View source for 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'''<ref name="litovitz">Litovitz T, Whitaker N, Clark L, White NC, Marsolek M. Emerging battery-ingestion hazard: clinical implications. ''Pediatrics''. 2010;125(6):1168-1177. PMID 20498173.</ref>
*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)'''<ref name="kramer">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.</ref>
*Between 2011–2021, the CPSC documented '''27 deaths and ~54,300 ED visits''' related to ingested or inserted button batteries in the US<ref name="cpsc">U.S. Consumer Product Safety Commission. Making Families Safer from Button Cell or Coin Battery Dangers: Reese's Law. September 2023.</ref>
*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)<ref name="jatana">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.</ref>
**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)<ref name="kramer"/>
*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<ref name="jatana"/>

==Differential Diagnosis==
*[[Coin Ingestion|Coin ingestion]] (most common radiographic mimic — see Diagnosis for distinguishing features)
*Other [[Foreign Body Ingestion|foreign body ingestion]]
*[[Alkali Ingestion|Caustic/alkali ingestion]]
*[[Esophageal Foreign Body]]
*[[Croup]], [[Epiglottitis]], [[Bronchiolitis]] (if respiratory symptoms predominate)
*URI / viral illness (BBI is frequently misdiagnosed as viral illness in young children)
*[[GERD]] or esophagitis

==Evaluation==
===Workup===
*Urgent AP and lateral radiographs of the upper airway, chest, and abdomen (if ingestion location uncertain) — '''do NOT delay imaging'''<ref name="mubarak">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.</ref>
*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<ref name="kramer"/>

===Diagnosis===
*Radiographic identification: Button battery vs. coin on X-ray
{| class="wikitable"
|-
! 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<ref name="litovitz"/>
*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<ref name="anfang">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.</ref>
**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<ref name="litovitz"/>
*Endoscopic removal is preferred (allows direct visualization of tissue injury)<ref name="mubarak"/>
*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<ref name="ncpc">National Capital Poison Center. Button Battery Ingestion Triage and Treatment Guideline. 2023. Available at: https://www.poison.org/battery/guideline</ref>
**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<ref name="jatana"/>

===Gastric Battery — Risk-Stratified===
*High risk (child < 5 years OR battery ≥ 15 mm):
**If battery remains in stomach at 48 hours → endoscopic removal<ref name="statpearls">Newman RK, Dijkstra B, Gibson J. Disk Battery Ingestion. In: ''StatPearls''. Treasure Island (FL): StatPearls Publishing; 2023. PMID 29261985.</ref>
**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<ref name="statpearls"/>
*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<ref name="kramer"/>
**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==
*[[Foreign body ingestion]]
*[[Coin ingestion]]
*[[Alkali ingestion]]
*[[Esophageal foreign body]]
*[[Caustic ingestion]]
*[[Foreign body ingestion]]

==External Links==
*[https://www.poison.org/battery/guideline National Capital Poison Center: Button Battery Triage and Treatment Guideline]
*[https://www.ncbi.nlm.nih.gov/books/NBK470298/ Disk Battery Ingestion - StatPearls]
*[https://pubmed.ncbi.nlm.nih.gov/20498173/ Emerging battery-ingestion hazard: clinical implications - Pediatrics 2010]
*[https://pubmed.ncbi.nlm.nih.gov/27861945/ Basic mechanism of button battery ingestion injuries and novel mitigation strategies - Laryngoscope 2017]
*[https://pubmed.ncbi.nlm.nih.gov/33853108/ ESPGHAN position paper: Diagnosis, management, and prevention of BBI - JPGN 2021]
*[https://pmc.ncbi.nlm.nih.gov/articles/PMC5425245/ Button battery ingestion: a paradigm for management - Gastrointest Endosc 2015]

==References==
<references/>

[[Category:Toxicology]] [[Category:GI]] [[Category:Pediatrics]]