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7. Button Battery Ingestion: The Battery That Is Not as Cute as a Button
Keywords
Caustic injuryMucosal ulcerationPerforationEsophagusEsophageal damageElectrical chargeBatteryCase
Foreign Body Ingestion
Pertinent History
A 5-year-old male presents at 2 pm with throat discomfort, coughing, gagging, and drooling for the past hour. He has a fever and is irritable. He was unable to eat or drink water without difficulty prior to arrival and had two episodes of nonbilious emesis. His mother had found him and his younger sibling playing in the tool drawer. She denies a history of asthma or allergies. The home medicine cabinet is locked, and sibling does not have any symptoms.
Pertinent Physical Exam
BP 95/46, Pulse 130, Temp 100.4 °F (38 °C) RR 37, SpO2 96%
Except as noted below, the findings of a complete physical exam are within normal limits.
Constitutional:
anxious appearing child; mild diaphoresis.
HEENT:
Increased secretions, moist mucous membranes, normal oropharynx with no tonsillar edema or erythema, uvula midline, no lymphadenopathy.
Respiratory:
Tachypnea, Equal breath sounds bilaterally. No wheeze or rhonchi.
Cardiovascular:
Tachycardia with regular rhythm, normal heart sounds, and intact distal pulses. Exam reveals no gallop and no friction rub or murmur heard.
Imaging:
X-ray soft tissue neck: unremarkable
CXR: 15 mm radio-opaque disk-shaped foreign body with 2 step-border within the upper third of the esophagus
Plan:
Stat GI consult. Contact The National Battery Ingestion Hotline (NBIH) (202)-625-3333
Update 1
(1530) Based on the size of the battery, the patient’s age, and his symptoms, GI plans to take the patient to the endoscopy suite to remove the battery. The patient has stopped vomiting and is able to control his airway and secretions. He remains slightly tachycardic but is otherwise hemodynamically stable.
Update 2
(1600) The patient is transported to the endoscopy suite.
Learning Points: Button Battery Ingestion
Priming Questions
- 1.
What symptoms should cause you to suspect your patient may have ingested a button battery?
- 2.
How do you distinguish between a button battery and a coin on xray and how does the size of the battery impact patient treatment?
- 3.
What types of complications result from button battery ingestions and how long after ingestion do these complications occur?
Introduction/Background
- 1.
The number of button battery ingestions (BBIs) has remained stable over the past 30 years [1], although the number of ED visits has increased over the past decade [2]. The incidence of morbidity and mortality has also increased 7-fold. This increase is related to a change in battery production using higher-voltage lithium cells and battery sizes [1]
- 2.
More than 90% of serious outcomes are due to ingestions of batteries greater than 20 mm in diameter, which are more likely to become lodged in the esophagus [1]. In fact, 12.6% of children who ingested a 20-mm battery suffered severe or fatal injuries [3].
- 3.
Most ingestions are unwitnessed and are by small children under 6 years old, with 2 years old being the most common age for ingestion. This often leads to a delay in recognition and diagnosis. More than 50% of serious outcomes due to BBI occur after unwitnessed ingestions, in which case, there is likely a delay in recognition and diagnosis [3].
Physiology/Pathophysiology
- 1.
Button batteries lodged in the mucosal tract cause caustic injury, mucosal ulceration, and, if impacted long enough, perforation. The esophagus is the most common site for impaction. The severity of esophageal damage is determined by the length of time that the battery is lodged in place, the amount of electrical charge remaining in the battery, and the size of the battery [4–6].
Damage to the esophagus may begin as early as 2 hours after ingestion with more severe damage occurring after 8–12 hours [4, 7].
Injury to tissue is worse near the negative pole of batteries. The flow of electrical current from the battery to the surrounding tissues occurs near the negative pole, causing corrosive tissue injury. Even “dead” batteries retain enough voltage and storage capability to generate an external current and mucosal damage [8].
Over 90% of fatalities or serious injuries from button batteries involve batteries that are 20 mm or more in diameter [1, 8]. This is likely because most batteries that are 20–25-mm in diameter are lithium batteries. These batteries have higher voltage and capacitance and are more likely to lead to esophageal burns, fistulas, perforations, and deaths.
In acidic environments like the stomach, the seal or crimp of the battery may erode and potentially release chemical contents including sodium or potassium hydroxide. As these alkaline solutions react with the mucosal surface of the GI tract, they cause liquefaction necrosis [9–11]. Systemic heavy metal or lithium poisoning is extremely rare.
- 2.
Long-term complications from button batteries are rare but devastating. Severe esophageal burns and perforations occur adjacent to the negative pole of the battery. This can lead to tracheoesophageal fistula, esophageal perforation, vocal cord paralysis, perforation of the aortic arch, gastric hemorrhage, and intestinal perforation. Death can occur and is usually associated with ingestion of large lithium cell batteries [1, 4, 11–14].
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