Disk Battery Ingestion

Article Author:
Bjorn Dijkstra
Article Editor:
William Gossman
Updated:
10/27/2018 12:31:32 PM
PubMed Link:
Disk Battery Ingestion

Introduction

Disk batteries can be found in many appliances, such as watches, calculators, and hearing aids.

Most cases of disk battery ingestion are benign. Complications are rare but can be severe. When swallowed batteries get lodged, they mostly get lodged in the esophagus. If they pass the esophagus, they are unlikely to get lodged elsewhere. Injury from an ingested button battery is due to electrical discharge (most prominent mechanism), pressure necrosis, or leaking of chemical contents (among others mercury). An electrical current causes local hydrolysis, liquefaction necrosis, and might progress to perforation (as rapidly as 6 hours). Alkalines from the battery also can cause liquefaction necrosis. Toxicity from chemical contents is very rare. More than 97% of battery ingestion cases have mild effects or none at all.

Etiology

When a disk battery is placed in an acidic environment in the gastrointestinal (GI) tract, an electrochemical reaction occurs that results in the dissolution of the cathode, usually in the crimp area. The batteries become lodged in the stomach, corrode, and fragment. Corrosion and fragmentation occur in batteries that lodge in the stomach for more than 48 hours. Approximately 3% of ingested disk batteries fragment within the GI tract, with 10% demonstrating severe crimp dissolution. Mercuric oxide cells fragment more often than batteries of other chemical compositions.

Epidemiology

Peak incidences can be seen in children under the age of six, with the most incidents occurring in children between the ages of one and three years and adults older than 60 years of age. Most ingestions are unwitnessed, which can be the cause of initial misdiagnosis. Most batteries are ingested within one-half hour after removal from the device.

Mortality/Morbidity

The usual outcome of disk battery ingestions is an eventful passage. Most ingestions have only mild effects or none at all.

  • Deaths due to button battery ingestion are very rare and usually occurs when a disk battery ingestion is missed.
  • Often there is no initial history of ingestion and nonspecific presenting symptoms such as vomiting, fever, decreased appetite, lethargy, irritability, wheezing, cough, or dehydration help little in making the diagnosis.
  • Exsanguination due to esophageal fistulae rarely occurs.

Complications include: 

  • Aspiration pneumonia
  • Empyema
  • Esophageal perforations
  • Esophageal strictures
  • Heavy metal poisoning
  • Lung abscess
  • Mediastinitis
  • Pneumothorax
  • Pneumoperitoneum
  • Spondylodiscitis
  • Tracheal stenosis
  • Tracheomalacia
  • Tracheoesophageal fistulas
  • Recurrent laryngeal nerve damage with vocal cord paralysis

New cells are more likely to be associated with clinically significant outcomes.

Age

Children younger than six years old have the majority of ingestions, with a peak incidence between one and three years. Most fatalities occur in children younger than four years old.

A second peak occurs in adults older than 60 years, with 10% occurring in patients aged 60 to 89 years. Elder patients are more likely to have disk batteries lodged in the small or large bowels.

Sex

A slight male predominance is observed in disk battery ingestions.

Pathophysiology

Disk batteries may cause serious problems if they become lodged in the nose, ears, or GI tract. The most common location resulting in serious sequelae is the esophagus. Batteries that traverse the esophagus often pass the GI tract successfully.

  • Batteries pass through the gastrointestinal tract relatively quickly: approximately 25% within 24 hours, 60% within 50 hours, 80% within 75 hours, and 90% within 100 hours. Only 1% take more than two weeks.
  • Damaging outcomes occur in only about 1% of cases. The younger or older the patient, the more like damage will occur. Also, the larger the size or chemical content of batteries the greater the risk of potential damage. 
  • Larger-sized batteries (20 mm to 25 mm) are the most important predictor of negative outcome. Disk batteries 16 mm or larger often become lodged in the esophagus of children younger than four years old.
  • Older children usually do not have problems with batteries smaller than 21 mm to 23 mm. 
  • The majority of fatal cases involve batteries that are 20 mm or greater in diameter. Lithium-containing batteries are more commonly associated with clinically significant negative outcomes. 
  • Of ingested batteries that are 20 mm to 25 mm diameter, over 99% contain lithium cells.
  • Esophageal damage can occur in as little as two to three hours if a disk battery is lodged in the esophagus.

To determine the size, recall that a dime is 18 mm, a nickel is 21 mm, and a quarter is 25 mm.

Liquefaction necrosis occurs due to sodium hydroxide generated by the current produced by the battery at the anode which is the flat surface with the "+" sign. 

  • Perforation occurs in as little as 6 hours after ingestion. Twenty-millimeter lithium batteries are typically 3-volt cells as compared to 1.5 volts and generate more current, which results from more hydroxide and more damage.
  • The most severe esophageal burns and perforations occur adjacent to the negative battery anode. 
  • The injury may continue after endoscopic battery removal due to residual alkali.

History and Physical

When seeing a patient who has ingested a disk battery, the history should include the type of battery (batteries of larger than 20 mm are more prone to lodgement), battery charge (new batteries have greater potential for tissue damage), time of ingestion (chances of more injury if presentation more than 2 to 4 hours after ingestion), number of batteries ingested, other objects ingested (magnet), and a history of an esophageal anomaly. In children with no evident history of ingestion who refuse oral intake, one should be aware of possible battery ingestion or ingestion of another foreign object.  

No physical examination findings are specific for disk battery ingestion. Most children remain symptom-free after ingestion, and 10% develop minor GI problems. With perforation, abdominal tenderness may be found.

Other symptoms with battery lodgement may include vomiting, abdominal pain, discolored stools, fever, diarrhea, rashes, respiratory distress, irritability, food refusal, coughing, increased salivation, retrosternal discomfort, and anorexia.

Evaluation

A plain film x-ray is often sufficient to diagnosis a disk battery location.

Treatment / Management

Management depends on where the battery is lodged. There should be no oral intake. In all children younger than 12 years of age with a larger than 12 mm large or unknown battery ingestion, an urgent evaluation, and plain radiography are warranted.

In asymptomatic, healthy patients older than 12 years with confirmed ingestion of a solitary, small battery without co-ingestion of a magnet, radiography may be deferred. Management is at home with normal diet and activity. Radiography is warranted if the battery is not passed in ten to 14 days or if the patient becomes symptomatic. The NBIH (National Battery Ingestion Hotline) guidelines advise radiography at 4 days after ingestion.

Usually, batteries get stuck in areas of physiological narrowings, such as the upper esophageal sphincter, the level of the aortic arch, and the lower esophageal sphincter. Patients with lodged esophageal button batteries should undergo emergent removal by endoscopy or by a surgeon if severe complications arise. A gastroenterologist should be consulted when any asymptomatic child younger than five years of age has ingested a battery larger than 20 mm or in whom a battery remains in the stomach on follow-up radiology at 48 hours after ingestion. Endoscopic removal follows if the patient develops signs of GI injury or when the battery remains in the stomach for more than 4 days and is unlikely to pass due to size or other considerations.

Pearls and Other Issues

After passing the stomach, batteries pass through the GI tract in a week without complications. Complications in major outcome cases include tracheoesophageal fistulas, esophageal perforations, esophageal strictures (in need of frequent dilation), vocal cord paralysis, mediastinitis, pneumothorax, pneumoperitoneum, tracheal stenosis, tracheomalacia, empyema, lung abscess. Even after removal, injury can occur because of residual chemicals or weakened tissue.