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DISC BATTERY INGESTION

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Disc batteries are button batteries that may contain mercuric oxide, silver oxide, manganese dioxide, and zinc air cells, all of which contain an alkaline electrolyte.

Specific Substances

    1) Varies
    2) BATTERY, BUTTON (DISC-SHAPED)
    3) BATTERY, CAMERA (DISC-SHAPED)
    4) BATTERY, DISC
    5) BATTERY, HEARING AID (DISC-SHAPED)
    6) BATTERY, WATCH (DISC-SHAPED)
    7) BUTTON BATTERY (DISC-SHAPED)
    8) CAMERA BATTERY (DISC-SHAPED)
    9) DISC BATTERY
    10) DISK BATTERY
    11) HEARING AID BATTERY (DISC-SHAPED)
    12) LITHIUM BATTERIES
    13) LITHIUM BATTERIES, LIQUID OR SOLID CATHODE
    14) WATCH BATTERY (DISC-SHAPED)

Available Forms Sources

    A) FORMS
    1) Button batteries are available in a variety of sizes and chemical systems.
    2) The battery consists of the anode (negative pole) and a cathode (positive pole).
    3) Button batteries are routinely marked with imprint codes which can be utilized to identify size, manufacturer, and contents. The most commonly ingested cells are 11.6 mm in diameter or smaller. Other standard but less frequently ingested battery diameters are 5.8 mm, 7.8 to 7.9 mm, 15.6 mm and 20 mm and 23 to 25 mm.
    4) Commonly ingested chemical systems include lithium, manganese dioxide, , silver oxide, and zinc air cells. Most batteries with the exception of lithium, contain an alkaline electrolyte. This electrolyte is standardly 26 to 45% sodium hydroxide (NaOH) or potassium hydroxide (KOH). Lithium contains an organic electrolyte that is less corrosive than the alkali, but may generate larger voltage and has greater capacitance than other button batteries.
    a) LITHIUM: At least five distinct lithium systems are known to be marketed at this time, including lithium hydroxide, lithium-manganese dioxide, lithium-carbon monofluoride, lithium-iron sulfide, and lithium-thionyl chloride. They contain higher capacitance, and may generate more current with increased potential for tissue destruction.
    b) MERCURIC OXIDE: Mercuric oxide cells have a mercuric oxide cathode and zinc anode. The US Mercury-Containing and Rechargeable Battery Management Act of 1996 banned the sale of mercuric oxide button cells. Therefore, button batteries manufactured in the United States do not pose a threat of mercury toxicity.
    c) MANGANESE DIOXIDE: The manganese dioxide system (also known as the alkaline cell, terminology which is confusing as most types of battery systems contain alkali) has a manganese dioxide cathode and zinc anode.
    d) SILVER OXIDE: Silver oxide cells have a silver oxide cathode and zinc anode.
    e) ZINC: Zinc air cells are utilized predominantly in hearing aids, are air-activated (the seal must be removed to activate them), and are readily recognized by the presence of several pores through the battery through which air enters. An alkaline electrolyte (the only potentially hazardous ingredient) is enclosed behind a membrane through which the air penetrates.
    5) LITHIUM: At least five distinct lithium systems are known to be marketed at this time, including lithium hydroxide, lithium-manganese dioxide, lithium-carbon monofluoride, lithium-iron sulfide, and lithium-thionyl chloride. The specifics of the chemical ingredients of lithium cells remain proprietary at this time.
    a) Esophageal stricture was reported in an 18-month-old child with an impacted 20 mm diameter lithium-manganese dioxide disc battery (Kost & Shapiro, 1987).
    B) USES
    1) Button batteries are intended for use in hearing aids, watches, calculators, photographic equipment, pointers and lights, toys, games, television remote control devices, including keyless entry fobs and key chains. Button batteries are found in multiple sources such as: toothbrushes, bedwetting monitors, lighted shoes, bookmarks, flashing or musical jewelry, digital thermometers, scales, greeting cards and many small electronic devices

Overview

Life Support

    A) This overview assumes that basic life support measures have been instituted.

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) USES: Disc, or button, batteries are used to power many small electronics, such as toys, watches, and hearing aids.
    B) TOXICOLOGY: Disc batteries can cause obstruction in either the esophagus and trachea if ingested or aspirated. Most esophageal impaction occurs with disc batteries that are larger than 15 to 20 mm in diameter. If retained in the esophagus, batteries can cause mucosal burns both from producing an electrical current generating hydroxide through electrolysis, and from leakage of an alkaline substance from the battery. Disc batteries can also cause local damage through a similar mechanism when lodged in the ear or nose. Significant mercury or lithium toxicity does not occur.
    C) EPIDEMIOLOGY: Ingestions are common and deaths have been reported.
    D) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: There have been no reports of disc batteries causing significant damage to the lower gastrointestinal tract if there is rapid transit through the esophagus and past the gastroesophageal junction.
    2) SEVERE TOXICITY: Complications from prolonged contact in the esophagus include fistulas, esophageal perforation, gastrointestinal bleed strictures, mediastinitis, pneumomediastinum, and erosion into a large blood vessel resulting in exsanguination.

Laboratory Monitoring

    A) Obtain a radiograph of the chest and abdomen to determine the location of the battery.
    B) Routine laboratory evaluation is not indicated.
    C) If the patient has clinical evidence of bleeding, CBC, type and cross, and coagulation panel may be indicated.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    1) Initial management in a non-toxic patient includes foreign body x-ray films to locate the position of the disc battery. If the battery has passed the pylorus, the patient may be discharged with instructions to monitor for passage of the battery in stools. If the battery is lodged in the esophagus, it must be endoscopically removed. Batteries lodged in the nose or ear must also be removed.
    B) MANAGEMENT OF SEVERE TOXICITY
    1) Batteries that have been aspirated may require emergent airway management and possibly a surgical airway. Impaction can occur at anatomic narrowing such as cricoid pharynx, aortic arch, gastroesophageal junction, pylorus, and ileocecal junction. Severe effects resulting from mucosal injury to the gastrointestinal tract may require hemodynamic support with intravenous fluids, blood products, and/or vasopressors for exsanguination. Tamponade techniques may be needed for significant mediastinal/gastrointestinal bleed.
    C) DECONTAMINATION
    1) There is no role for gastrointestinal decontamination following disc battery ingestions.
    D) AIRWAY MANAGEMENT
    1) Batteries that have been aspirated may require emergent airway management and possibly a surgical airway.
    E) ANTIDOTE
    1) There is no antidote for exposure.
    F) ENHANCED ELIMINATION
    1) There is no role for enhanced elimination.
    G) PATIENT DISPOSITION
    1) HOME CRITERIA: There is no role for home management of suspected disc battery ingestion.
    2) OBSERVATION CRITERIA: All possible disc battery ingestions need immediate evaluation in an emergency department in order to perform radiograph imaging to determine the location of the battery. If the battery is past the esophagus and does not require emergent removal, the patient should be instructed to monitor for battery passage in the stools, and to return if they develop bloody stool, abdominal pain, vomiting, fever, or loss of appetite. If the battery does not pass spontaneously, follow-up x-rays should be performed 3 to 4 days following ingestion to evaluate the location of the battery. Batteries lodged in the ear or nose must also be removed.
    3) ADMISSION CRITERIA: If the disc battery is retained in the esophagus, the battery will need immediate removal. If an unknown amount of time has passed since the ingestion, and the disc battery is located in the stomach, the battery may also need to be removed. At a minimum, the patient warrants an observation period to look for signs of injury and passage down the gastrointestinal tract. If the battery is beyond the pylorus and the patient becomes symptomatic, it should be removed.
    4) CONSULT CRITERIA: Consult a poison center or medical toxicologist for assistance in managing patients. Gastrointestinal and/or surgical consultation is needed for endoscopic removal of the battery and evaluation for mucosal injury.
    H) PITFALLS
    1) Failure to recognize ingestion of a disc battery, mistaking a disc battery for a coin or other round radiopaque object, and failure to recognize signs of delayed transit through the esophagus with injury to the gastrointestinal tract or bleeding. Failure to appreciate that children in whom the battery has been impacted for long periods of time, or in whom there is evidence of esophageal erosion when the battery is endoscopically removed, require further evaluation as they may develop delayed complications such as fistulas.
    I) DIFFERENTIAL DIAGNOSIS
    1) Ingestions of other round objects such as coins, tokens, or medallions.

Range Of Toxicity

    A) TOXICITY: Ingestion of a single button battery can cause life-threatening complications if it becomes lodged in the esophagus. Batteries greater than 20 mm in diameter are also at higher risk for obstruction, delayed passage, and serious complications.

Clinical Effects

Summary Of Exposure

    A) USES: Disc, or button, batteries are used to power many small electronics, such as toys, watches, and hearing aids.
    B) TOXICOLOGY: Disc batteries can cause obstruction in either the esophagus and trachea if ingested or aspirated. Most esophageal impaction occurs with disc batteries that are larger than 15 to 20 mm in diameter. If retained in the esophagus, batteries can cause mucosal burns both from producing an electrical current generating hydroxide through electrolysis, and from leakage of an alkaline substance from the battery. Disc batteries can also cause local damage through a similar mechanism when lodged in the ear or nose. Significant mercury or lithium toxicity does not occur.
    C) EPIDEMIOLOGY: Ingestions are common and deaths have been reported.
    D) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: There have been no reports of disc batteries causing significant damage to the lower gastrointestinal tract if there is rapid transit through the esophagus and past the gastroesophageal junction.
    2) SEVERE TOXICITY: Complications from prolonged contact in the esophagus include fistulas, esophageal perforation, gastrointestinal bleed strictures, mediastinitis, pneumomediastinum, and erosion into a large blood vessel resulting in exsanguination.

Heent

    3.4.2) HEAD
    A) WITH POISONING/EXPOSURE
    1) A 4-year-old girl presented to the emergency department with edema of the right side of her face. Physical exam revealed marked edema and ecchymosis of right upper and lower eyelid. Erythematous edema extended from the right one-half of the nose to the right mandible and anterior cervical area. The right nasal mucosa was edematous. Nasal discharge of a bloody brown color was present. Sinus films revealed a button battery lodged in the right nostril (Dane et al, 2000).
    3.4.3) EYES
    A) WITH POISONING/EXPOSURE
    1) CASE REPORT: A 2-year-old child presented with a 3-hour history of mild swelling and redness of her right upper eyelid. Physical examination showed a swollen, erythematous right upper eye lid, with congestion of her conjunctiva. The patient also exhibited pseudo-ptosis. Fluorescein staining demonstrated corneal and conjunctival abrasion of the upper right quadrant of the eye. Continued investigation of the eye revealed a button battery that was lodged in the superonasal conjunctival fornix. During removal of the battery under general anesthesia, pigmentation and necrosis of the surrounding conjunctiva was observed. Following the procedure and supportive therapy, including saline irrigation and administration of topical steroids and topical and IV antibiotics, the patient's recovery was uneventful and she was discharged the next day (Khan et al, 2014).
    3.4.4) EARS
    A) WITH POISONING/EXPOSURE
    1) Button batteries have caused severe local tissue injury and erosions through the external ear canal when placed in the ear (Kavanagh & Litovitz, 1986a; Fernando, 1987; Capo & Lucente, 1986; McRae et al, 1989).
    2) Otic and nasal drops should be withheld since they may provide an electrolyte bath and cause increased leakage, generation of an external current, as well as electrolysis and hydroxide formation (Kavanagh & Litovitz, 1986).
    3.4.5) NOSE
    A) WITH POISONING/EXPOSURE
    1) Nasal septal perforations, erosions into the mastoid cavity and severe local tissue injury have occurred when placed in the nose (Kavanagh & Litovitz, 1986a; Fernando, 1987; Capo & Lucente, 1986; Palmer et al, 1994). Saddle deformity with delayed septal perforation, developing 6 weeks after battery removal, has been reported when a battery remained in the nose for several days prior to removal (Palmer et al, 1994). Facial edema and nasal discharge have been reported (Dane et al, 2000).
    3.4.6) THROAT
    A) WITH POISONING/EXPOSURE
    1) Ingestion of batteries lodging in the esophagus may result in excessive salivation and difficulty in swallowing (Anand et al, 2002).
    2) VOCAL CORDS
    a) An 11-month-old girl presented with respiratory distress and was diagnosed with a button battery impaction in the hypopharynx. Her course was complicated by corrosive injury to the hypopharyngeal mucosa, and bilateral vocal cord palsy from presumed injury to the recurrent laryngeal nerves in the tracheo-esophageal groove(Bernstein et al, 2007)

Cardiovascular

    3.5.2) CLINICAL EFFECTS
    A) AORTO-ESOPHAGEAL FISTULA
    1) WITH POISONING/EXPOSURE
    a) Aorto-esophageal fistulas have been reported following pediatric ingestions of button batteries, occurring up to 21 days following battery removal, and may be indicated by the development of hematemesis or melena (Spiers et al, 2012; Brumbaugh et al, 2011) . In one instance, delay in determining ingestion of the battery in a 14-month-old child resulted in his death. A post-mortem CT scan indicated a flat, circular foreign object located in the trachea, and an autopsy identified the object as a 20 mm button battery. Further examination revealed esophageal wall erosion with fistulization occurring into the distal part of the aortic arch (Mortensen et al, 2010).

Respiratory

    3.6.2) CLINICAL EFFECTS
    A) TRACHEOESOPHAGEAL FISTULA
    1) WITH POISONING/EXPOSURE
    a) A TRACHEOESOPHAGEAL FISTULA may occur following disc battery ingestions. Chances of tracheoesophageal fistula, mediastinitis and perforation of the aortic arch increase with longer delays in presentation (Harjai et al, 2012; Jarugula & Dorofaeff, 2011; Anand et al, 2002).
    1) CASE REPORT: A 4-month-old boy developed a small posterior and lateral tracheoesophageal fistula at the level of the previous burn from a lodged disc battery (Sigalet & Lees, 1988).
    2) CASE REPORT: A tracheoesophageal fistula was reported in a 9-month-old infant after ingestion of a 16 mm diameter mercury camera battery. The fistula resolved spontaneously after endoscopic removal of the battery (Van Asperen et al, 1986).
    3) CASE REPORT: A tracheoesophageal fistula occurred in an 11-month-old infant after ingestion of a 15.6 mm diameter mercury camera battery, requiring tracheostomy and partial surgical resection of the esophagus (Litovitz, 1985).
    4) CASE REPORT: Accidental ingestion of an alkaline disc battery in a 3-year-old child, who presented to the emergency department 10 days after the ingestion, resulted in tracheoesophageal fistula; surgical removal of the battery and conservative treatment resulted in spontaneous closure (Anand et al, 2002).
    5) CASE REPORT: A 6-week-old girl presented to the hospital with respiratory distress and feeding problems. A chest radiograph revealed two foreign bodies in the esophagus; however, it was assumed that these objects were electrocardiography pads on the radiograph taken on admission. During endoscopy, extensive tracheo-esophageal lacerations and fistulas were observed. Two alkaline button batteries were obtained from the proximal esophagus. Tracheal resection and end-to-end anastomosis were performed; however, one of the fistulas persisted. Following supportive care for almost a year, she recovered without further sequelae (Bekhof et al, 2004).
    6) CASE REPORT: A 16-month-old girl presented to the hospital with inability to swallow, choking, vomiting and fever, without parental suspicion for foreign body ingestion. Chest radiograph demonstrated a button battery at the T1-T2 area, and esophagoscopy revealed a 23 mm button battery with local tissue erosion. She was discharged to home and re-admitted with worsening clinical status and esophagoscopy 15 days post-retrieval demonstrated a large tracheoesophageal fistula necessitating surgical repair (Alkan et al, 2004)
    7) CASE REPORT: A 20-month-old boy was admitted with one week history of dysphagia and an incidental finding of an esophageal foreign body. Endoscopic removal demonstrated a 20 mm button battery and surrounding esophageal corrosive injury. One week after hospital discharge, the patient was re-admitted for difficulty swallowing, cough and dyspnea and was found to have a large tracheoesophageal fistula requiring surgical repair. (Okuyama et al, 2004).
    8) CASE REPORT: A 17-month-old girl presented to the hospital with complaints of fever, productive cough, and trouble swallowing. A chest radiograph demonstrated a button battery at the level of esophageal sphincter. Endoscopy revealed corrosive injury to the esophageal mucosa and a tracheoesophageal fistula. Further bronchoscopy demonstrated another fistula. Ingestion was estimated to occur 4 days prior to presentation. The child deteriorated hemodynamically, requiring extracorporeal membrane oxygen (ECMO) support (Slamon et al, 2008).
    9) CASE REPORT: A 3-year-old girl presented to the hospital with a radiographic evidence of foreign body ingestion. Esophagoscopy demonstrated a disc battery distal to the cricopharyngeus muscle with local injury. Patient presented to the hospital 2 days following discharge with persistent emesis and cough, and was discovered to have tracheoesophageal fistula (Grisel et al, 2008).
    10) CASE REPORT: A 15-month-old boy presented to the hospital with six-day history of cough and poor feeding, and incidental discovery of an esophageal foreign body. Esophagoscopy revealed a 21 mm button battery with surrounding necrotic tissue and a tracheoesophageal fistula. The fistula closed spontaneously in four weeks(Biswas et al, 2010).

Gastrointestinal

    3.8.2) CLINICAL EFFECTS
    A) FOREIGN BODY IN ESOPHAGUS
    1) WITH POISONING/EXPOSURE
    a) Reported cases of esophageal battery lodgement have been associated with symptoms including irritability, pain or discomfort on swallowing, vomiting, refusal to take foods. Diagnosis was frequently delayed as these symptoms were mistaken for nonspecific gastroenteritis or viral syndromes. Esophageal burns have been noted as early as 4 hours after alkaline battery ingestion (Litovitz, 1983)and as early as 2 hours following lithium battery ingestion (Litovitz et al, 2010).
    b) Button batteries are capable of causing severe local tissue injury and create a very high pH environment even while intact (Rauber, 1990). Injury may persist following removal of the battery, commonly observed with ingestion of lithium batteries.
    c) CASE REPORT: A 5-month-old child presented to the emergency department with persistent cough, vomiting, and decreased feeding over a 24-hour period. A chest X-ray revealed a foreign body in the upper esophagus, a button battery was subsequently removed via endoscopy, and the patient was discharged home approximately 3 days post-presentation. Two weeks later, the child presented with feeding issues and noisy breathing. Over the next week, the patient continued to have oral feeding challenges and persistent noisy breathing. An esophageal endoscopy and subsequent CT and MRI revealed a granulomatous obstructive esophageal mass eroding the C7, T1, and T2 of the vertebrae. With supportive care, including antibiotics, proton pump inhibitor administration, and orthopedic management with a spinal brace, the patient's condition improved with partial resolution of the mass as indicated by a repeat MRI of the spine obtained 6 weeks post-presentation (Jarugula & Dorofaeff, 2011).
    B) RUPTURE OF ESOPHAGUS
    1) WITH POISONING/EXPOSURE
    a) Impaction of a disc battery in the esophagus may result in esophageal perforation and mediastinitis (Soccorso et al, 2012). In one child, several weeks following the esophageal perforation, an esophageal stricture resulted (Gossweiler et al, 1999).
    C) STRICTURE OF ESOPHAGUS
    1) WITH POISONING/EXPOSURE
    a) Esophageal stricture was reported in an 18-month-old child with an impacted 20 mm diameter lithium-manganese dioxide disc battery (Kost & Shapiro, 1987).
    D) MELENA
    1) WITH POISONING/EXPOSURE
    a) Melena suggests a significant gastrointestinal injury.
    b) CASE SERIES: Melena was noted in two cases of disc battery ingestion in a series of 109 cases (Cremers & Hofstee, 1989).
    E) NAUSEA AND VOMITING
    1) WITH POISONING/EXPOSURE
    a) Gossweiler et al (1999) report in a case series of 236 pediatric disc battery ingestions, 16 children (7%) with mild initial symptoms of eating difficulties, dysphagia, abdominal cramps, nausea, vomiting, diarrhea and/or black stools (Gossweiler et al, 1999).
    F) INTESTINAL OBSTRUCTION
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: Nine days after initial laparotomy to remove a ruptured disc battery, a small bowel obstruction occurred in a 2-year-old girl. Multiple small ulcers surrounded by a black precipitate was found in the cecum (Mant et al, 1987).
    G) PERFORATION OF INTESTINE
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: A 10-year-old boy presented to the hospital with abdominal pain, vomiting, fever, and peritoneal signs of physical exam following ingestion of a button battery and magnet. Computed tomography demonstrated a bowel obstruction. Laparotomy revealed a necrotic perforated loop of ileum that was trapped between the button battery and the magnet (Nagaraj & Sunil, 2005).
    H) NECROSIS
    1) WITH POISONING/EXPOSURE
    a) Co-ingestion of a button battery with a magnet may be associated with necrosis of the tissue that becomes entrapped between the battery and the magnet during passage through the gastrointestinal tract (Brown et al, 2012; Shastri et al, 2011; Nagaraj & Sunil, 2005).
    I) GASTROINTESTINAL TRACT FINDING
    1) WITH POISONING/EXPOSURE
    a) GASTROINTESTINAL TRANSIT TIME: In 36 cases of button battery ingestion, the gastrointestinal transit time ranged from 13 hours to 3.9 days with an average time of 38.5 hours (Litovitz et al, 1990).
    b) Battery entrapment in a Meckel's diverticulum has been reported.
    c) Passage of a button battery through a gastrointestinal tract should be completed within 10 to 14 days after ingestion (Litovitz et al, 2010).

Dermatologic

    3.14.2) CLINICAL EFFECTS
    A) SKIN NECROSIS
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: Full thickness skin necrosis occurred in an 18-month-old boy who placed a button battery (manganese dioxide) beneath the plaster of Paris cast on his left leg (Lewandowski & Leditschke, 1991). There were no signs of corrosion of the battery nor evidence of residual active charge.

Musculoskeletal

    3.15.2) CLINICAL EFFECTS
    A) DISCITIS
    1) WITH POISONING/EXPOSURE
    a) SPONDYLODISCITIS is a combination of discitis and spondylitis and is a rare complication of button battery ingestions. Two pediatric patients (a 14-month-old girl and an 18-month-old boy) had ingested button batteries and had them removed successfully. Approximately 1 month to 6 weeks after removal of the batteries, both patients presented with neck pain and stiffness with restricted movement. In the 14-month-old girl, a CT scan of the cervical spine and a subsequent MRI revealed erosion of the T1 and T2 vertebrae with soft tissue inflammation of the pre-vertebral space, consistent with the diagnosis of spondylodiscitis. In the 18-month-old boy, an MRI revealed mediastinitis with associated spondylodiscitis (Tan et al, 2010; Sudhakar et al, 2008).

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Obtain a radiograph of the chest and abdomen to determine the location of the battery.
    B) Routine laboratory evaluation is not indicated.
    C) If the patient has clinical evidence of bleeding, CBC, type and cross, and coagulation panel may be indicated.
    4.1.2) SERUM/BLOOD
    A) Routine laboratory evaluation is not indicated.
    B) If the patient has clinical evidence of bleeding, CBC, type and cross, and coagulation panel may be indicated.

Radiographic Studies

    A) RADIOGRAPHIC-OTHER
    1) X-RAY localization is recommended in all cases of suspected button battery ingestions to confirm the diagnosis, evaluate the location, and serve as baseline so the progress of the battery through the GI tract can be followed by subsequent radiographs. An approximation of battery size should be determined from this initial film (or from inspection of a replacement battery).
    2) It has been suggested that both a PA and lateral film be performed to distinguish between a disc battery and coins. The anterior view may demonstrate a characteristic double density shadow due to the bilaminar battery structure. If the film technique is inadequate, the lateral view may show a smooth round edge and step-off shadow (Maves et al, 1986).
    3) A button battery may be mistaken for a coin (Lin et al, 2004; Bernstein et al, 2007) or externally placed objects, such as electrocardiogram electrodes (Litovitz et al, 2010).
    B) MRI
    1) In some centers, if significant esophageal erosion in noted when the battery is removed, an MRI is performed within the following week to evaluate the extent of injury and to look for evidence involvement of vascular structures (Brumbaugh et al, 2011).

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Patient Disposition

    6.3.1) DISPOSITION/ORAL EXPOSURE
    6.3.1.1) ADMISSION CRITERIA/ORAL
    A) If the disc battery is retained in the esophagus, the battery will need immediate removal. If an unknown amount of time has passed since the ingestion, and the disc battery is located in the stomach, the battery may also need to be removed. At a minimum, the patient warrants an observation period to look for signs of injury and passage down the gastrointestinal tract. If the battery is beyond the pylorus and the patient becomes symptomatic, it should be removed.
    6.3.1.2) HOME CRITERIA/ORAL
    A) There is no role for home management of suspected disc battery ingestion.
    6.3.1.3) CONSULT CRITERIA/ORAL
    A) Consult a poison center or medical toxicologist for assistance in managing patients. Gastrointestinal and/or surgical consultation is needed for endoscopic removal of the battery and evaluation for mucosal injury.
    6.3.1.5) OBSERVATION CRITERIA/ORAL
    A) All possible disc battery ingestions need immediate evaluation in an emergency department in order to perform radiograph imaging to determine the location of the battery. If the battery is past the esophagus and does not require emergent removal, the patient should be instructed to monitor for battery passage in the stools, and to return if they develop bloody stool, abdominal pain, vomiting, fever, or loss of appetite. If the battery does not pass spontaneously, follow-up x-rays should be performed 3 to 4 days following ingestion to evaluate the location of the battery. Batteries lodged in the ear or nose must also be removed.

Monitoring

    A) Obtain a radiograph of the chest and abdomen to determine the location of the battery.
    B) Routine laboratory evaluation is not indicated.
    C) If the patient has clinical evidence of bleeding, CBC, type and cross, and coagulation panel may be indicated.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) There is no role for gastrointestinal decontamination following disc battery ingestions.
    6.5.2) PREVENTION OF ABSORPTION
    A) INDUCTION OF EMESIS should be avoided and is unlikely to evacuate the battery from the stomach. Ipecac syrup has failed to expel the battery in all cases but one in which its use has been reported (Litovitz & Schmitz, 1992) and may be potentially dangerous if the battery lodges in the esophagus or has already caused a full thickness burn (Sheikh, 1993).
    B) ACTIVATED CHARCOAL has been recommended as a marker, but should not be administered as it may obscure the ability to recognize hematochezia in the patient undergoing observation at home.
    6.5.3) TREATMENT
    A) MONITORING OF PATIENT
    1) Obtain a radiograph of the chest and abdomen to determine the location of the battery.
    2) Routine laboratory evaluation is not indicated.
    3) If the patient has clinical evidence of bleeding, CBC, type and cross, and coagulation panel may be indicated.
    B) DILUTION
    1) NEUTRALIZATION
    a) An in vivo study in cats demonstrated no benefit from administration of various diluents, including vinegar, orange juice, and Mylanta II (R), on severity of esophageal injury 2 hours after placement of a manganese dioxide disc battery (Rivera & Maves, 1987).
    C) RADIOGRAPHIC IMAGING PROCEDURE
    1) X-RAY LOCALIZATION is recommended in all cases of suspected button battery ingestion to confirm the diagnosis, exclude an esophageal location, and serve as baseline so the progress of the battery through the GI tract can be followed by subsequent radiographs. An approximation of battery size should be determined from this initial film (or from inspection of a replacement battery).
    2) X-rays should be taken so as to include the area from the top of the nose and ear canals down to the rectal areas, and should include both a PA and lateral film. An approximation of battery size should also be determined from this initial film. Estimate whether battery is the size of a quarter (24 mm) or the size of a dime (18 mm), pencil eraser (6 to 7 mm)(Litovitz et al, 2010).
    3) Most batteries which become lodged in the esophagus are 20 mm or bigger in diameter.
    4) CASE SERIES: Gossweiler et al (1999) reported a series of 1095 pediatric button battery ingestions. Of these, 756 (69%) required no emergency department admission and 339 (31%) required medical evaluation. 220 (93%) of the evaluated children remained symptom free, with batteries excreted in feces and no late GI complications developing. 16 children (7%) experienced mild symptoms, with only one child developing a severe outcome (battery radiographically localized in esophagus, developed esophageal perforation, mediastinitis and delayed stricture formation). The authors conclude that radiographic evaluation is indicated only in symptomatic patients (Gossweiler et al, 1999).
    5) CASE SERIES: Litovitz et al (2010) studied a series of 8648 children with reported button battery ingestions to the National Battery Ingestion Hotline, with ingestions confirmed in 81.9% cases. 6349 children (77.8%) remained asymptomatic; 508 children (6.22%) experienced minor effects; 129 children (1.58%) experienced moderate effects, 41 children (0.5%) experience major effects, and 2 children (0.02%) died. The 20 mm lithium cell was implicated in majority of severe injuries, especially in children younger than 4 years of age. Injuries extended after removal, with delayed esophageal perforations, tracheoesophageal fistulas, and hemorrhage. The authors advocate radiographic confirmation for all patients who ingest button batteries, noting the high rate of missed diagnosis of serious ingestions (Litovitz et al, 2010).
    D) ENDOSCOPIC PROCEDURE
    1) Endoscopic or surgical removal is indicated in the symptomatic patient or when there is evidence of esophageal impaction or a corroded battery. Endoscopic or surgical removal may be considered in cases where the battery stops progressing through the GI tract or if the battery is larger than 20 mm in diameter.
    2) BATTERY LOCATED IN THE ESOPHAGUS require emergent endoscopic removal. Although the success rate of button battery retrieval by endoscopy from the more distal parts of the gastrointestinal tract has been extremely low (about one third of attempts are successful), battery retrieval from the esophagus by endoscopy has proved uniformly successful.
    3) Endoscopic retrieval may be more successful with the use of a fiberoptic endoscope equipped with a basket rather than pinchers. Additionally, the attachment of a small magnet to the tip of the endoscope may aid in battery retrieval. Where endoscopy fails (and in the presence of peritoneal signs and symptoms), laparotomy may be required.
    4) One study (Volle et al, 1989) recommends immediate removal of batteries lodged in the esophagus less than 24 to 30 hours with the FE-EX(R) OGTM (oral gastric tube magnet) procedure under fluoroscopic control. Esophageal battery lodgement greater than 50 hours should be removed via endoscopic techniques. McDermott et al (1995) reported successful battery removal in 32 children, without anesthesia, by use of an orogastric magnet under fluoroscopy (McDermott et al, 1995).
    5) Some authors recommend battery retrieval from the esophagus utilizing the Foley Catheter technique (Rumack & Rumack, 1983), but this procedure does not allow direct assessment of the severity of esophageal injury, and should be avoided if the battery has been lodged for more than 24 hours or the patient is symptomatic.
    a) Furthermore, this is a blind technique and may therefore pose a greater risk of esophageal perforation (in the setting of chemical and electrical esophageal burns) than retrieval under direct endoscopic visualization.
    b) Disc batteries are often found to be adherent to the esophagus, requiring greater care in removal than allowed by the Foley technique (Maves et al, 1986).
    E) FOREIGN BODY IN STOMACH
    1) IF THE BATTERY HAS PASSED BEYOND THE ESOPHAGUS, the patient may be sent home and instructed to watch for vomiting, tarry or bloody stools, fever, abdominal pain, or decreased appetite.
    2) If the patient remains asymptomatic, hospitalization is NOT indicated, and the patient should NOT be placed NPO or restricted to fluids, as these maneuvers may delay gastric transit. A normal activity level and diet should be permitted.
    3) MAGNETS: Co-ingested batteries and magnets require prompt removal, endoscopically if possible, surgically if not (Litovitz et al, 2010).
    4) REPEAT X-RAY
    a) In the absence of symptoms a REPEAT X-RAY may be performed 4 to 7 days after the ingestion if battery passage in the stool has not been documented. If this roentgenogram demonstrates a persistent gastric position of the battery, several doses of metoclopramide are advised, based on the theoretical advantages of rapid gastric transport.
    b) X-ray evidence of a battery becoming "hung-up" at a certain location in the gastrointestinal tract beyond the esophagus does NOT mandate endoscopic or surgical intervention in an asymptomatic patient. If battery transit is arrested, endoscopic or surgical intervention are indicated in the presence of associated symptoms.
    c) More frequent (daily) x-ray localization of the battery is indicated for the larger 23 millimeters diameter cells as these often fail to pass spontaneously beyond the pylorus.
    5) METOCLOPRAMIDE/CIMETIDINE
    a) Metoclopramide administration may speed gastric transit of these cells, and cimetidine administration may minimize acid-induced corrosion. These therapeutic adjuncts, however, are currently only recommended for the larger size button cells because of the frequent association of delayed gastric transit with these cells.
    b) The clinician should note that their recommended use is based on entirely theoretical considerations; no controlled clinical trials or animal studies document their efficacy.
    c) Cimetidine, metoclopramide, and magnesium citrate were not shown to protect against button-battery injury in dogs (Litovitz et al, 1984).
    F) SURGICAL PROCEDURE
    1) LAPAROTOMY INDICATIONS
    a) Failure of endoscopic removal in a symptomatic patient, mucosal damage, or a badly corroding battery (usually the battery is pushed into the stomach and a gastrotomy is performed) (Thompson et al, 1990)
    b) Signs of peritonitis (Kuhns & Dire, 1989; Anon, 1989)
    c) When less invasive techniques (test of time, WBI, endoscopy) fail to retrieve the battery in an asymptomatic patient
    d) Failure of WBI and the location of the battery is inaccessible to endoscopic retrieval
    e) Signs of peritonitis (Kuhns & Dire, 1989; Anon, 1989)
    G) MERCURY
    1) The issue of concern is that mercury batteries tend to open (Litovitz & Schmitz, 1992). Although elevated mercury concentrations have been reported (Kulig et al, 1983), no clinical mercury toxicity has been described in these patients (Blatnik et al, 1977).
    2) Where a button cell is noted to be split on roentgenogram, where the button cell chemical system is possibly mercuric oxide (as determined from the battery's imprint code), and especially where visible droplet-like opacities are noted on the abdominal x-ray, the split battery should be removed promptly by purging or enema and the patient's blood and urine should be evaluated for heavy metal concentrations.
    3) The US Mercury-Containing and Rechargeable Battery Management Act of 1996 banned the sale of mercuric oxide button cells. Therefore, button batteries manufactured in the United States do not pose a treat of mercury toxicity.

Enhanced Elimination

    A) ENHANCED ELIMINATION
    1) There is no role for enhanced elimination.

Abstracts

Case Reports

    A) PEDIATRIC
    1) ROUTE OF EXPOSURE
    a) ORAL
    1) A 2-year-old boy presented to the trauma unit 6 hours post-ingestion of a pocket calculator button battery. Abdominal x-ray revealed the battery located in the stomach. The child was discharged home after being given a single dose of magnesium sulfate and metoclopramide to encourage downward progression of the battery. The child was re-admitted the next day and an x-ray revealed the battery situated in the left upper quadrant surrounded by droplets of mercury.
    a) A pediatric bisacodyl suppository was administered, and the battery was passed through the stool showing signs of corrosion and mercury leakage. Urinary mercury concentration was 74 mcg/mL. Renal and liver function tests were normal. At one week follow-up, the urine mercury concentration had fallen to normal limits with no evidence of renal dysfunction or neural toxicity (Bass & Millar, 1992).
    2) A 5-year-old boy presented to the emergency department 1 hour after swallowing a lithium button battery. X-ray examination showed that the battery appeared to be in the stomach. Repeat x-rays at 48 and 96 hours post-ingestion showed that the battery remained in the stomach. He was admitted to the hospital and the battery was successfully removed via gastrotomy. Serum lithium concentrations at 96 hours post-ingestion were 0.71 mmol/L. At 24 hours after gastrotomy, lithium concentrations had fallen to undetectable concentrations. There was no clinical evidence of lithium toxicity and the child was discharged home (Mallon et al, 2004).
    b) EAR
    1) Skinner & Chui (1986) reported a 12-year-old who had inserted a disc battery into his right ear. He reported right-sided otalgia of 7 days duration followed by profuse mucopurulent otorrhea of 3 days duration.
    a) Removal of the battery was performed under general anesthesia. The battery appeared corroded. An edematous external auditory meatus, extensive granulation tissue were reported, and the malleus was found completely blackened on the floor of the deep meatus.
    b) The ear was cleaned of debris and antibiotics were started. A conductive 50 db hearing loss without sensori-neural component was reported 1 month post removal of the disk battery (Skinner & Chui, 1986).
    c) NOSE
    1) A five-year-old child presented to a ENT outpatient clinic with left-sided , purulent rhinorrhea and feeling unwell of 3 days duration. A painful swelling was noted over the left alar infra-orbital region of the face 12 hours prior to presentation. On examination, foreign body was not visualized.
    a) There was a profuse, blood-stained, purulent discharge within the left nasal cavity. X-ray views of the sinuses and nose revealed a metallic disc foreign body. It was removed under general anesthesia and found to be a corroded disc hearing aid battery.
    b) The area from where the battery had been removed appeared blackened and necrotic. The area was cleared of debris and oral antibiotic was started. At 1 year post removal there was no evidence of external deformity or intranasal adhesions but a persistent crusting within the nasal cavity was reported (Skinner & Chui, 1986a).

Range Of Toxicity

Summary

    A) TOXICITY: Ingestion of a single button battery can cause life-threatening complications if it becomes lodged in the esophagus. Batteries greater than 20 mm in diameter are also at higher risk for obstruction, delayed passage, and serious complications.

Minimum Lethal Exposure

    A) CASE REPORTS
    1) Two fatalities have been reported in the medical literature as a result of esophageal impaction of the large diameter (23 mm) button batteries (Blatnik et al, 1977; Shabino & Feinberg, 1979).
    2) Delay in determining ingestion of a button battery in a 14-month-old child resulted in his death. The patient initially was in contact with pediatricians 10 days prior to his death with symptoms of fever, coughing, vomiting, black stools, and decreased feeding. Infection was suspected and antibiotics were administered. Ten days later, the patient developed hematemesis and presented to the hospital in asystole. Despite aggressive resuscitative measures, the patient remained unresponsive, and was declared dead approximately 50 minutes after onset of symptoms. A post-mortem CT scan indicated a flat, circular foreign object located in the trachea, and an autopsy identified the object as a 20 mm button battery. Further examination revealed esophageal wall erosion with fistulization occurring into the distal part of the aortic arch (Mortensen et al, 2010).

Maximum Tolerated Exposure

    A) GENERAL/SUMMARY
    1) In a review of 119 ingestions, 90% of the batteries were passed spontaneously without complication. Of these, 69% had a transit time of 48 hours, whereas 85% passed in 72 hours, although some remained as long as 14 days. Only 11 patients had symptoms (usually GI upset), and only one battery became lodged in the esophagus (Litovitz, 1985).
    2) In a series of 1276 cases reported to the AAPCCNDCS there were no deaths and no severe outcomes (Litovitz & Schmitz, 1992). When this series was expanded to 2320 cases, similar findings were noted (Litovitz & Schmitz, 1992).
    3) An issue of concern is that mercury batteries tend to open (Litovitz & Schmitz, 1992). Although elevated mercury concentrations have been reported (Kulig et al, 1983), no clinical mercury toxicity has been described in these patients (Blatnik et al, 1977).
    4) CASE REPORT: A 17-day-old neonate presented to a tertiary care center with a 10-day history of poor feeding, crying, and occasional frothing. An initial chest x-ray, conducted 5 days earlier by a local physician, indicated a radiopaque image in the esophagus, that was confirmed, via a second chest x-ray, following presentation to the tertiary care center. An esophagoscopy revealed a lithium button battery , 10 mm in diameter, that was removed without complications; there was minimal erythema of the underlying mucosa. Other than the initial presenting signs, there were no other signs or symptoms following ingestion of the button battery. After removal of the battery, recovery was uneventful and the infant was discharged without sequelae (Sahni et al, 2012).

Pharmacology Toxicology

Toxicologic Mechanism

    A) Button batteries may cause local tissue injury through three possible mechanisms:
    1) Actual leakage of the NaOH or KOH electrolyte from within the battery leading to localized tissue necrosis when the battery is lodged on a single site (rather than diluted and diffuse as would be expected after leakage from a free-floating battery). The extent of damage depends on the amount of electrolyte base (NaOH and KOH) present in the battery; thus, discharged batteries cause less damage than charged batteries (Anand et al, 2002).
    a) Evidence against this mechanism is the finding that mercury containing button batteries can cause severe tissue necrosis without measurable leakage of potassium hydroxide (Yamashita et al, 1987).
    b) The risk of battery leakage is presumably increased as the battery can (crimp area) dissolves. This dissolution occurs rapidly in the stomach as a result of the electrical current established in the acid environment.
    2) Electrical current injury to tissue caused by a current beginning at the anode end of the battery and through the highly electrolytic media of gastrointestinal fluids and body tissues (Yamashita et al, 1987).
    3) Localized electrolysis with NaOH production in the tissue caused by the electrical current generated external to the battery (Yamashita et al, 1983; Yamashita et al, 1987). It has been calculated that the complete discharge of a mercury type battery can generate 325 mg of sodium hydroxide by this mechanism.
    4) An impacted battery may exert constant mechanical force against the tissue resulting in pressure necrosis of the tissue (Anand et al, 2002).
    B) Tissue injury persists after button battery removal, and may result in esophageal perforations, esophageal strictures, and tracheoesophageal fistulas.
    1) Co-ingestion of a button battery with a magnet may be associated with necrosis of the tissue that becomes entrapped between the batter and the magnet during passage through the gastrointestinal tract.

References

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