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
• 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)
• Between 2011–2021, the CPSC documented 27 deaths and ~54,300 ED visits related to ingested or inserted button batteries in the US
• 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)
  • 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)
• 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

Differential Diagnosis

• Coin ingestion (most common radiographic mimic — see Diagnosis for distinguishing features)
• Other foreign body 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
• 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

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
• 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
  • 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
• Endoscopic removal is preferred (allows direct visualization of tissue injury)
• 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
  • 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

Gastric Battery — Risk-Stratified

• High risk (child < 5 years OR battery ≥ 15 mm):
  • If battery remains in stomach at 48 hours → endoscopic removal
  • 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
• 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
  • 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

• National Capital Poison Center: Button Battery Triage and Treatment Guideline
• Disk Battery Ingestion - StatPearls
• Emerging battery-ingestion hazard: clinical implications - Pediatrics 2010
• Basic mechanism of button battery ingestion injuries and novel mitigation strategies - Laryngoscope 2017
• ESPGHAN position paper: Diagnosis, management, and prevention of BBI - JPGN 2021
• Button battery ingestion: a paradigm for management - Gastrointest Endosc 2015