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.
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.
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.
The usual outcome of disk battery ingestions is an eventful passage. Most ingestions have only mild effects or none at all.
New cells are more likely to be associated with clinically significant outcomes.
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.
A slight male predominance is observed in disk battery ingestions.
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.
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.
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.
A plain film x-ray is often sufficient to diagnosis a disk battery location.
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 a 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.
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.
\Disk battery ingestion is a relatively common problem seen in the emergency department. The vast majority of disk battery ingestion are in children who simply are exploring their home environment. However, disk battery ingestion can lead to serious complications. The ingestion is best managed by a multidisciplinary team that can provide aggressive care that may include surgical removal. The triage nurse must be fully aware of the consequences of disk battery ingestion and quickly get the patient admitted and seen by the emergency department physician. The prognosis for those who undergo prompt removal of the foreign body is excellent. However, delayed removal may lead to perforation or necrosis of the esophagus. The key to managing disk battery ingestion is the education of the parent who should keep these items locked up safely in an unreachable area.