Disk Battery Ingestion

Disk batteries are small, coin-shaped batteries used in watches, calculators, toys, small electronic devices, musical greeting cards, 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 fistula). 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.[1]

Fatal cases or those with major sequelae usually involve esophageal or airway battery lodgment.[2, 3]

For patient education resources, see First Aid and Injuries Center, as well as Battery Ingestion.

Disk batteries

Disk batteries are formed by compacting metals and metal oxides on either side of an electrolyte-soaked separator.[1] The unit is then placed in a 2-part metal casing held together by a plastic grommet (see the image below).

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).[2] 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.

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.[2] See the image below.

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%).[2] "CR" represents the battery chemistry, "20" is the diameter, and "32" indicates the thickness (3.2 mm) of the battery. See the image below.

Disk batteries do not usually require medical attention unless they become lodged in the digestive tract, nose, or ears. The esophagus is the most common place disk batteries become lodged, resulting in clinical sequelae. The likelihood of a disk battery lodging in the esophagus is a function of the patient's age (very young or old), esophagus and disk battery size (diameter in mm), and battery type (chemical content).

Battery size and type are the two most important predictors of a clinically significant outcome. The larger the battery, the increased likelihood of it becoming lodged and thus causing clinical issues. Although the culprit size varies (20-25 mm), a disk battery size of 20 mm is the most commonly problematic. However, disk battery diameters of 16 mm have become lodged in the esophagi of children younger than 4 years.[2] Older children generally do not have problems with disk batteries smaller than 21-23 mm. For comparison, the diameter of a dime is 18 mm, that of a nickel is 21 mm, and that of 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.[2, 4]

Batteries that successfully traverse the esophagus are unlikely to lodge at any other location. Batteries pass through the gastrointestinal 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.

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.[2] 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.

When a disk battery is in an acid environment, an electrochemical reaction occurs that leads to dissolution of the cathode, primarily in the crimp area. Not surprisingly, batteries that become lodged in the stomach corrode and fragment more frequently than other ingested batteries. Corrosion and fragmentation are most common in batteries that lodge in the stomach for more than 48 hours. Approximately 2-3% of ingested batteries fragment within the GI tract, and 10.7% demonstrate severe crimp dissolution. Mercuric oxide cells are substantially more likely to fragment than batteries of other chemical compositions.

United States data

From 1985-2017, 83,469 disk battery ingestions were reported to the National Poison Data System.[5] Clinically significant outcomes (moderate, major, or fatal) occurred in only 1.3% cases from 1985-2009.[2] The number of disk battery injuries trended upward as their use became increasingly common in household items, but has started to slowly decline. In 2017, 3,244 disk battery ingestions were reported to the National Poison Data System compared to 3,758 in 2007. However, the percentage of significant outcomes (moderate, major, and fatal) has increased from 2.6% to 4.4% in the same time period, likely owing to the increased use of lithium cells.[5, 6]

International data

Gerner at al analyzed the incidence of disk battery ingestions in children younger than 5 years in Germany from 2011 to 2016, including 258 cases reported to the Freiburg poison center and survey data collected from pediatric gastroenterologists and surgeons.[7] The battery was located in the esophagus in 116 cases; 47 children developed severe complications and 5 children died.

Krom et al conducted a retrospective survey on the incidence of significant complications of disk battery ingestions in the Netherlands from 2008 to 2016. They found 16 cases with serious and fatal outcomes, all in children younger than 5 years; 75% of the batteries were more than 20 mm.[8]

Sex- and age-related demographics

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

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.[2]

A second peak is observed in adults older than 60 years, with 10.3% of cases occurring in patients aged 60-89 years.[9] 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.

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 the image below.

Morbidity/mortality

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.[2]

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.[10]

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.[2]

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.

Deaths due to button battery ingestion are rare, but the numbers have been on the rise.[5, 7, 8, 11] From 1985 to 2009, only 13 of 56,535 reported button battery ingestions were fatal (0.02%).[2] Ingestion of a disk battery was initially missed by providers in 7 (54%) of the those 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 fistula occurred in 9 cases (69%), of which 7 were aortoesophageal.[2] From 2014 to 2017, 12 fatalities were reported in 13,094 cases (0.09%).[5]

A 2022 report of US emergency department visits from 2010-2019 for battery ingestions by children found a two-fold increase in such visits over the decade 2010-2019 compared to 1990-2009, of which 85% involved disk batteries.[12]

Occasionally, the ingestion of a disk battery is observed. More than one half of disk battery ingestions (53%) occur immediately following removal from a product.[9] Another 41% involve batteries that are loose, either sitting out or discarded. More than one battery is ingested in 8.5% of the episodes.

In 56% of the cases where a major outcome occurred in children less than 4 years old, the ingestion was unwitnessed.[2] Of these, 46% were initially misdiagnosed (including being mistaken for a coin). Most of the initially misdiagnosed cases involved failure to recognize the ingestion due to nonspecific symptoms.

Powering hearing aids is the most common intended use of the ingested batteries (44.6%). In 32.8% of the cases, the child removed the battery from his or her own hearing aid. Watch batteries account for 16% of ingestions. Other sources of disk batteries that are ingested include garage door openers, games and toys, calculators, cameras, lighted key chains, fishing bobs, flashing jewelry, musical greeting cards or books, and digital thermometers.

Most children who ingest a disk battery remain asymptomatic and pass the battery in their stool within 2-7 days.[13, 14] Only 10% of patients who ingest disk batteries report symptoms, which are predominantly minor GI problems.

Rashes following disk battery ingestion have been reported infrequently and may be a manifestation of nickel hypersensitivity, as many disk batteries are nickel-plated.

Lodging of lithium cells is associated with disproportionately more adverse effects than lodging of other types of batteries due to their larger size and increased likelihood of impaction as well as their ability to generate more current.[15] Symptoms reportedly associated with the lodging of the battery in the GI tract include the following (in order of decreasing frequency)[15] :

• Vomiting (occasionally bloody)

• Abdominal pain

• Discolored stools (eg, green)

• Fever

• Diarrhea

• Rashes

• Respiratory distress

• Others - Irritability, food refusal, dysphagia, coughing or gagging, anorexia, increased salivation (often with black flecks in the saliva), retrosternal discomfort, and abdominal pain

No physical examination findings are specific for patients who ingest disk batteries.

Children with a battery lodged in the esophagus typically present with the following:

• Refusal to take fluids

• Increased salivation (often with black flecks in the saliva)

• Dysphagia

• Vomiting

• Hematemesis occasionally

Patients may have airway compromise following disk battery ingestion.

Hematochezia or abdominal tenderness suggests GI injury, possibly due to battery rupture.

In one study, 9 of 25 patients (36%) with batteries in the esophagus were asymptomatic; therefore, do not rely on the lack of symptoms as an indicator to rule out esophageal lodgment.

Consider obtaining blood and urine mercury levels only if a mercury-containing cell has been observed to fragment in the gastrointestinal tract or if radiopaque droplets are observed in the gut on radiographs.

Radiography is indicated to confirm the ingestion and to establish the location of ingested disk batteries. Disk batteries have a relatively characteristic appearance on radiograph. When viewed from above, they appear much like a coin; however, a double density is often present. When viewed on edge, a much more rounded edge with a step off at the junction of the cathode and anode is seen (see the image below).

Batteries located in the esophagus on initial radiographs frequently (28%) pass into the stomach spontaneously.

Radiopaque droplets in the gut may be found on radiograph in patients with fragmented mercuric oxide cells.

Most batteries pass through the gastrointestinal tract in a relatively short period of time and are eliminated naturally.[14] Disk batteries that are lodged in the esophagus, ear, or nose need to be removed emergently.

If the battery is lodged in the esophagus, consider urgent endoscopic removal, as perforation can happen within 6 hours of ingestion.

Batteries that have passed the esophagus can be managed expectantly with follow-up.

Consider calling the National Button Battery Ingestion Hotline: 800-498-8666.

Surgical procedures to remove ingested batteries or to treat complications rarely are needed (< 1% of patients). Obtain consultation for possible surgical removal when the battery is beyond the reach of an endoscope in patients with occult or visible bleeding, persistent or severe abdominal pain, vomiting, signs of acute abdomen, fever, or profoundly decreased appetite (unless symptoms are unrelated to the battery).

Hospitalization for battery ingestion is infrequent (4.5%) and generally brief (< 2 d).

More than one half of ingested batteries (53%) were removed from a product before ingestion. Products need to be designed with secure battery compartments that can withstand a child's prying hands or a fall.

The recommended management algorithm for dealing with the ingestion of disk batteries is shown in the image below.

Secure the ABCs, and resuscitate the patient as necessary. Make sure the patient is not given anything by mouth.

Obtain an initial radiograph of the chest and abdomen to determine the battery location. See the image below.

Remove batteries located in the esophagus emergently because of the risk of esophageal burns and resultant complications. The procedure of choice is flexible fiberoptic endoscopy, and the goal should be to remove the battery within 2 hours of ingestion when possible.

In very rare situations when an endoscopist is not available within 2 hours, the battery is in the upper third of the esophagus, and the history of ingestion less than 2 hours earlier is reliable, consider attempting the Foley balloon catheter technique for removal as follows:

• A Foley catheter (10-16 French) is passed orally, as the patient sits upright on the fluoroscopy table. Some sedation may be required for small children.

• After the Foley catheter is inserted, place the patient in the lateral decubitus or Trendelenburg position, and fluoroscopically confirm the distal catheter tip position by introducing contrast into the balloon. Slowly inflate the balloon with 3-5 mL, and slowly withdraw the catheter under fluoroscopic guidance.

• With the operator's thumb on the syringe plunger, the syringe remains in contact with the balloon. Filling adjustments can be made as the operator senses subtle pressure changes in the balloon as the catheter is withdrawn.

• Use constant, moderate traction to withdraw the balloon, while avoiding hesitation at the hypopharynx; there the balloon meets and pushes the battery into the oral pharynx, where it can be removed with McGill forceps or expelled by the patient.

• When the battery is successfully removed by this technique, the patient should still undergo endoscopy for direct visualization for esophageal injury.

Batteries localized beyond the esophagus rarely need to be retrieved unless the patient manifests signs or symptoms of gastrointestinal (GI) tract injury (eg, hematochezia, abdominal pain, tenderness) or a large-diameter battery fails to pass beyond the pylorus. Some experts suggest that any delay in GI transit (distal to the pylorus) longer than 8 hours mandates some form of intervention because of the potential for erosive/corrosive complications.

Do not give ipecac to patients with disk batteries located in the stomach. Instances have been reported of patients who were given ipecac that resulted in the battery becoming lodged in the esophagus by retrograde movement during emesis. Emergent endoscopic removal was required.

Confirm battery passage by daily inspections of all stools. Weekly radiographs are recommended to confirm battery passage and to observe for battery fragmentation (see the image below). This is particularly important with the 15.6-mm mercuric oxide cell because of its greater likelihood of splitting in the GI tract.

Patients younger than 6 years who have ingested a battery with a diameter of 15 mm or more should have a repeat radiograph in 4 days if the battery was originally in the stomach to determine that the battery has moved passed the pylorus. Endoscopic retrieval is recommended for gastric batteries that remain in the stomach for 4 days. Obviously, any patient with GI symptoms should have stomach batteries removed earlier because gastric ulcerations or sequelae from undetected previous esophageal lodgment may present.

Endoscopic removal is indicated for any disk battery in the stomach when a magnet was co-ingested.

Chelation therapy is not necessary in asymptomatic patients unless toxic mercury levels are documented.

Whole-bowel irrigation, colonic enemas, and cathartics all have been used successfully to evacuate disk batteries situated below the pylorus in pediatric ingestions. Although no controlled studies of these modalities have been reported, they should be considered for situations in which delayed transit (below the level of the pylorus) is documented.

Transfer

Transfer patients with disk batteries lodged in the esophagus to a medical treatment facility capable of performing endoscopic procedures.

The need for endoscopic retrieval is a function of battery size. Of batteries that are larger than 15 mm in diameter, 25% require endoscopic retrieval, whereas only 2.8% of smaller batteries require endoscopic retrieval. Endoscopy is successful in 90% of patients with batteries located in the esophagus. One animal study demonstrated that the Roth net was the optimal device for endoscopic retrieval of disk batteries in the stomach.

Pugmire et al conducted a comprehensive, imaging-focused review of all patients with confirmed button battery ingestions/insertions imaged at their institution in the past 15 years (N=276). Batteries retained in the esophagus were, on average, larger in diameter than batteries that had passed distally. The review showed that battery diameter ≥20 mm was associated with esophageal impaction (P< 0.0001) and higher-grade esophageal injury (P< 0.0001), leading the investigators to conclude that button batteries with a diameter larger than 20 mm warrant increased clinical scrutiny.[16]

In a study of children who had ingested foreign bodies, Lee et al found evidence that the type and voltage of a button battery should be considered when determining whether endoscopy is necessary to remove it from the stomach. For button battery ingestion, investigators found that all 5 cases with lithium battery (≥1.5 cm, 3 V) ingestion presented moderate to major complications in the esophagus and stomach without any symptoms, but that the 7 cases with alkaline battery (< 1.5 cm, 1.5 V) ingestion did not present any complications. The investigators concluded that for lithium battery ingestion in young children, urgent endoscopic removal might be important to prevent complications, even if the battery is smaller than 2 cm and the child is asymptomatic.[17]