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Disk Battery Ingestion

  • Author: Daniel J Dire, MD, FACEP, FAAP, FAAEM; Chief Editor: Asim Tarabar, MD  more...
 
Updated: Dec 28, 2015
 

Background

Disk batteries are small, coin-shaped batteries used in watches, calculators, and hearing aids. The vast majority of disk battery ingestions occur when curious children explore their environment.

Early published case reports of ingestion of disk batteries were concerned with serious sequelae (eg, esophageal perforation, aortic perforation with exsanguination, tracheoesophageal fistulae). From these reports, recommendations were made for aggressive management, including surgical removal. Information gained from the National Button Battery Investigation Study combined with more recent case reports and series involving successful conservative management has shown that these ingestions usually are benign.

Fatal cases or those with major sequelae usually involve esophageal or airway battery lodgement.[1]

Disk batteries

Disk batteries are formed by compacting metals and metal oxides on either side of an electrolyte-soaked separator.[2] The unit is then placed in a 2-part metal casing held together by a plastic grommet (see the image below).

Cross-section of a typical disk battery. Cross-section of a typical disk battery.

The grommet electrically insulates the anode from the cathode. The metal undergoes oxidation on one side of the separator, while the metal oxide is reduced to the metal on the other side, producing a current when a conductive path is provided.

Disk batteries contain mercury, silver, zinc, manganese, cadmium, lithium, sulfur oxide, copper, brass, or steel. These are the components of the anode, cathode, and case containing the battery. Disk batteries also contain sodium hydroxide or potassium hydroxide to facilitate the electrochemical reaction through the separator. In a series of 56,535 battery ingestions from 1985-2009 in which the type of battery was known in 57.7% of the cases, 42% were manganese dioxide, 32% were zinc-air, 13% were silver oxide, and 9% were lithium (up from 1.3% in 1900-1993).[1] In 2008, 24% of the batteries ingested were lithium cells; an upward trend that started in the late 1990s with a corresponding drop in the number of mercuric oxide cells. See the image below.

Changes in chemical systems of ingested disk batte Changes in chemical systems of ingested disk batteries from 1990-2008.

Disk batteries vary in diameter from 7.9-23 mm and in weight from 1-10 g. Known diameters of ingested disk batteries are as follows: 11.6 mm (55% of cases), 7.8-7.9 mm (31% of cases), 20 mm or more (6.7% of cases), 5.8 mm (3% of cases). Cases of large diameter (≥20 mm) disk battery ingestions increased from 1% of cases from 1990-1993 to 18% of cases in 2008.[1] See the image below.

Changes in the diameter of disk battery ingestions Changes in the diameter of disk battery ingestions from 1990-2008.

From 2000-2009, 92% of disk batteries from fatal ingestions or those with major outcomes were 20-mm lithium cells. Most were imprint code CR 2032 (71%) or CR 2025 (21%).[1] "CR" represents the battery chemistry, "20" is the diameter, and "32" indicates the thickness (3.2 mm) of the battery. See the image below.

20 mm CR 2032 Lithium Cell Disk Battery shown with 20 mm CR 2032 Lithium Cell Disk Battery shown with a U.S. Quarter: On the left is the Cathode (positive pole) and on the right the narrower Anode (negative pole).
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Pathophysiology

Disk batteries do not usually cause problems unless they become lodged in the GI tract, nose, or ears. The most common place disk batteries become lodged, resulting in clinical sequelae, is the esophagus. Batteries that successfully traverse the esophagus are unlikely to lodge at any other location.

Batteries pass through the GI tract in a relatively short period of time: 23% within 24 hours, 61% within 48 hours, 78% within 72 hours, and 86% within 96 hours. Only 1% of batteries take more than 2 weeks.

Clinically significant outcomes (moderate, major, or fatal) occurred in only 1.3% cases from 1985-2009.[1] The likelihood that a disk battery lodges in the esophagus is a function of the patient's age (very young or old) and the size (diameter in mm) and type (chemical content) of the battery.

The larger size (20-25 mm batteries) is the most important predictor of a clinically significant outcome. Disk batteries of 16 mm have become lodged in the esophagi of 2 occurred in children who were younger than 4 years old.[1] Older children do not have problems with batteries smaller than 21-23 mm. For comparison, a dime is 18 mm, a nickel is 21 mm, and a quarter is 25 mm.

When the diameter of the battery is known, 94% of fatal cases or those with major outcomes involve batteries 20 mm or more in diameter. Lithium-containing batteries are more commonly associated with clinically significant outcomes than all other chemical types combined. Of ingested batteries that are 20-25 mm diameter, 99% are lithium cells.

Esophageal damage can occur in a relatively short period of time (2-2.5 h) when a disk battery is lodged in the esophagus.[1, 3]

Endoscopic view of disk battery in esophagus of a Endoscopic view of disk battery in esophagus of a child demonstrating esophageal burns.

Liquefaction necrosis may occur because sodium hydroxide is generated by the current produced by the battery (usually at the anode which is the flat surface without an imprint code or "+" sign). Perforation has occurred as rapidly as 6 hours after ingestion. The 20 mm lithium batteries are 3V cells as compared with 1.5V for other disk batteries. They have a higher capacitance and generate more current, which results in the production of more hydroxide more rapidly.[1] The most severe esophageal burns (and subsequent perforations) occur adjacent to the negative battery pole (anode). Injury can continue after endoscopic battery removal for days to weeks due to residual alkali or weakened tissues.

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Epidemiology

Frequency

United States

From 1985-2009, 56,535 disk battery ingestions were reported to the National Poison Data System.[1] See the image below.

Exposures to disk batteries reported to the Americ Exposures to disk batteries reported to the American Association of Poison Control Centers, 1986-2009.

Mortality/Morbidity

Prognosis

The usual outcome of disk battery ingestions is an uneventful passage. More than 97% of disk battery ingestions have only mild effects or none at all. See image below.

NPDS button-battery ingestion frequency and severi NPDS button-battery ingestion frequency and severity (for moderate, major, and fatal outcomes), according to year.

Morbidity/mortality

Deaths due to button battery ingestion are rare. From 1985-2009, only 13 of 56,535 reported ingestions were fatal cases (0.02%).[1] Ingestion of a disk battery was initially missed by providers in 7 (54%) of the cases due to no initial history of ingestion and nonspecific presenting symptoms such as vomiting, fever, lethargy, poor appetite, irritability, wheezing, cough, and/or dehydration. Exsanguination due to esophageal fistulae occurred in 9 cases (69%), of which 7 were aortoesophageal.

Complications in major outcome cases have included tracheoesophageal fistulas, other esophageal perforations, esophageal strictures requiring repeated dilations, vocal cord paralysis from recurrent laryngeal nerve damage, mediastinitis, pneumothorax, pneumoperitoneum, tracheal stenosis, tracheomalacia, aspiration pneumonia, empyema, lung abscess, and spondylodiscitis.[1]

The possibility of heavy metal poisoning, especially from mercury, has been considered. A typical battery may contain from 15-50% mercuric oxide, leading to possible ingestion of as much as 5 g of mercury, a potentially lethal amount. This theoretical threat of toxicity has not been borne out by clinical experience. In a series of 2382 battery ingestions, no clinical evidence of mercury toxicity was observed.[4]

A spent cell, which no longer has enough power for the intended device, may still maintain considerable residual voltage. However, new cells are 3.2 times likely to be associated with clinically significant outcomes than spent cells.[1]

Retrograde movement of the battery from the stomach to the esophagus has been reported as a complication of use of ipecac syrup, necessitating emergent endoscopic removal. If the battery produces a mucosal burn, a theoretical risk exists of battery aspiration and perforation of the esophagus or stomach.

Sex

Male predominance (59%) is observed in disk battery ingestions.

Age

Children younger than 6 years account for 61% of ingestions, with a peak incidence in those aged 1 and 3 years. All fatalities from 1985-2009 and 85% of cases with major outcomes occurred in children who were younger than 4 years old and were often nonverbal.[1]

A second peak is observed in adults older than 60 years, with 10.3% of cases occurring in patients aged 60-89 years. Elderly patients are more likely to have batteries lodged in the small or large bowels. Patients older than 79 years account for only 4.6% of ingestions; in 31% of those cases, the battery lodges in the bowels.

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Contributor Information and Disclosures
Author

Daniel J Dire, MD, FACEP, FAAP, FAAEM Clinical Professor, Department of Emergency Medicine, University of Texas Medical School at Houston; Clinical Professor, Department of Pediatrics, University of Texas Health Sciences Center San Antonio

Daniel J Dire, MD, FACEP, FAAP, FAAEM is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Pediatrics, American Academy of Emergency Medicine, American College of Emergency Physicians, Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

Specialty Editor Board

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

Additional Contributors

Steven A Conrad, MD, PhD Chief, Department of Emergency Medicine; Chief, Multidisciplinary Critical Care Service, Professor, Department of Emergency and Internal Medicine, Louisiana State University Health Sciences Center

Steven A Conrad, MD, PhD is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American College of Emergency Physicians, American College of Physicians, International Society for Heart and Lung Transplantation, Louisiana State Medical Society, Shock Society, Society for Academic Emergency Medicine, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Eugene Hardin, MD, FAAEM, FACEP Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center

Disclosure: Nothing to disclose.

References
  1. Litovitz T, Whitaker N, Clark L, White NC, Marsolek M. Emerging battery-ingestion hazard: clinical implications. Pediatrics. 2010 Jun. 125(6):1168-77. [Medline].

  2. Kuhns DW, Dire DJ. Button battery ingestions. Ann Emerg Med. 1989 Mar. 18(3):293-300. [Medline].

  3. Langkau JF, Noesges RA. Esophageal burns from battery ingestion. Am J Emerg Med. 1985 May. 3(3):265. [Medline].

  4. Litovitz T, Schmitz BF. Ingestion of cylindrical and button batteries: an analysis of 2382 cases. Pediatrics. 1992 Apr. 89(4 Pt 2):747-57. [Medline].

  5. Chan YL, Chang SS, Kao KL, Liao HC, Liaw SJ, Chiu TF, et al. Button battery ingestion: an analysis of 25 cases. Chang Gung Med J. 2002 Mar. 25(3):169-74. [Medline].

  6. Slamon NB, Hertzog JH, Penfil SH, Raphaely RC, Pizarro C, Derby CD. An unusual case of button battery-induced traumatic tracheoesophageal fistula. Pediatr Emerg Care. 2008 May. 24(5):313-6. [Medline].

  7. Bass DH, Millar AJ. Mercury absorption following button battery ingestion. J Pediatr Surg. 1992 Dec. 27(12):1541-2. [Medline].

  8. Bronstein AC, Spyker DA, Cantilena LR Jr, Green J, Rumack BH, Heard SE. 2006 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS). Clin Toxicol (Phila). 2007 Dec. 45(8):815-917. [Medline].

  9. Campbell JB, Foley LC. A safe alternative to endoscopic removal of blunt esophageal foreign bodies. Arch Otolaryngol. 1983 May. 109(5):323-5. [Medline].

  10. Gomes CC, Sakano E, Lucchezi MC, Porto PR. Button battery as a foreign body in the nasal cavities. Special aspects. Rhinology. 1994 Jun. 32(2):98-100. [Medline].

  11. Gordon AC, Gough MH. Oesophageal perforation after button battery ingestion. Ann R Coll Surg Engl. 1993 Sep. 75(5):362-4. [Medline].

  12. Lai MW, Klein-Schwartz W, Rodgers GC, Abrams JY, Haber DA, Bronstein AC. 2005 Annual Report of the American Association of Poison Control Centers' national poisoning and exposure database. Clin Toxicol (Phila). 2006. 44(6-7):803-932. [Medline].

  13. Mariani PJ, Wagner DK. Foley catheter extraction of blunt esophageal foreign bodies. J Emerg Med. 1986. 4(4):301-6. [Medline].

  14. Palmer O, Natarajan B, Johnstone A, Sheikh S. Button battery in the nose--an unusual foreign body. J Laryngol Otol. 1994 Oct. 108(10):871-2. [Medline].

  15. Sheikh A. Button battery ingestions in children. Pediatr Emerg Care. 1993 Aug. 9(4):224-9. [Medline].

  16. Tong MC, Van Hasselt CA, Woo JK. The hazards of button batteries in the nose. J Otolaryngol. 1992 Dec. 21(6):458-60. [Medline].

  17. Watson WA, Litovitz TL, Klein-Schwartz W, et al. 2003 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. 2004 Sep. 22(5):335-404. [Medline].

  18. Barabino AV, Gandullia P, Vignola S, Arrigo S, Zannini L, Di Pietro P. Lithium battery lodged in the oesophagus: A report of three paediatric cases. Dig Liver Dis. 2015 Nov. 47(11):984-6. [Medline].

  19. Panella NJ, Kirse DJ, Pranikoff T, Evans AK. Disk battery ingestion: case series with assessment of clinical and financial impact of a preventable disease. Pediatr Emerg Care. 2013 Feb. 29(2):165-9. [Medline].

 
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Cross-section of a typical disk battery.
Exposures to disk batteries reported to the American Association of Poison Control Centers, 1986-2009.
Lateral radiographic appearance of a 7.9-mm disk battery. Photographed by Daniel J. Dire, MD.
Recommended management algorithm for patients with disk battery ingestions. Notes: (1) Serum mercury levels and chelation therapy should be reserved for patients who develop signs of mercury toxicity, not simply because mercury is noted on radiograph. (2) Acute abdomen, tarry or bloody stools, fever, and persistent vomiting. (3) Disk batteries in the esophagus must be removed. Endoscopy should be used if available. The Foley catheter technique may be used if the ingestion is less than 2 hours old but not if more than 2 hours old because it may increase the damage to the weakened esophagus. (4) When the Foley technique fails or is contraindicated, the disk battery should be removed endoscopically. This may require transfer to a more comprehensive medical treatment facility.
Radiograph of child 1 week after ingestion of a disk battery. The battery has passed into the rectum. Photographed by Daniel J. Dire, MD.
Disk battery in the stomach of an 18-month-old child.
Changes in the diameter of disk battery ingestions from 1990-2008.
Changes in chemical systems of ingested disk batteries from 1990-2008.
Endoscopic view of disk battery in esophagus of a child demonstrating esophageal burns.
Endoscopic view of a nickle and penny in the esophagus of a child that was initially misdiagnosed as a disc battery.
Lateral chest radiograph of a child with a nickle and penny adhered to each other in the upper esophagus initially misdiagnosed as a disk battery.
20 mm CR 2032 Lithium Cell Disk Battery shown with a U.S. Quarter: On the left is the Cathode (positive pole) and on the right the narrower Anode (negative pole).
NPDS button-battery ingestion frequency and severity (for moderate, major, and fatal outcomes), according to year.
 
 
 
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