Disk Battery Ingestion Treatment & Management

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.

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.

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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.

Disk battery in the stomach of an 18-month-old child.

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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.

Radiograph of child 1 week after ingestion of a disk battery. The battery has passed into the rectum. Photographed by Daniel J. Dire, MD.

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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]