Continuing Education Activity

Disk batteries (or button batteries) are found in many consumer electronics. The last few decades have seen an increase in demand for compact electronic products with a broadened use of larger and more powerful batteries. With the rise in the use of button batteries, the incidence of battery ingestion has also increased. Disk batteries can cause serious injury when aspirated or swallowed. Most ingestions occur in small children. This review presents the pathophysiology of disk battery ingestion, the epidemiology, presentation, and management by an interprofessional team.

Objectives:

• Describe the pathophysiology of disk battery ingestion.
• Outline the presentation of a patient with disk battery ingestion.
• Review the treatment and management options available for disk battery ingestion.
• Explain interprofessional team strategies for improving care and outcomes in patients with disk battery ingestion.

Introduction

Disk batteries (or button batteries) are found in many consumer electronics.  The last few decades have seen an increase in demand for compact electronic products with a broadened use of both more substantial and more powerful batteries. [1]  With the rise in the use of button batteries, the incidence of battery ingestion has also increased.  Disk batteries can cause significant serious injury when aspirated or swallowed.  Most ingestions occur in small children.  Fortunately, most cases of disk battery ingestion are benign. Complications are rare but can be severe and may include injury to the esophagus, trachea, laryngeal nerve, or adjacent structures.  More than 97% of battery ingestion cases have mild effects or none at all.[2][3]

Etiology

Injury may occur when batteries are swallowed or aspirated. Most batteries pass through the GI tract without incident. Damage occurs when disk batteries become lodged in the nasopharynx, oropharynx, trachea, esophagus, or GI tract and lead to local injury, ulceration, perforation, or fistula formation. Damage may be acute but is often delayed, and long-term sequelae may occur days to weeks after injury and initial treatment. [1]

Epidemiology

56,535 button battery ingestions were reported to the National Poison Data System from 1985–2009. 68.1% occurred in children who were younger than six years and 20.3% in children who were aged 6 through 19 years. [1]  American Poison Control Centers report over 3300 ingestions each year. [4]

Most cases of ingestion are seen in children under the age of six, with the peak frequency occurring in children between the ages of one and three years. The majority of ingestions are unwitnessed. More than half of ingestions occur within one-half hour after removal from the device.[5]  There is a second peak in ingestions in elderly patients, with 10% occurring in patients aged 60 to 89 years. Elderly 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.

There has been a nearly seven-fold increase in the incidence of severe morbidity and fatalities over the last decade.  This increase is not due to a rise in the number of ingestions overall and may reflect the increased use of larger and more powerful batteries. [4]

Pathophysiology

Several mechanisms of injury have been theorized and include local pressure necrosis, corrosive damage from leakage of battery contents, heavy metal toxicity, and direct electrical discharge. Electrical injuries appear to be the most likely mechanism. [4] 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.  This process generates an electrical current, which leads to electrolysis and liquefactive necrosis.[6]  The batteries become lodged in the stomach, corrode, and fragment. Corrosion and fragmentation occur in batteries that stay 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.[7]

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.[8][9]  Unfortunately, damage can occur in as little as two hours after becoming lodged in tissue. [10] Injury appears to be proportional to size and type of battery ingested, with more damage caused by lithium batteries. The leaking of battery contents does not appear to be the cause of local injury, but rather the higher capacitance of the batteries, which can generate more current and thus more tissue damage. [1]  

History and Physical

The clinical presentation of disc battery ingestion can vary based on the timing of ingestion, type of battery, and its location in the body.  The vast majority of patients presenting with known or suspected button battery ingestion are asymptomatic. The most common acute symptoms are nonspecific and include nausea, vomiting, dysphagia, irritability, and abdominal pain but are only present in 10% to 20% of patients. [6]  Batteries in the nasopharyngeal cavity can present with bloody nasal discharge. [11] More severe injuries usually occur when ingestions are unwitnessed, and presentation is delayed, when the batteries are more likely to lead to perforation and tissue necrosis.  Complications can vary widely and include pneumonia, fistula formation, mediastinitis, pneumothorax, intestinal perforation, peritonitis, vertebral osteomyelitis, recurrent laryngeal nerve injury, and vocal cord paralysis.  Symptoms of these problems are delayed hours to days after ingestion and could include: chest pain, stridor, melena, bloody stools, hematemesis, hoarseness, cough, abdominal pain, and fever. [6] [4] When seeing a patient who has ingested a disk battery, the history should include the type of battery as batteries of larger than 20 mm are more prone to lodgement, last time the battery was changed as new batteries have more significant potential for tissue damage, time of ingestion as chances of more injury if presentation more than 2 to 4 hours after ingestion, and potential number of batteries ingested. 

No physical examination findings are specific for acute disk battery ingestion. Batteries in the nasal cavity may be visualized directly, but findings in patients who have batteries in the esophagus or distal structures are typically unremarkable.  With a delay in presentation, examination findings may vary greatly and depend on the location of the injury.  [11]

Evaluation

Evaluation of suspected button battery ingestion should include plain radiographs with both anteroposterior and lateral views of the head, neck, chest, and abdomen. Button batteries have a distinctive appearance with a step-off seen in the lateral view and a "double-density" or halo sign noted on the A-P view. [12]  Disc batteries can often be mistaken for coins, so care should be taken to make an accurate diagnosis.  Ordering repeat films at alternate angles may aid in the diagnosis.

Treatment / Management

Initial management of button battery ingestion should include an assessment of the patient's age, type, and size of the battery when ingestion occurred, and where it is currently located. Low-risk, asymptomatic patients with batteries that have passed through the esophagus have a low risk of significant morbidity or mortality.  The current national guidelines (NBIH and Button Battery Taskforce) support observation and serial radiographs in 10-14 days. For higher-risk patients (less than age six or with button batteries 15 mm or greater), repeat films should be obtained in 4 days, with endoscopic removal for batteries that have not passed through the stomach. [13] Current recommendations include consideration of early endoscopy in high-risk patients (age less than 5 years or batteries greater than 20 mm) over concerns for unrecognized esophageal injury during passage into the stomach. [14]  All other patients should have emergent endoscopic removal. It is essential to consider the appropriate venue for endoscopy, especially if there is a concern for bleeding or the inability to remove the battery using an endoscope. High-risks cases may be best managed in the cardiac catheterization laboratory or in a general operating room, which offers improved imaging capabilities and the ability to convert to an open surgical case if needed. Cases involving button battery ingestion should be considered high priority given the potential for severe injury after a relatively short impaction time.  Care should be coordinated with the appropriate medical and surgical specialists anticipated for each case. Patients should remain NPO, with airway precautions in place. Specifics involving removal of the battery need to be determined, with particular attention to its location relative to the aorta and other large vessels. Angiography may be considered if vascular involvement is suspected. [13]  Post removal endoscopy may be helpful in evaluating the extent of the injuries and potential complications. 

Differential Diagnosis

The diagnosis is usually straightforward; however, disc batteries may be mistaken for a coin or an EKG lead on plain films. 

Enhancing Healthcare Team Outcomes

Disk battery ingestion is a relatively common problem seen in the emergency department. The vast majority of disk battery ingestion is in children who merely are exploring their home environment. However, disk battery ingestion can lead to serious complications. The ingestion is best managed by an interprofessional 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. Gastroenterologists and GI nurses are needed for endoscopy. 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. [15][9]