Poison.org from America has worry statistics showing the general risk in mortality from button battery ingestions. Many news sites have begun in 2016 to raise awareness and now even manufacturers are changing their packaging. It is almost exclusively a paediatric problem and most do well if the battery keeps travelling through the gastrointestinal system. The main concern if oesophageal erosion due to the battery lodging, this can be fatal when the presentation or the diagnosis is delayed.
The battery generates hydroxide ions at the negative pole once ingested. This accumulation of hydroxide produces a localised alkaline corrosive injury with tissue liquefactions and necrosis. Corrosive injury can develop within 2 hours of lodgement. The severity of injury is all dependent on the size of the battery, current produced, length of time it is lodged. Complications include oesophageal perforation, teacher-oesophageal fistula, aorta-oesophageal fistula and stricture formation.
- Rarely required
- Need to consider airway obstruction
- Delayed presentations may result in cardiovascular collapse from haemorrhage or sepsis and should be managed along conventional lines. Another possibility would be respiratory distress from a trachea-oesophageal fistula.
- Batteries of <20 mm are less likely to lodge in the oesophagus and cause complications.
- Batteries >20 mm can cause severe local damage within 2 hours
- Smaller batteries can also cause localised damage when placed in aural or nasal cavities
- Age is a risk factor as most fatalities occur in the under 4 year old age group
- Delayed diagnosis has a worse outcome
- A spent battery is less likely to cause as much damage but this should not alter your risk assessment as batteries can still produce a charge for a long time.
- Clinical features:
- Normally asymptomatic as a care giver has noted or suspected an ingestion and brought them to hospital.
- If unwitnessed or delayed consideration of a button battery ingestion needs to be considered if the presenting complaint is: airway obstruction, cough, fever, dysphagia, sore throat, chest discomfort, decreased oral intake, or coughing or choking with eating and drinking.
- Where oesophageal injury is established, perforations and fistulas may not be evident for up to 28 days. Strictures take weeks or months to form.
- Routine cares for the paediatric patient:
- Keep nil by mouth until a full assessment is made.
- Specific: Plain anteroposterior X-ray of the neck, chest and abdomen (need a lethal if an object is identified above the diaphragm). Do not mistake a button battery for a coin – the battery should have a “double ring” and “step off” appearance on lateral view. See radiopedia for some examples.
- If in the oesophagus the battery should be removed within 2 hours of ingestion endoscopically.
- Equally any batteries in the nose or ear requires urgent removal, expert advice maybe required form ENT.
- Battery in the oesophagus requires urgent endoscopy for removal.
- If the battery is in the stomach, the risk of complication is low, TOXBASE in the UK states that a repeat x-ray should be done in 2 days if the child is asymptomatic. If it has not moved at this stage, discuss with your upper GI surgeon or endoscopy team, most will remove the battery from the stomach if it has been there for a maximum of 4 days.
- If the battery is beyond the pylorus and the child is asymptomatic, they can be discharged and observed at home for a repeat X-ray in 10 – 14 days if the battery has not been observed in the stool (I think most parents would go for a repeat x-ray as opposed to sifting through 2 weeks worth of poo). Once the battery is beyond the pylorus it is very unlikely they will develop any complications.
- If discharging the patient give parents the advice to return if they are concerned, the child develops abdominal pain, bloody vomit or faces, problems swallowing, respiratory distress or a persistent cough.
Additional Resources and References:
- Jatana KR, Litovitz T, Reilly JS et al. Pediatric button battery injuries; 2013 task force update. International Journal of Pediatric Otorhinolaryngology 2013; 77:1392-1399
- Murray L et al. Toxicology Handbook 3rd Edition. Elsevier Australia 2015. ISBN 9780729542241
- Litovitz T. Whitaker N, Clark L et al. Emerging battery-ingestion hazard: clinical implications. Pediatrics 2010; 125: 1168-1177