyond the pylorus. Some experts suggest that any delay in GI transit (distal to the pylorus) greater than 8 hours mandates some form of intervention because of the potential for erosive/corrosive complications.
• Do not give ipecac to patients with disk batteries located in the stomach. Instances have been reported of patients who were given ipecac that resulted in the battery becoming lodged in the esophagus by retrograde movement during emesis. Emergent endoscopic removal was required.
• Confirm battery passage by daily inspections of all stools. Weekly radiographs are recommended to confirm battery passage and to observe for battery fragmentation (see Media file 5). This is particularly important with the 15.6-mm mercuric oxide cell because of its greater likelihood of splitting in the GI tract.
• Patients younger than 6 years who have ingested a battery with a diameter of 15 mm or greater should have a repeat radiograph in 48 hours if the battery was originally in the stomach. These batteries do not generally pass the pylorus after 48 hours. Endoscopic retrieval may be necessary.
• Chelation therapy is not necessary in asymptomatic patients unless toxic mercury levels are documented.
• Whole-bowel irrigation, colonic enemas, and cathartics all have been used successfully to evacuate disk batteries situated below the pylorus in pediatric ingestions. Although no controlled studies of these modalities have been reported, they should be considered for situations in which delayed transit (below the level of the pylorus) is documented.

Consultations

• The need for endoscopic retrieval is a function of battery size. Of batteries that are larger than 15 mm in diameter, 25% require endoscopic retrieval, whereas only 2.8% of smaller batteries require endoscopic retrieval. Endoscopy is successful in 90% of patients with batteries located in the esophagus. One animal study demonstrated that the Roth net was the optimal device for endoscopic retrieval of disk batteries in the stomach.
• Hospitalization for battery ingestion is infrequent (4.5%) and generally brief (<2 d). Surgical procedures to remove ingested batteries or to treat complications rarely are needed (<1% of patients).

FOLLOW-UP

Section 7 of 10  

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Transfer

• Transfer patients with disk batteries lodged in the esophagus to a medical treatment facility capable of performing endoscopic procedures.

Deterrence/Prevention

• More than one half of ingested batteries (53%) were removed from a product before ingestion. Products need to be designed with secure battery compartments that can withstand a child's prying hands or a fall.

Complications

• Esophageal stenosis may occur from batteries lodged in the esophagus, requiring repeated dilations or surgery.
• Other reported complications from esophageal lodgment include esophageal perforation and tracheoesophageal fistula formation. One patient had esophageal perforation only 6 hours after ingestion.
• The possibility of heavy metal poisoning, especially from mercury, has been considered. A typical battery may contain from 15-50% mercuric oxide, leading to possible ingestion of up to 5 g of mercury, a potentially lethal amount. This theoretical threat of toxicity has not been borne out by clinical experience. In a series of 2382 battery ingestions, no clinical evidence of mercury toxicity was observed.¹
• A spent cell, which no longer has power, may still maintain considerable residual voltage. This may account for the finding that the discharge state of the battery does not appear to be related to the patient's outcome.
• Retrograde movement of the battery from the stomach to the esophagus has been reported as a complication of use of ipecac syrup, necessitating emergent endoscopic removal. If the battery produces a mucosal burn, a theoretical risk exists of battery aspiration and perforation of the esophagus or stomach.

Prognosis

• The usual outcome of disk battery ingestions is an uneventful passage. No deaths attributed to disk battery ingestion were reported to the American Academy of Poison Control Centers from 1986-2003 (see Media file 2).

Patient Education

• For excellent patient education resources, visit eMedicine's Poisoning Center. Also, see eMedicine's patient education article Battery Ingestion.

MISCELLANEOUS

Section 8 of 10  

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• Miscellaneous
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• References

Special Concerns

• The National Button Battery Ingestion Hotline (202-625-3333) was established in 1982 at Georgetown University Hospital's National Capital Poison Center and functions as an emergency consultation service and case registry.
• Disk batteries placed in the ear have been reported to cause the following:
• • Tympanic membrane perforation
  • Skin necrosis in the external auditory canal
  • Dysacusis from ossicle destruction
  • Facial nerve paralysis
  • Chondritis
• Nasal septal perforation with resultant saddle deformity has been reported after disk battery placement in the nose. The clinical presentation of a nasal disk battery is usually unilateral nasal discharge with or without features of a secondary infection. Early recognition and removal of the battery is important to prevent adverse sequelae.

MULTIMEDIA

Section 9 of 10  

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• Miscellaneous
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Media file 1:  Cross-section of a typical disk battery.
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Media file 2:  Exposures to disk batteries reported to the American Association of Poison Control Centers, 1986-2005.
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Media file 3:  Lateral radiographic appearance of a 7.9-mm disk battery. Photographed by Daniel J. Dire, MD.
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Media file 4:  Recommended management algorithm for patients with disk battery ingestions. Notes: (1) Serum mercury levels and chelation therapy should be reserved for patients who develop signs of mercury toxicity, not simply because mercury is noted on radiograph. (2) Acute abdomen, tarry or bloody stools, fever, and persistent vomiting. (3) Disk batteries in the esophagus must be removed. Endoscopy should be used if available. The Foley catheter technique may be used if the ingestion is less than 2 hours old but not if more than 2 hours old because it may increase the damage to the weakened esophagus. (4) When the Foley technique fails or is contraindicated, the disk battery should be removed endoscopically. This may require transfer to a more comprehensive medical treatment facility.
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Media type:  Graph

Media file 5:  Radiograph of child 1 week after ingestion of a disk battery. The battery has passed into the rectum. Photographed by Daniel J. Dire, MD.
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Media type:  X-RAY

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
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• Miscellaneous
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• References

1. Litovitz T, Schmitz BF. Ingestion of cylindrical and button batteries: an analysis of 2382 cases. Pediatrics. Apr 1992;89(4 Pt 2):747-57. [Medline].
2. Bass DH, Millar AJ. Mercury absorption following button battery ingestion. J Pediatr Surg. Dec 1992;27(12):1541-2. [Medline].
3. Campbell JB, Foley LC. A safe alternative to endoscopic removal of blunt esophageal foreign bodies. Arch Otolaryngol. May 1983;109(5):323-5. [Medline].
4. Gomes CC, Sakano E, Lucchezi MC, Porto PR. Button battery as a foreign body in the nasal cavities. Special aspects. Rhinology. Jun 1994;32(2):98-100. [Medline].
5. Gordon AC, Gough MH. Oesophageal perforation after button battery ingestion. Ann R Coll Surg Engl. Sep 1993;75(5):362-4. [Medline].
6. Kuhns DW, Dire DJ. Button battery ingestions. Ann Emerg Med. Mar 1989;18(3):293-300. [Medline].
7. Lai MW, Klein-Schwartz W, Rodgers GC, Abrams JY, Haber DA, Bronstein AC. 2005 Annual Report of the American Association of Poison Control Centers' national poisoning and exposure database. Clin Toxicol (Phila). 2006;44(6-7):803-932. [Medline].
8. Mariani PJ, Wagner DK. Foley catheter extraction of blunt esophageal foreign bodies. J Emerg Med. 1986;4(4):301-6. [Medline].
9. Palmer O, Natarajan B, Johnstone A, Sheikh S. Button battery in the nose--an unusual foreign body. J Laryngol Otol. Oct 1994;108(10):871-2. [Medline].
10. Sheikh A. Button battery ingestions in children. Pediatr Emerg Care. Aug 1993;9(4):224-9. [Medline].
11. Tong MC, Van Hasselt CA, Woo JK. The hazards of button batteries in the nose. J Otolaryngol. Dec 1992;21(6):458-60. [Medline].
12. Watson WA, Litovitz TL, Klein-Schwartz W, et al. 2003 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 2004;22(5):335-404. [Medline].

Article Last Updated: Feb 11, 2008