Button and cylindrical battery ingestion: Clinical features, diagnosis, and initial

management
Authors:
Kelly Sinclair, MD
Ivor D Hill, MD
Section Editors:
Michele M Burns, MD, MPH
Melvin B Heyman, MD, MPH
Deputy Editor:
James F Wiley, II, MD, MPH

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review
process is complete.
Literature review current through: Jul 2017. | This topic last updated: Mar 03, 2017.

INTRODUCTION The evaluation and management of button and cylindrical battery

ingestion will be presented here.

The management of button batteries in the ear or nose, esophageal foreign bodies other
than button batteries, and corrosive esophageal injury are discussed separately as
follows:

(See "Diagnosis and management of foreign bodies of the outer ear", section on
'Foreign bodies of the external auditory canal (EAC)'.)
(See "Diagnosis and management of intranasal foreign bodies", section on
'Foreign body removal'.)
(See "Foreign bodies of the esophagus and gastrointestinal tract in
children" and "Ingested foreign bodies and food impactions in adults".)
(See "Caustic esophageal injury in children" and "Caustic esophageal injury in
adults".)

BUTTON BATTERY INGESTION

Epidemiology The National Battery Ingestion Hotline (NBIH) was created in 1982
and collects data, provides consultation, and promulgates recommendations for battery
ingestions [1]. Up to 15 battery ingestion cases per one million people occur each year
in the United States [2]. The incidence has increased with expanded use of button
batteries in household and recreational products [1-8].

From 2007 to 2009, serious sequelae (eg, esophageal burn, perforation, or fistula)
occurred in 2.7 percent of all button battery ingestions reported to the National Poison
Data System, which compiles all calls to United States regional poison control centers
[2]. Ingestion of large diameter (20 mm) lithium cell batteries was strongly associated
with these major outcomes and death. (See 'Complications' below.)

Battery ingestion has been described in several retrospective case series [1,3-5,9]. The
largest series, from the NBIH, describes 8648 battery ingestions, 94 percent of which
involved button batteries and 6 percent of which involved cylindrical batteries (eg, AA,
AAA, C, N) [9].

In this series, battery ingestions had the following characteristics:

The majority of ingestions occurred in children younger than six years of age, with
the peak frequency between one and two years of age.
Among children, over half of the batteries were ingested immediately after removal
from a product.
Ingested batteries were obtained from a variety of devices including (in decreasing
order of frequency) hearing aids, games and toys, watches, calculators, lighting
devices (eg, flashlights, light/laser pointer, penlight), and remote control devices
(eg, television, garage door, key fob).
By 2008, 18 percent of ingested batteries were 20 mm, and most of these large
diameter batteries were lithium cells. (See 'Battery description' below.)
Patients with hearing aid battery ingestions were the user of the hearing aid in a
large majority of cases.
In a significant number of ingestions, the hearing aid battery was mistaken for a
pill. A common scenario involved storage of hearing aid batteries near medications.
In some instances, the patient swallowed the battery and then realized their mistake
when they tried to put their pill into the hearing aid and found it did not fit.
Other reasons for ingestion included placement on the tongue to "test" the battery,
holding the battery in the mouth, and suicidal intent.

These findings suggest that parents and users of hearing aids should be made aware of
the danger of button battery ingestion. In addition, measures by the manufacturer to
secure the battery compartment of devices using button batteries could prevent over half
of pediatric button battery ingestions. (See 'Prevention' below.)

Battery description Between 30 and 60 percent of each battery contains inert

components [4]. The active portion of the battery consists of a negative terminal and a
positive terminal (figure 1) [10]. The negative terminal of the battery is typically made of
zinc or lithium, and the positive terminal of one of the following substances [2,4]:

Lithium manganese (3 volts, most common)

Manganese dioxide (1.5 volts)
Oxygen (zinc-air cells, 1.5 volts)
Silver oxide (1.5 volts)
Mercuric oxide (1.5 volts)

The negative terminal is the narrow portion of the battery where the electric current flows
into the tissue and usually creates the most damage.

The negative and positive terminals are typically separated by a disc that is embedded
with potassium hydroxide, sodium hydroxide, or an organic solution with varying
concentrations [11]. The terminals and salt solution are encased in steel and/or nickel
(figure 1).
Battery identification Button batteries range in diameter from 6 to 25 mm, a range
that closely approximates that of pills. Lithium batteries are preferred by manufacturers
because they maintain a longer charge, provide a higher voltage, and are lighter than
other cell types [12]. Batteries that are larger than 12 mm in diameter are most likely to
become lodged in the esophagus, especially in young children.

The chemical content, diameter, and height of the battery can be determined from the
imprinted code found on the battery case as determined by the International
Electrotechnical Commission [13]. The first letter gives the chemical identification of the
positive terminal as follows:

L: Manganese dioxide
S: Silver oxide
P: Oxygen
C: Manganese dioxide
B: Carbon monofluoride
G: Copper oxide
LR (or AG): Alkaline
SR: Silver oxide
CR: Lithium/manganese dioxide
BR: Lithium carbon monofluoride

A battery with a three number code has the diameter given by the first number (eg,
SR516 is 5 mm in diameter).

A battery with a four number code has the diameter given by the first two numbers (eg,
CR2032 is 20 mm in diameter).

The last two numbers give the battery height in tenths of millimeters (eg, CR2032 is 3.2
mm in height).

The package code also corresponds to the battery diameter in millimeters. For example,
a battery with a package code of 23 has a diameter of 23 mm.

The type of device from which the battery was removed or for which it was intended may
also help in identification as indicated below [10]:

Calculator HgO, AgO

Camera HgO, MnO2
Computer game HgO, AgO
Hearing aid HgO, AgO, zinc-air
Watch AgO, HgO, MnO2, lithium
Remote control Lithium

Pathogenesis Button batteries that become lodged in the mucosa of the

gastrointestinal (GI) tract cause caustic injury, mucosal ulceration, and, if impacted long
enough, perforation. Although injury may occur at any site, the esophagus is most prone
to impaction. The severity of esophageal damage after button battery ingestion depends
upon the length of time that the battery is lodged in place, the amount of electrical charge
remaining, and the size of the battery [14-16]. Damage to the esophagus may be seen
as early as two hours after ingestion, with more severe damage after 8 to 12 hours
[4,14,17]. As the duration of impaction increases, the mucosa becomes edematous and
the battery adheres tightly to the mucosa. If the battery remains in place, ulceration and
perforation can occur [16,18].

Electrical discharge appears to be the most prominent mechanism for mucosal injury
after button battery ingestion in most clinically significant cases. Mechanisms of injury
from battery ingestion include electrical discharge, pressure necrosis, and leakage of
battery contents [2,4,5], each of which contribute to corrosive damage when the battery
is in contact with a mucosal surface for a sufficient period of time as follows:

Electrical discharge The flow of electric current from the battery through the
surrounding tissue occurs near the negative pole and can cause local hydrolysis,
hydroxide accumulation, and corrosive tissue injury [3,14,18-20]. Discharged
batteries still retain enough voltage and storage capability to generate an external
current. Thus, ingestion of "dead" button batteries is still a major concern.
The corrosive injury caused by electrical discharge cannot be differentiated from
that caused by leakage of battery contents. However, this mechanism appears of
primary importance for the following reasons:
In an in vitro study, after less than one minute, the electric discharge from a
battery generated enough sodium hydroxide at and near the anode to raise the
pH to 11 [19].
Several case reports describe increased severity of mucosal injury near the
negative pole of batteries removed from the esophagus [19].
Major complications (eg, esophageal burns, fistula, or perforation) and deaths
are associated with lithium batteries which contain higher voltage (3 volts) and
capacitance than most other button batteries [2]. (See 'Battery
description' above.)
Among patients who ingested large (20 mm in diameter) button batteries,
clinically significant esophageal injury was significantly associated with new
batteries [2].
Significant esophageal mucosal injury has been documented in patients with
intact batteries lodged for less than two hours, an insufficient amount of time
for pressure necrosis [2].
Leakage of contents In an acidic environment such as the stomach, the seal
or crimp of the battery may erode, potentially releasing chemical contents, including
sodium or potassium hydroxide [17,21,22]. In vitro experiments and examination of
ingested batteries after passage through the gastrointestinal (GI) tract provide
information about the likelihood of dissolution of the battery seal [1,22].
In the large series of cases from the NBIH, 1809 batteries were available for
examination after transit through the GI tract [2]. Two percent of the batteries
fragmented within the GI tract and 13 percent had severe crimp dissolution or
extensive perforations. Severe outcomes were significantly more likely in
 patients with severe crimp dissolution or battery fragmentation (4 versus 1
percent).
In an in vitro experiment, button batteries were placed into a 0.1 N
hydrochloric acid solution to mimic the pH of the stomach [22]. The percent
erosion of the crimp seal after 24 hours was directly related to the amount of
charge remaining in the battery, with complete crimp dissolution in fully
charged cells, 50 to 60 percent dissolution in 50 percent discharged cells, 10
to 20 percent dissolution in 75 percent discharged cells, and only minor pitting
in the fully discharged cells [22].
Alkaline solutions As the alkaline solutions (potassium and/or sodium
hydroxide) react with the exposed proteins on the mucosal surface of the GI tract,
they may cause liquefaction necrosis and saponification of lipid membranes [23].
(See "Caustic esophageal injury in children".)
The dissolution process is slowed somewhat when the battery enters the intestines,
where the pH is higher than in the stomach [3].
Heavy metals Absorption of heavy metals from broken or fragmented batteries
is another potential mechanism of injury. However, cases of heavy metal poisoning
from disc battery ingestion are quite rare. In one case, a five-year-old boy's serum
lithium concentration peaked at 0.7 mEq/L after swallowing a button battery [24].
Mercury batteries are the most concerning in this regard because they are the most
likely to fragment [1], and because of the potential severity of mercury poisoning.
However, mercury toxicity from battery ingestions is extremely rare. There are
several case reports describing elevated serum or urine levels of mercury after
battery ingestion with radiologic evidence of battery fragmentation and radiopaque
droplets in the intestines [1,3,4,17,25-28]. However, none of the involved patients
had clinical signs or symptoms of mercury toxicity. In the one possible case where
symptoms of mercury poisoning (malaise and lethargy) were present, mercury
levels were not obtained [29].
The absence of symptomatic cases of mercury poisoning among battery ingestion
victims is thought to be related to the conversion of mercuric oxide to the less easily
absorbed elemental mercury in the presence of soluble iron (released from the
corrosion of the steel casing), according to the following reactions [30]:
HgO + 2HCl > HgCl2 + H2O
HgCl2 + Fe > FeCl2 + Hg
Pressure necrosis When an ingested foreign body, such as a button battery,
lodges at a single site, it can place pressure on the surrounding tissue and cause
irritation, inflammation, and ischemia. This series of events may lead to tissue
necrosis [5,23,31]. The magnitude of the contribution of pressure necrosis to the
overall mucosal damage in patients after button battery ingestions is less certain
[3,4].

Clinical features

History In most instances, battery ingestions are witnessed or the child tells the
caregiver about the ingestion. The clinician should obtain the following information:
 Battery type The battery type may be known by the patient or caregiver,
available from the code on an identical battery, or determined based upon
descriptions of the battery or the device it operates [32]. (See 'Battery
identification' above.)
Most large diameter (20 mm) batteries are lithium cells and are associated with
the most severe sequelae, including death [2]. For comparison, a dime is 18 mm, a
nickel 21 mm, and a quarter 24 mm in diameter [2,25]. (See 'Complications' below.)
Battery charge state The charge state of the battery is important because new
batteries are associated with a greater potential for tissue damage if they are 20
mm in diameter [2]. However, "dead" batteries still have significant potential for
tissue damage. (See 'Pathogenesis' above.)
Time of ingestion The time elapsed since ingestion can indicate the severity of
damage, particularly when it exceeds two to four hours.
Number of batteries ingested Ingestion of multiple button batteries is
associated with more severe clinically significant outcomes [2].
Magnet coingestion Although rare, ingestion of a button battery and a magnet
may lead to bowel necrosis and perforation should the intestinal wall be trapped
between the battery and the magnet [2,33].
History of esophageal anomaly, stricture, or surgery These patients are at
greater risk for esophageal impaction after button battery ingestion. Furthermore,
the site of impaction may differ from what is seen in patients with normal anatomy
(figure 2).

Signs and symptoms Most patients are asymptomatic although one or more of the
following symptoms may be present [1-4,10]:

Chest pain
Cough
Anorexia
Nausea/vomiting
Hematemesis
Diarrhea
Epigastric pain
Abdominal pain
Fever

Many of these symptoms are caused by the battery's lodging within the esophagus,
where it can cause corrosive tissue damage. (See "Foreign bodies of the esophagus and
gastrointestinal tract in children".)

Additional clinical features include dysphagia, drooling, and black flecks in the saliva [25].

Symptoms of esophageal perforation or tracheo-esophageal fistula in children with

button battery ingestion include hematemesis, drooling, refusal of oral
intake, and/or respiratory distress [34]. Physical findings in these patients can include:
 Fever
Hemorrhagic shock with pallor, tachycardia, and hypotension
Subcutaneous emphysema with crepitus
Tension pneumothorax with tracheal deviation, decreased chest wall excursion,
hyperresonance on the side of the pneumothorax, distended neck veins,
tachycardia, and/or hypotension [35]

The clinician should also maintain a high level of suspicion for an esophageal button
battery or other foreign body, despite a negative history of ingestion, in young children
who are refusing oral intake. In a case series of 13 deaths after button battery ingestion,
misdiagnosis occurred in seven patients because of a lack of ingestion history combined
with nonspecific presenting symptoms, such as fever, vomiting, lethargy, poor appetite,
irritability, cough, wheezing, and/or dehydration [2].

Diagnosis Most patients or caretakers provide a history of button battery ingestion at

initial evaluation and many patients are asymptomatic. However, especially in young
children, ingestion should be included in the differential diagnosis of patients with abrupt
onset of any one of the following symptoms [2,36] (see 'Clinical features' above):

Airway obstruction
Wheezing (without typical prodrome of viral illness or history of atopy)
Stridor (without typical prodrome of viral croup)
Drooling
Chest pain
Difficulty swallowing
Symptoms (eg, coughing, choking, or gagging) with oral intake
Refusal of oral intake
Abdominal pain

Demonstration of the battery on plain radiographs confirms ingestion. Radiographic

location also determines appropriate management. The radiographs should cover the
area from the nasopharynx to the anus. (See 'Radiographic localization' below.)

Management The National Battery Ingestion Hotline (NBIH) (202-625-3333,

telecommunication device for the deaf [TDD] 202-362-8563) or a Poison Control Center
is available to provide guidance for the management of patients with button battery
ingestions. If available, the clinician should try to determine the battery identification
code, which is typically located on the package or on a matching battery. (See 'Additional
resources' below.)

Approach As with all acute ingestions, stabilization of the cardiorespiratory status is

the first priority. However, most patients with button battery ingestion are asymptomatic
or present in stable condition, and localization of the battery is typically the first step. All
patients with suspected button batteries should have no oral intake during evaluation.

Guidelines developed by the National Battery Ingestion Hotline (NBIH) and the North
American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Endoscopy
Committee (NASPGHAN) provide the basis for the approach to button battery ingestion.
The NBIH guideline is available at its website. The NASPGHAN guideline is found in the
reference [12].

These guidelines are largely consistent with respect to recommendations for timely
radiographic localization and emergent endoscopic removal of esophageal button
batteries and emergent endoscopic or surgical removal of button batteries, regardless of
location, in symptomatic patients.

Important differences between the NASPGHAN and NBIH guidelines do exist for
management of asymptomatic young children with button batteries in the stomach as
summarized below. (See 'Gastric location' below.)

Radiographic localization We recommend emergent evaluation and plain

radiography after ingestion of a button battery for patients who meet any one of the
following criteria [2,37]:

All children 12 years of age

All patients who have ingested a button battery that is 12 mm in diameter
All patients for whom the diameter of the battery is not known

Because approximately 10 percent of cases involve ingestion of multiple items, the

radiographs should cover the area from the nasopharynx to the anus [15,18].

In asymptomatic, healthy patients older than 12 years of age with confirmed ingestion of
a solitary, small (12 mm in diameter) battery andwithout coingestion of a magnet,
radiography may be deferred [2,37]. These patients may undergo observation for battery
passage at home without initial radiographs as long as the patient or caregiver is reliable
and able to promptly seek treatment should symptoms develop. Radiographic
localization is warranted if battery passage is not confirmed in 10 to 14 days.

Important radiographic features of button batteries that have lodged in the esophagus
include:

Anatomic site of impaction In otherwise healthy patients, esophageal foreign

bodies tend to lodge in areas of physiologic narrowing, such as the cricopharyngeus
muscle (upper esophageal sphincter), the level of the aortic arch, and the lower
esophageal sphincter (figure 2). Patients with a history of esophageal anomalies,
strictures, esophagitis (particularly eosinophilic esophagitis), or surgery may have
impactions at sites that do not correspond to physiologic narrowing. (See "Foreign
bodies of the esophagus and gastrointestinal tract in children".)
Differentiating a button battery from a coin Patients with button battery
ingestions usually present with a chief complaint of button battery ingestion. When
the ingestion is an incidental finding on plain radiograph, it may be difficult to
differentiate between a button battery and a coin. This distinction is essential to
proper management, especially when the foreign body is in the esophagus,
because batteries require emergent removal whereas coins may or may not.
(See "Foreign bodies of the esophagus and gastrointestinal tract in children",
section on 'Coins'.)
The characteristic features of button batteries versus coins are as follows:
Button batteries have a bilaminar structure, making them appear as a double-
ring or halo on plain radiographs. The double-ring shadow helps to differentiate
battery from coin ingestions (image 1).
On lateral view of the foreign body, the button battery has a step-off at the
separation between the anode and cathode (image 2) [38]. By contrast, the
coin has a sharp, crisp edge (image 2).
Enlargement of the radiograph may help to demonstrate these differences when
interpreting the image. Misidentifying the foreign body as a coin when it is actually
a battery can have significant adverse consequences. As an example, an 11-month-
old infant incurred bilateral vocal cord paralysis when a button battery was misread
as a coin on plain radiographs; she remained intubated for six days [39].
Estimation of battery size Although size of an object cannot be reliably
predicted based upon radiographs, objects greater than 50 mm in length or 20 mm
in diameter are less likely to pass into the stomach [40].
Findings of esophageal perforation Although rarely seen in children with
esophageal button battery impaction, findings suggestive of an esophageal
perforation on chest radiograph include mediastinal or free peritoneal air or
subcutaneous emphysema. With cervical esophageal perforations, plain films of the
neck may show air in the soft tissues of the prevertebral space. Other findings
suggestive of an esophageal perforation include pleural effusions, mediastinal
widening, hydrothorax, hydropneumothorax, or subdiaphragmatic air. However,
 plain radiographs are an insensitive means for establishing the presence of
esophageal perforation [35].

Esophageal impaction We recommend that patients with button batteries that are
lodged in the esophagus undergo emergent removal with direct endoscopic
visualization by an appropriate specialist (eg, in children, a pediatric gastroenterologist,
otolaryngologist, or surgeon). These patients should receive nothing by mouth until the
battery is removed. General anesthesia with endotracheal intubation usually is
recommended to protect the airway during performance of this procedure.

Airway compromise from esophageal edema has been reported as early as three hours
post-ingestion, and esophageal injury has occurred in patients with a battery lodged for
less than two hours [3,14,25]. Thus, every effort should be made to expedite removal
once esophageal impaction has been identified.

The determination of which specialist to perform button battery removal depends upon
the presence and type of symptoms as follows:

Asymptomatic In asymptomatic patients, removal by any of the above

specialists is reasonable and the choice should be based upon who can accomplish
removal in the timeliest fashion. In many institutions, specific guidelines determine
which specialty manages esophageal foreign bodies based upon a variety of factors
including anatomic location and provider expertise.
Symptomatic with no bleeding Symptomatic patients without hematemesis
have a higher likelihood of esophageal perforation with complications and warrant
involvement of a pediatric surgeon. Patients with symptoms of upper airway
compromise (eg, drooling, stridor, or respiratory distress) also warrant consultation
with an otolaryngologist who can assess and address any airway damage.
Symptomatic with bleeding Patients with hematemesis require stabilization
and battery removal in conjunction with a surgeon with cardiothoracic expertise as
follows [12,41]:
Patients with a low-volume sentinel bleed in association with an impacted
esophageal button battery warrant rapid hemodynamic stabilization and
emergent removal in the operating room with surgeons present and prepared
to perform a thoracotomy.
Patients with active bleeding warrant endotracheal intubation, hemodynamic
stabilization, and emergent thoracotomy by a surgeon with cardiothoracic
expertise in the operating room. Placement of a Sengstaken-Blakemore tube
designed to tamponade esophageal sites of bleeding may be a temporizing
measure if the tube and clinicians knowledgeable with its use are available.

The disposition after button battery removal is based upon mucosal findings as follows:

Normal Patients with normal esophageal mucosa may be discharged home

from the post-operative care area.
Esophageal caustic injury Based upon expert consensus, hospitalization is
warranted in patients with any esophageal injury [2,12]. Additional specialty
 guidance for ongoing management of these patients is provided in the reference
[12]. Esophageal perforation and tracheoesophageal fistula (TEF) with erosion into
the aorta or other arteries are rare complications, described in case reports and
case series [41-44]. Although these injuries are not necessarily apparent at the time
of endoscopy, they have occurred in children with moderate to severe esophageal
injury at the time of battery removal. Fatal complications have been described 1 to
18 days after battery removal. (See 'Complications' below.)
Patients with severe injury (grade 2B or 3 [deep ulcers or necrosis]) warrant
evaluation for stricture formation. The typical approach is to perform
a barium esophagogram four to six weeks after the ingestion or sooner if the patient
develops dysphagia (difficulty swallowing). Patients with mild to moderate injury are
also at risk for stricture formation and warrant repeat clinical evaluation and imaging
if symptoms develop. The peak incidence of dysphagia after corrosive esophageal
injury is two months, although it can occur as early as two weeks or as late as years
after ingestion. (See "Caustic esophageal injury in children", section on 'Stricture
formation' and "Caustic esophageal injury in adults", section on 'Esophageal
strictures'.)

Before endoscopy became a standard technique for removal of esophageal batteries,

other techniques were used with some regularity. The two most common were Foley
catheter removal [4] and retrieval of the battery via insertion of an orogastric tube with a
magnet attached to the distal end [45-47]. However, such "blind" techniques do not
permit evaluation of the esophageal mucosa surrounding the battery, and may have
increased risk for airway compromise, emesis, lodging of the battery in the esophagus,
and esophageal perforation compared to endoscopy. These techniques
are not recommended [2-4,18,31,48].

Gastric location Based upon one large prospective study and expert consensus,
patients who have a button battery localized to the stomach and signs or symptoms of
esophageal or gastric injury at initial presentation, even if minor, warrant emergent
endoscopy and removal [2,12,37]. (See 'Signs and symptoms' above.)

As discussed below, two guidelines, the National Battery Ingestion Hotline (NBIH) and
the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition
Endoscopy Committee (NASPGHAN), address the approach to asymptomatic patients
with a button battery in the stomach and have important differences [2,12]. There is no
evidence to indicate that one guideline provides better clinical outcomes than the other.

Because these guidelines differ, we advise consultation with a gastroenterologist for the
following situations:

Any asymptomatic child younger than five years of age who has ingested a button
battery 20 mm. Consultation should occur at initial presentation and involve a
pediatric gastroenterologist.
Any asymptomatic patient five years of age or older in whom the battery remains
in the stomach on follow-up radiograph at 48 hours or longer after ingestion.
The induction of emesis with syrup of ipecac is not recommended for patients with
batteries in the stomach because batteries are dense and unlikely to be expelled. In one
case series, emetics were administered to 57 patients, but resulted in successful removal
of the battery in only four [1]. In addition, induced emesis may cause the battery to lodge
in the esophagus.

Indications for endoscopic removal and follow-up of patients with gastric button batteries
are summarized by guideline as follows:

NBIH guidelines The NBIH guidelines suggest the following approach based
upon a large prospective observational experience [1,2,37]:
Patients with no signs of serious gastrointestinal injury or obstruction
should not undergo endoscopy and should be managed at home with a normal
diet and activity.
Obtain follow-up radiographs:
-If the patient becomes symptomatic
-Four days after ingestion in children under six years of age who have
ingested a button battery with a diameter 15 mm.
-To prove ultimate passage of the battery if not visualized intact in the
stool one to two weeks after ingestion.
-Weekly to monitor progression of the battery through the GI tract if it has
not been seen in the stool and is present on follow-up radiographs.
Endoscopic or surgical removal of the battery is suggested if:
-The patient develops signs of gastrointestinal injury, such as occult or
visible bleeding, fever, vomiting, severe abdominal pain, or acute
abdomen.
-The battery remains in the stomach for more than four days and is
unlikely to pass due to large size (eg, 15 mm in diameter in a child under
six years of age) [17,49].
NASPGHAN guidelines The NASPGHAN guidelines also recommend
emergent endoscopy and removal in patients who are symptomatic at initial
presentation with a button battery located in the stomach or in asymptomatic
patients who develop signs of gastrointestinal injury, such as occult or visible
bleeding, fever vomiting, severe abdominal pain, or acute abdomen subsequent to
the initial evaluation [12].
These guidelines differ from the NBIH guidelines with respect to asymptomatic
patients based upon expert consensus as follows [12]:
Urgent endoscopy (within 48 hours) is suggested for asymptomatic patients
who are younger than five years of age and have ingested a button battery
that is 20 mm. The primary reason for endoscopy in these patients is to
exclude concomitant esophageal injury.
Repeat radiographs at 48 hours are recommended for asymptomatic patients
five years of age and older who have ingested a button battery 20 mm.
Endoscopic removal is advised if the battery remains in the stomach at that
time.
 For asymptomatic patients of all ages who have ingested button batteries <20
mm in diameter, repeat radiographs are suggested at 10 to 14 days if button
battery passage in the stool has not occurred. Endoscopic removal is advised
if the battery remains in the stomach at 10 to 14 days.

Successful endoscopic removal of button batteries from the stomach is less likely than
from the esophagus (33 to 66 percent versus 90 percent, respectively) [1,4,5]. In
addition, there is a low risk of damage from the battery once it has cleared the
esophagus, unless it becomes impacted in the gastric or intestinal mucosa [1,16,17].

Intestinal location Button batteries that have cleared the stomach usually pass
through the gastrointestinal tract within one week without complication [2]. Prolonged
battery transit is more common in patients older than 65 years of age.

Patients and their caretakers should be counseled to seek immediate medical attention
for emergent radiography if abdominal pain, hematochezia, or fever develops before
battery passage in the stool is confirmed. Such symptoms may indicate intestinal
perforation or lodging of the battery in the appendix. Although not reported after button
battery ingestion, appendiceal impaction of a wide variety of ingested foreign bodies,
including smooth foreign bodies, has been described. Prompt surgical consultation for
removal is indicated in symptomatic patients with radiographic documentation of a
retained intestinal button battery. (See "Foreign bodies of the esophagus and
gastrointestinal tract in children", section on 'Clinical manifestations'.)

Follow-up radiographs should be performed in asymptomatic patients who have not

passed the battery by 10 to 14 days, regardless of size. In almost all patients, the battery
will have passed by this time. If the battery still remains in the intestine, then further
evaluation is warranted to determine if the lack of passage reflects a dysfunction of
motility or an abnormality of anatomy (eg, intestinal duplication or stricture). Consultation
with appropriate specialists (eg, gastroenterologist or surgeon) is warranted.

Increasing GI motility, bowel irrigation, and repeated enemas in patients with an intestinal
button battery have been performed in the past with the goal of hastening passage
[4,26,50]. However, given the inconsistent benefit of these measures and the limited risk
of heavy metal toxicity or intestinal caustic injury, these measures
are not recommended.

Mercury toxicity Although elevated blood mercury levels have occurred after
mercuric button battery ingestion, symptomatic mercury toxicity has not been reported
and is unlikely [1]. Furthermore, most button batteries in use contain lithium and
significant absorption of lithium is also unlikely.

However, because of the potential severity of mercury poisoning, patients with ingestion
of batteries containing mercury that have fragmented or who demonstrate radiopaque
droplets in the intestines on follow-up radiographs warrant evaluation for toxicity and
consultation with a medical toxicologist and/or a poison control center [1].
(See 'Additional resources' below.)
Signs and symptoms of mercury toxicity include intention tremor, ataxia, psychiatric
disturbances, anorexia, weakness, hyperreflexia, and paresthesias. Mercury also can
impair kidney function, leading to a nephrotic-like syndrome and/or tubular injury with
tubular dysfunction. The recognition and management of mercury toxicity is discussed
separately. (See "Mercury toxicity", section on 'Treatment' and "Mercury toxicity".)

Complications Complications from button battery ingestion are rare, but potentially
devastating. They include, but are not limited to, tracheoesophageal fistula, vocal cord
paralysis, esophageal perforation, esophageal stenosis, mediastinitis, spondylodiscitis,
aspiration pneumonia, perforation of the aortic arch, gastric hemorrhage, gastric
perforation, and intestinal perforation [2,14,17,31,51-55]. Deaths have been reported
and are associated with ingestion of large (20 mm) lithium cell button batteries [2].

One case series of 86 patients with major outcomes (esophageal burns, perforations, or
fistulas) and 13 deaths after button battery ingestion identified the following risk factors
[2]:

Button battery diameter 20 mm

Patient younger than four years of age
Ingestion of more than one button battery
Unwitnessed or unknown ingestion time
Misdiagnosis of button battery ingestion
Delayed battery removal
Coingestion of a magnet

In this series, tracheoesophageal fistula or esophageal stricture were not symptomatic

for many days after removal. In one case, fatal bleeding from an aortoesophageal fistula
occurred 18 days after battery retrieval [2].

Esophageal stenosis is a late complication of button battery ingestion (image 3). When
it occurs, it typically does so weeks to months after endoscopic removal [1,42]. Thus,
patients with esophageal injury after button battery ingestion warrant evaluation, as
determined by the degree of injury, as described above. (See 'Esophageal
impaction' above.)

The diagnosis and treatment of esophageal stricture after corrosive esophageal injury is
discussed separately. (See "Caustic esophageal injury in children", section on 'Stricture
formation' and "Caustic esophageal injury in adults", section on 'Esophageal strictures'.)

Prevention As with other ingestions, primary prevention of ingestion is preferable to

treatment. Children and their caregivers should be educated about the dangers of button
battery ingestion, proper disposal of batteries, and avoidance of the use of one's mouth
as a "third hand" while changing batteries.

Other measures that caregivers may consider include the following [9]:

Check and secure (with tape) battery compartments on household products

Store batteries out of reach and sight of children
 Do not allow children to play with batteries

In addition, changes in the design of button batteries and/or the products they power
could prevent morbidity from ingestion. These include [1,3,9,18,56]:

Developing child-resistant, unit-of-use battery packaging.

Providing package warnings regarding the potential for serious injury or death if a
button battery is ingested.
Securing the battery compartment of devices using button batteries so that a tool
is required to open them.
Altering the design of hearing aids and other battery-containing products that are
used by children to make the battery less accessible.
Improving the integrity of the seal and crimp area of button batteries.
Eliminating button batteries greater than 15 mm in diameter (since these are more
likely to lodge in the esophagus).

CYLINDRICAL BATTERY INGESTION The National Battery Ingestion Hotline

(NBIH) (202-625-3333, TDD 202-362-8563) or a Poison Control Center is available to
provide guidance for the management of patients with cylindrical battery ingestions.

Most cylindrical battery ingestions occur in patients between 6 and 39 years of age and
are intentional [2,9]. Intact cylindrical batteries (eg, AA, AAA, C type batteries) pose a
low threat for caustic damage after ingestion but because of their length (>2.5 cm) may
become entrapped in the stomach in both children and adults. (See "Ingested foreign
bodies and food impactions in adults", section on 'Blunt objects'.)

Leaking batteries do have the potential to cause corrosive injury. As an example, sucking
on the fluid from a leaking cylindrical alkaline battery has caused esophageal burns in a
child [57].

All patients who ingest cylindrical batteries warrant prompt localization with plain
radiography that includes anterior-posterior (AP) and lateral views from the mouth to the
anus, and urgent endoscopic removal of batteries located in the esophagus [12].
Depending upon the specific type of cylindrical battery (eg, larger C or D type battery),
the presence of leakage, concern that follow-up will be difficult, and/or the age of the
patient (eg, young child), some specialists may also choose to remove batteries localized
to the stomach at initial evaluation. An alternative approach is to re-evaluate the patient
with a radiograph 48 hours after ingestion and remove batteries that remain in the
stomach at that time.

Patients with batteries that have exited the stomach may be observed with follow-up
radiographs at weekly intervals or until passage in the stool is confirmed. Endoscopic or
surgical removal (depending upon the location of the object) is warranted if the battery
remains in the same location for more than one week. Patients should immediately seek
medical attention for surgical removal if symptoms of perforation and peritonitis (eg,
fever, vomiting, and abdominal pain) develop. (See "Ingested foreign bodies and food
impactions in adults", section on 'Blunt objects'.)
INFORMATION FOR PATIENTS UpToDate offers two types of patient education
materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces
are written in plain language, at the 5th to 6th grade reading level, and they answer the
four or five key questions a patient might have about a given condition. These articles
are best for patients who want a general overview and who prefer short, easy-to-read
materials. Beyond the Basics patient education pieces are longer, more sophisticated,
and more detailed. These articles are written at the 10th to 12th grade reading level and
are best for patients who want in-depth information and are comfortable with some
medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you
to print or e-mail these topics to your patients. (You can also locate patient education
articles on a variety of subjects by searching on "patient info" and the keyword(s) of
interest.)

Basics topic (see "Patient education: Swallowed objects (The Basics)")

ADDITIONAL RESOURCES Regional poison control centers in the United States are
available at all times for consultation on patients who are critically ill, require admission,
or have clinical pictures that are unclear (1-800-222-1222). In addition, some hospitals
have clinical and/ormedical toxicologists available for bedside
consultation and/or inpatient care. Whenever available, these are invaluable resources
to help in the diagnosis and management of ingestions or overdoses. The World Health
Organization (WHO) provides a listing of international poison centers at its
website: www.who.int/gho/phe/chemical_safety/poisons_centres/en/index.html.

Information specific to button battery exposure and expert guidance on management of

serious cases is available at the National Battery Ingestion Hotline (NBIH) (202-625-
3333) and at its website: www.poison.org/battery.

SUMMARY AND RECOMMENDATIONS

The chemical content and diameter of the button battery can be determined from
the imprinted code found on the battery case. This code may be known by the
caregiver or patient or can be obtained from a spare matching battery. (See 'Battery
identification' above.)
Most button battery ingestions are witnessed, and most patients are asymptomatic
at the time of presentation. The clinician should also maintain a high level of
suspicion for an esophageal button battery or other foreign body, despite a negative
history of ingestion, in young children with abrupt onset of any one of the following:
refusal of oral intake, difficulty swallowing, chest pain, drooling, airway obstruction,
or wheezing or stridor without typical prodromal symptoms of viral illness.
Demonstration of the battery on plain radiographs confirms ingestion. (See 'Clinical
features' above and 'Diagnosis' above.)
Guidelines developed by the National Battery Ingestion Hotline (NBIH, available
at its website) and the North American Society for Pediatric Gastroenterology,
Hepatology, and Nutrition Endoscopy Committee (NASPGHAN) provide the basis
for the approach to button battery ingestion. (See 'Approach' above.)
Patients with suspected button battery ingestion should have no oral intake until
the evaluation is complete. (See 'Approach' above.)
We recommend emergent evaluation and plain radiography for patients who meet
any one of the following criteria:
All children under 12 years of age who ingest button batteries
All patients who have ingested a button battery that is 12 mm in diameter
All patients for whom the diameter of the button battery is not known
Plain radiographs should include anteroposterior (AP) and lateral views from the
nasopharynx to the anus. (See 'Radiographic localization'above.)
Asymptomatic, healthy patients over 12 years of age with confirmed ingestion of
a solitary button battery that is 12 mm in diameter and without coingestion of a
magnet may undergo observation for battery passage at home without initial
radiographs as long as the patient or caregiver is reliable and able to promptly seek
treatment should symptoms develop. Radiographic localization is warranted if
battery passage is not confirmed in 10 to 14 days. (See 'Radiographic
localization' above.)
We recommend that patients with button batteries that are lodged in the
esophagus undergo emergent removal with direct endoscopic visualization by an
appropriate specialist (Grade 1B). Further management is determined by the
presence and degree of injury at endoscopy. (See 'Esophageal impaction' above.)
Symptomatic patients who have a button battery localized to the stomach, even if
symptoms are minor, also warrant emergent endoscopy and removal. (See 'Gastric
location' above.)
We advise consultation with a gastroenterologist for the following situations
(see 'Gastric location' above):
Any asymptomatic child younger than five years of age with a gastric button
battery that is 20 mm. Consultation should occur at initial presentation and
involve a pediatric gastroenterologist.
Any asymptomatic patient five years of age or older in whom the button battery
remains in the stomach on follow-up radiograph at 48 hours or longer after
ingestion.
Button batteries that have cleared the stomach usually pass through the
gastrointestinal tract within one week without complication. Patients with symptoms
of abdominal pain, hematochezia, or fever without confirmed battery passage
should seek immediate medical attention for emergent radiography. Prompt surgical
consultation for removal is indicated in symptomatic patients with radiographic
documentation of a retained intestinal button battery. (See 'Intestinal
location' above.)
Follow-up radiographs should be performed in asymptomatic patients with an
intestinal button battery who have not passed the battery by 10 to 14 days,
regardless of size. (See 'Intestinal location' above.)
 Cylindrical batteries (eg, AA, AAA, C type batteries) pose a lower threat for caustic
damage after ingestion than button batteries but because of their size may become
entrapped in the stomach. All patients who ingest cylindrical batteries warrant
prompt radiographic localization and urgent endoscopic removal of batteries located
in the esophagus. Depending upon the specific situation, cylindrical batteries
located in the stomach may be removed at initial evaluation or if they remain in the
stomach at 48 hours after ingestion. (See 'Cylindrical battery ingestion' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
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