ถ้าพิจารณาตามแนวทางของราชวิทยาลัยศัลยแพทย์แห่งประเทศไทยทางกุมารศัลยศาสตร์ แนะนำให้ส่องกล้องเอาออกไม่แนะนำให้รอสังเกตอาการแม้ว่าจะอยู่ในกระเพาะอาหารแล้วเป็นข้อยกเว้นพิเศษ ไม่เหมือนกรณีกลืนเหรียญ ถ้าดูตำราภาวะฉุกเฉินที่เขียนใหม่ขึ้นมาก็จะแนะนำว่าถ้าลงมาอยู่ในกระเพาะอาหาร 48 ชั่วโมงแล้วยังไม่ไปไหนก็ต้องส่องกล้องเอาออก นั่นคือเปลี่ยนจากส่องกล้องทันทีเป็นรอได้ 48 ชั่วโมง ถ้าไม่มีอาการใด ๆ มาดูreview ล่าสุดใน UpToDate เมื่อ 3 มีนาคม พ.ศ.2560 กรณีที่ button battery อันเดียว อยู่ในกระเพาะอาหาร โดยผู้ป่วยไม่มีอาการใด ๆ มีคำแนะนำจาก 2 สถาบัน ที่มีข้อแตกต่างกันอยู่ โดยไม่สามารถบอกได้ว่าของใครดีกว่า (เน้นว่ากรณีที่มันอยู่ในกระเพาะอาหารแล้วนะครับ ถ้าอยู่ในหลอดอาหารยังต้องรีบเอาออก )

ทั้งสองสถาบันกล่าวไว้ดังนี้

The national battery ingestion hotline(NBIH)

• • ผู้ป่วยที่ไม่มีอาการแสดงใด ๆ ว่ามีการบาดเจ็บหรืออุดตันของระบบทางเดินอาหาร ไม่จำเป็นต้องไปส่องกล้องเอาออก และแนะนำว่ากลับไปใช้ชีวิตตามปกติที่บ้านได้

  • แนะนำกลับมาพบแพทย์เพื่อ x-ray ดังนี้

    • มีอาการเช่นปวดท้อง มีไข้ คลื่นไส้ อาเจียน เป็นต้น

    • ถ้าอายุน้อยกว่า 6 ปี และกลืน battery ที่มีขนาดตั้งแต่ 15 มิลลิเมตรขึ้นไป 4 วันหลังจากกินแล้วยังไม่ขี้ออกมา

    • ถ้าหนึ่งสัปดาห์แล้วยังไม่ถ่ายออกมาให้เห็นก็มาดู และนัดถ่าย x-rayดูทุกสัปดาห์ ถ้ายังไม่ออกมา

  • จะต้องไปส่องกล้อง หรือผ่าตัดเพื่อเอาออกในกรณีที่

    • ผู้ป่วยมีอาการแสดงของการบาดเจ็บต่อระบบทางเดินอาหาร

    • Battery ยังอยู่ในกระเพาะอาหาร มากกว่า 4 วันขึ้นไป และมีแนวโน้มว่าจะไม่สามารถออกจากกระเพาะอาหารได้เพราะมีขนาดใหญ่(เช่นขนาดตั้งแต่ 15 มิลลิเมตรขึ้นไป ในเด็กอายุน้อยกว่า 6 ปี)

The North American Society for Pediatric Gastroenterology,Hepatology,and Nutrition Endoscopy Committee(NASPGHAN)

• • ถึงแม้ไม่มีอาการแสดงใด ๆ ก็ควรไปส่องกล้องเอาออกภายใน 48 ชั่วโมง ในเด็กที่อายุน้อยกว่า 5 ปี และกิน battery ที่มีขนาดตั้งแต่ 20 มิลลิเมตรขึ้นไป เหตุผลหลักคือเพื่อ exclude concomitant esophageal injury (โอกาสสูงที่จะมี esophageal injury ร่วมและต้องการ management ต่างจากกรณีทั่วไป delayed diagnosis อาจถึงตายได้)

  • อายุตั้งแต่ 5 ปีขึ้นไป และกิน battery ที่มีขนาดตั้งแต่ 20 มิลลิเมตรขึ้นไป ให้มา x-ray ดูที่ 48 ชั่วโมง ถ้ายังอยู่ในกระเพาะอาหารแนะนำให้ส่องกล้องเอาออก

  • ถ้ากิน battery ขนาดเล็กกว่า 20 มิลลิเมตร ไม่ว่าอายุเท่าใด ถ้าไม่มีอาการอะไรเลย แนะนำ x-ray ที่ 10-14 วัน ถ้ายังไม่ถ่ายออกมา และถ้า 10-14 วันแล้วยังอยู่ในกระเพาะอาหารก็แนะนำให้ส่องกล้องเอาออก

UpToDate 2017 สรุปว่า

• • ถ้าไม่มีอาการใดๆและอายุมากกว่า 12 ปีขึ้นไป กิน battery ขนาดไม่เกิน 12 มิลลิเมตรเพียงก้อนเดียว โดยไม่ได้กินแม่เหล็กร่วมด้วย สามารถกลับไปสังเกตอาการที่บ้านได้โดยไม่ต้องทำอะไร ไม่ต้อง x-ray ถ้าผู้ปกครองสามารถเอาใจใส่ดูแลเด็กและพามาพบแพทย์เมื่อเกิดอาการ จะพิจารณา x-rayดู เมื่อผ่านไป 10-14 วันแล้ว ยังไม่มี battery ถ่ายออกมาให้เห็น

  • ถ้าค้างอยู่ในหลอดอาหารแม้ยังไม่มีอาการก็ต้องส่องกล้องเอาออกโดยด่วน(Emergent removal)

  • Battery ที่ค้างในกระเพาะอาหาร ถ้าทำให้เกิดอาการแม้เพียงเล็กน้อย ก็ควรรีบส่องกล้องเอาออก(Emergent endoscopy)

  • กรณีต่อไปนี้แนะนำให้ปรึกษา gastroenterologist

    • เด็กอายุน้อยกว่า 5 ปี แม้ไม่มีอาการใดๆ ถ้าพบ battery ขนาดตั้งแต่ 20 มิลลิเมตร อยู่ที่กระเพาะอาหาร

    • เด็กอายุตั้งแต่ 5 ปี ขึ้นไปแม้ไม่มีอาการใดๆ ถ้าพบว่า button battery ยังอยู่ในกระเพาะอาหารตั้งแต่ 48 ชั่วโมงขึ้นไป

ตัวอย่าง

เด็กชายอายุ 8 ปี มารดาให้ประวัติว่าเล่นมายากลกับเพื่อน แล้ว Battery พลาดหลุดกลืนลงท้อง เมื่อ 1 ชั่วโมงก่อนมารพ. มารดานำตัวอย่างมาให้ดูเป็น button battery รหัส CR 2032 ถ้าพิจารณาตาม guideline ต้องทำอย่างไร ผู้ป่วยดูสบายดี ไม่มีอาการใด ๆ

คำถาม ต้องส่ง x-ray หรือไม่

ตอบ แนะนำส่ง x-ray ใน

• เด็กทุกคนที่อายุน้อยกว่า 12 ปี ซึ่งกิน button battery

• ผู้ป่วยทุกคนที่กิน button battery ขนาดตั้งแต่ 12 มิลลิเมตรขึ้นไป

• ผู้ป่วยทุกคนที่กิน button battery แต่ไม่ทราบขนาด

ผู้ป่วยรายนี้เข้าเกณฑ์หัวข้อแรกคืออายุเพียง 8 ปี และเข้าหัวข้อที่สองเพราะตัวเลขสองตัวแรกของรหัสจะบอกเส้นผ่าศูนย์กลางของbattery ในกรณีนี้คือ 20 มิลลิเมตร ดังนั้นรายนี้ควร x-ray

คำถาม เมื่อ x-ray พบว่า button battery อยู่ในตำแหน่งกระเพาะอาหารแล้ว โดยยังไม่มีอาการใดๆ จะทำอย่างไรต่อ?

ตอบ ถ้าเชื่อตาม NBIH รายนี้แนะนำให้กลับไปใช้ชีวิตตามปกติ

กลับมาพบแพทย์เมื่อมีอาการ หรือผ่านไป 1 สัปดาห์แล้วยังไม่ถ่ายออกมาให้เห็นก็มา x-ray ติดตาม ถ้ายังอยู่ในกระเพาะอาหาร ก็ควรพิจารณาส่องกล้องเอาออก

ถ้าเชื่อตามNASPGHAN ก็จะนัดมา x-ray ดูที่ 48 ชั่วโมง ถ้ายังอยู่ในกระเพาะอาหาร ก็ควรส่องกล้องเอาออก

ทั้งสองแนวทางนี้ยังไม่มีหลักฐานสนับสนุนว่าของใครดีกว่ากันครับ

Authors:Kelly Sinclair, MDIvor D Hill, MDSection Editors:Michele M Burns, MD, MPHMelvin B Heyman, MD, MPHDeputy Editor:James F Wiley, II, MD, MPH

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Mar 2017. | This topic last updated: Mar 03, 2017.

INTRODUCTION — The evaluation and management of button and cylindrical battery ingestion will be presented here.

The management of button batteries in the ear or nose, esophageal foreign bodies other than button batteries, and corrosive esophageal injury are discussed separately as follows:

●(See "Diagnosis and management of foreign bodies of the outer ear", section on 'Foreign bodies of the external auditory canal (EAC)'.)

●(See "Diagnosis and management of intranasal foreign bodies", section on 'Foreign body removal'.)

●(See "Foreign bodies of the esophagus and gastrointestinal tract in children" and "Ingested foreign bodies and food impactions in adults".)

●(See "Caustic esophageal injury in children" and "Caustic esophageal injury in adults".)

BUTTON BATTERY INGESTION

Epidemiology — The National Battery Ingestion Hotline (NBIH) was created in 1982 and collects data, provides consultation, and promulgates recommendations for battery ingestions [1]. Up to 15 battery ingestion cases per one million people occur each year in the United States [2]. The incidence has increased with expanded use of button batteries in household and recreational products [1-8].

From 2007 to 2009, serious sequelae (eg, esophageal burn, perforation, or fistula) occurred in 2.7 percent of all button battery ingestions reported to the National Poison Data System, which compiles all calls to United States regional poison control centers [2]. Ingestion of large diameter (≥20 mm) lithium cell batteries was strongly associated with these major outcomes and death. (See 'Complications' below.)

Battery ingestion has been described in several retrospective case series [1,3-5,9]. The largest series, from the NBIH, describes 8648 battery ingestions, 94 percent of which involved button batteries and 6 percent of which involved cylindrical batteries (eg, AA, AAA, C, N) [9].

In this series, battery ingestions had the following characteristics:

●The majority of ingestions occurred in children younger than six years of age, with the peak frequency between one and two years of age.

●Among children, over half of the batteries were ingested immediately after removal from a product.

●Ingested batteries were obtained from a variety of devices including (in decreasing order of frequency) hearing aids, games and toys, watches, calculators, lighting devices (eg, flashlights, light/laser pointer, penlight), and remote control devices (eg, television, garage door, key fob).

●By 2008, 18 percent of ingested batteries were ≥20 mm, and most of these large diameter batteries were lithium cells. (See 'Battery description' below.)

●Patients with hearing aid battery ingestions were the user of the hearing aid in a large majority of cases.

●In a significant number of ingestions, the hearing aid battery was mistaken for a pill. A common scenario involved storage of hearing aid batteries near medications. In some instances, the patient swallowed the battery and then realized their mistake when they tried to put their pill into the hearing aid and found it did not fit.

●Other reasons for ingestion included placement on the tongue to "test" the battery, holding the battery in the mouth, and suicidal intent.

These findings suggest that parents and users of hearing aids should be made aware of the danger of button battery ingestion. In addition, measures by the manufacturer to secure the battery compartment of devices using button batteries could prevent over half of pediatric button battery ingestions. (See 'Prevention' below.)

Battery description — Between 30 and 60 percent of each battery contains inert components [4]. The active portion of the battery consists of a negative terminal and a positive terminal (figure 1) [10]. The negative terminal of the battery is typically made of zinc or lithium, and the positive terminal of one of the following substances [2,4]:

●Lithium manganese (3 volts, most common)

●Manganese dioxide (1.5 volts)

●Oxygen (zinc-air cells, 1.5 volts)

●Silver oxide (1.5 volts)

●Mercuric oxide (1.5 volts)

The negative terminal is the narrow portion of the battery where the electric current flows into the tissue and usually creates the most damage.

The negative and positive terminals are typically separated by a disc that is embedded with potassium hydroxide, sodium hydroxide, or an organic solution with varying concentrations [11]. The terminals and salt solution are encased in steel and/or nickel (figure 1).

Battery identification — Button batteries range in diameter from 6 to 25 mm, a range that closely approximates that of pills. Lithium batteries are preferred by manufacturers because they maintain a longer charge, provide a higher voltage, and are lighter than other cell types [12]. Batteries that are larger than 12 mm in diameter are most likely to become lodged in the esophagus, especially in young children.

The chemical content, diameter, and height of the battery can be determined from the imprinted code found on the battery case as determined by the International Electrotechnical Commission [13]. The first letter gives the chemical identification of the positive terminal as follows:

●L: Manganese dioxide

●S: Silver oxide

●P: Oxygen

●C: Manganese dioxide

●B: Carbon monofluoride

●G: Copper oxide

●LR (or AG): Alkaline

●SR: Silver oxide

●CR: Lithium/manganese dioxide

●BR: Lithium carbon monofluoride

A battery with a three number code has the diameter given by the first number (eg, SR516 is 5 mm in diameter).

A battery with a four number code has the diameter given by the first two numbers (eg, CR2032 is 20 mm in diameter).

The last two numbers give the battery height in tenths of millimeters (eg, CR2032 is 3.2 mm in height).

The package code also corresponds to the battery diameter in millimeters. For example, a battery with a package code of 23 has a diameter of 23 mm.

The type of device from which the battery was removed or for which it was intended may also help in identification as indicated below [10]:

●Calculator – HgO, AgO

●Camera – HgO, MnO2

●Computer game – HgO, AgO

●Hearing aid – HgO, AgO, zinc-air

●Watch – AgO, HgO, MnO2, lithium

●Remote control – Lithium

Pathogenesis — Button batteries that become lodged in the mucosa of the gastrointestinal (GI) tract cause caustic injury, mucosal ulceration, and, if impacted long enough, perforation. Although injury may occur at any site, the esophagus is most prone to impaction. The severity of esophageal damage after button battery ingestion depends upon the length of time that the battery is lodged in place, the amount of electrical charge remaining, and the size of the battery [14-16]. Damage to the esophagus may be seen as early as two hours after ingestion, with more severe damage after 8 to 12 hours [4,14,17]. As the duration of impaction increases, the mucosa becomes edematous and the battery adheres tightly to the mucosa. If the battery remains in place, ulceration and perforation can occur [16,18].

Electrical discharge appears to be the most prominent mechanism for mucosal injury after button battery ingestion in most clinically significant cases. Mechanisms of injury from battery ingestion include electrical discharge, pressure necrosis, and leakage of battery contents [2,4,5], each of which contribute to corrosive damage when the battery is in contact with a mucosal surface for a sufficient period of time as follows:

●Electrical discharge – The flow of electric current from the battery through the surrounding tissue occurs near the negative pole and can cause local hydrolysis, hydroxide accumulation, and corrosive tissue injury [3,14,18-20]. Discharged batteries still retain enough voltage and storage capability to generate an external current. Thus, ingestion of "dead" button batteries is still a major concern.

The corrosive injury caused by electrical discharge cannot be differentiated from that caused by leakage of battery contents. However, this mechanism appears of primary importance for the following reasons:

•In an in vitro study, after less than one minute, the electric discharge from a battery generated enough sodium hydroxide at and near the anode to raise the pH to 11 [19].

•Several case reports describe increased severity of mucosal injury near the negative pole of batteries removed from the esophagus [19].

•Major complications (eg, esophageal burns, fistula, or perforation) and deaths are associated with lithium batteries which contain higher voltage (3 volts) and capacitance than most other button batteries [2]. (See 'Battery description' above.)

•Among patients who ingested large (≥20 mm in diameter) button batteries, clinically significant esophageal injury was significantly associated with new batteries [2].

•Significant esophageal mucosal injury has been documented in patients with intact batteries lodged for less than two hours, an insufficient amount of time for pressure necrosis [2].

●Leakage of contents – In an acidic environment such as the stomach, the seal or crimp of the battery may erode, potentially releasing chemical contents, including sodium or potassium hydroxide [17,21,22]. In vitro experiments and examination of ingested batteries after passage through the gastrointestinal (GI) tract provide information about the likelihood of dissolution of the battery seal [1,22].

•In the large series of cases from the NBIH, 1809 batteries were available for examination after transit through the GI tract [2]. Two percent of the batteries fragmented within the GI tract and 13 percent had severe crimp dissolution or extensive perforations. Severe outcomes were significantly more likely in patients with severe crimp dissolution or battery fragmentation (4 versus 1 percent).

•In an in vitro experiment, button batteries were placed into a 0.1 N hydrochloric acid solution to mimic the pH of the stomach [22]. The percent erosion of the crimp seal after 24 hours was directly related to the amount of charge remaining in the battery, with complete crimp dissolution in fully charged cells, 50 to 60 percent dissolution in 50 percent discharged cells, 10 to 20 percent dissolution in 75 percent discharged cells, and only minor pitting in the fully discharged cells [22].

●Alkaline solutions – As the alkaline solutions (potassium and/or sodium hydroxide) react with the exposed proteins on the mucosal surface of the GI tract, they may cause liquefaction necrosis and saponification of lipid membranes [23]. (See "Caustic esophageal injury in children".)

The dissolution process is slowed somewhat when the battery enters the intestines, where the pH is higher than in the stomach [3].

●Heavy metals – Absorption of heavy metals from broken or fragmented batteries is another potential mechanism of injury. However, cases of heavy metal poisoning from disc battery ingestion are quite rare. In one case, a five-year-old boy's serum lithium concentration peaked at 0.7 mEq/L after swallowing a button battery [24].

Mercury batteries are the most concerning in this regard because they are the most likely to fragment [1], and because of the potential severity of mercury poisoning. However, mercury toxicity from battery ingestions is extremely rare. There are several case reports describing elevated serum or urine levels of mercury after battery ingestion with radiologic evidence of battery fragmentation and radiopaque droplets in the intestines [1,3,4,17,25-28]. However, none of the involved patients had clinical signs or symptoms of mercury toxicity. In the one possible case where symptoms of mercury poisoning (malaise and lethargy) were present, mercury levels were not obtained [29].

The absence of symptomatic cases of mercury poisoning among battery ingestion victims is thought to be related to the conversion of mercuric oxide to the less easily absorbed elemental mercury in the presence of soluble iron (released from the corrosion of the steel casing), according to the following reactions [30]:

HgO + 2HCl –> HgCl2 + H2O

HgCl2 + Fe –> FeCl2 + Hg

●Pressure necrosis – When an ingested foreign body, such as a button battery, lodges at a single site, it can place pressure on the surrounding tissue and cause irritation, inflammation, and ischemia. This series of events may lead to tissue necrosis [5,23,31]. The magnitude of the contribution of pressure necrosis to the overall mucosal damage in patients after button battery ingestions is less certain [3,4].

Clinical features

History — In most instances, battery ingestions are witnessed or the child tells the caregiver about the ingestion. The clinician should obtain the following information:

●Battery type – The battery type may be known by the patient or caregiver, available from the code on an identical battery, or determined based upon descriptions of the battery or the device it operates [32]. (See 'Battery identification' above.)

Most large diameter (≥20 mm) batteries are lithium cells and are associated with the most severe sequelae, including death [2]. For comparison, a dime is 18 mm, a nickel 21 mm, and a quarter 24 mm in diameter [2,25]. (See 'Complications' below.)

●Battery charge state – The charge state of the battery is important because new batteries are associated with a greater potential for tissue damage if they are ≥20 mm in diameter [2]. However, "dead" batteries still have significant potential for tissue damage. (See 'Pathogenesis' above.)

●Time of ingestion – The time elapsed since ingestion can indicate the severity of damage, particularly when it exceeds two to four hours.

●Number of batteries ingested – Ingestion of multiple button batteries is associated with more severe clinically significant outcomes [2].

●Magnet coingestion – Although rare, ingestion of a button battery and a magnet may lead to bowel necrosis and perforation should the intestinal wall be trapped between the battery and the magnet [2,33].

●History of esophageal anomaly, stricture, or surgery – These patients are at greater risk for esophageal impaction after button battery ingestion. Furthermore, the site of impaction may differ from what is seen in patients with normal anatomy (figure 2).

Signs and symptoms — Most patients are asymptomatic although one or more of the following symptoms may be present [1-4,10]:

●Chest pain

●Cough

●Anorexia

●Nausea/vomiting

●Hematemesis

●Diarrhea

●Epigastric pain

●Abdominal pain

●Fever

Many of these symptoms are caused by the battery's lodging within the esophagus, where it can cause corrosive tissue damage. (See "Foreign bodies of the esophagus and gastrointestinal tract in children".)

Additional clinical features include dysphagia, drooling, and black flecks in the saliva [25].

Symptoms of esophageal perforation or tracheo-esophageal fistula in children with button battery ingestion include hematemesis, drooling, refusal of oral intake, and/or respiratory distress [34]. Physical findings in these patients can include:

●Fever

●Hemorrhagic shock with pallor, tachycardia, and hypotension

●Subcutaneous emphysema with crepitus

●Tension pneumothorax with tracheal deviation, decreased chest wall excursion, hyperresonance on the side of the pneumothorax, distended neck veins, tachycardia, and/or hypotension [35]

The clinician should also maintain a high level of suspicion for an esophageal button battery or other foreign body, despite a negative history of ingestion, in young children who are refusing oral intake. In a case series of 13 deaths after button battery ingestion, misdiagnosis occurred in seven patients because of a lack of ingestion history combined with nonspecific presenting symptoms, such as fever, vomiting, lethargy, poor appetite, irritability, cough, wheezing, and/or dehydration [2].

Diagnosis — Most patients or caretakers provide a history of button battery ingestion at initial evaluation and many patients are asymptomatic. However, especially in young children, ingestion should be included in the differential diagnosis of patients with abrupt onset of any one of the following symptoms [2,36] (see 'Clinical features' above):

●Airway obstruction

●Wheezing (without typical prodrome of viral illness or history of atopy)

●Stridor (without typical prodrome of viral croup)

●Drooling

●Chest pain

●Difficulty swallowing

●Symptoms (eg, coughing, choking, or gagging) with oral intake

●Refusal of oral intake

●Abdominal pain

Demonstration of the battery on plain radiographs confirms ingestion. Radiographic location also determines appropriate management. The radiographs should cover the area from the nasopharynx to the anus. (See 'Radiographic localization' below.)

Management — The National Battery Ingestion Hotline (NBIH) (202-625-3333, telecommunication device for the deaf [TDD] 202-362-8563) or a Poison Control Center is available to provide guidance for the management of patients with button battery ingestions. If available, the clinician should try to determine the battery identification code, which is typically located on the package or on a matching battery. (See 'Additional resources' below.)

Approach — As with all acute ingestions, stabilization of the cardiorespiratory status is the first priority. However, most patients with button battery ingestion are asymptomatic or present in stable condition, and localization of the battery is typically the first step. All patients with suspected button batteries should have no oral intake during evaluation.

Guidelines developed by the National Battery Ingestion Hotline (NBIH) and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Endoscopy Committee (NASPGHAN) provide the basis for the approach to button battery ingestion. The NBIH guideline is available at its website. The NASPGHAN guideline is found in the reference [12].

These guidelines are largely consistent with respect to recommendations for timely radiographic localization and emergent endoscopic removal of esophageal button batteries and emergent endoscopic or surgical removal of button batteries, regardless of location, in symptomatic patients.

Important differences between the NASPGHAN and NBIH guidelines do exist for management of asymptomatic young children with button batteries in the stomach as summarized below. (See 'Gastric location'below.)

Radiographic localization — We recommend emergent evaluation and plain radiography after ingestion of a button battery for patients who meet any one of the following criteria [2,37]:

●All children ≤12 years of age

●All patients who have ingested a button battery that is ≥12 mm in diameter

●All patients for whom the diameter of the battery is not known

Because approximately 10 percent of cases involve ingestion of multiple items, the radiographs should cover the area from the nasopharynx to the anus [15,18].

In asymptomatic, healthy patients older than 12 years of age with confirmed ingestion of a solitary, small (≤12 mm in diameter) battery and without coingestion of a magnet, radiography may be deferred [2,37]. These patients may undergo observation for battery passage at home without initial radiographs as long as the patient or caregiver is reliable and able to promptly seek treatment should symptoms develop. Radiographic localization is warranted if battery passage is not confirmed in 10 to 14 days.

Important radiographic features of button batteries that have lodged in the esophagus include:

●Anatomic site of impaction – In otherwise healthy patients, esophageal foreign bodies tend to lodge in areas of physiologic narrowing, such as the cricopharyngeus muscle (upper esophageal sphincter), the level of the aortic arch, and the lower esophageal sphincter (figure 2). Patients with a history of esophageal anomalies, strictures, esophagitis (particularly eosinophilic esophagitis), or surgery may have impactions at sites that do not correspond to physiologic narrowing. (See "Foreign bodies of the esophagus and gastrointestinal tract in children".)

●Differentiating a button battery from a coin – Patients with button battery ingestions usually present with a chief complaint of button battery ingestion. When the ingestion is an incidental finding on plain radiograph, it may be difficult to differentiate between a button battery and a coin. This distinction is essential to proper management, especially when the foreign body is in the esophagus, because batteries require emergent removal whereas coins may or may not. (See "Foreign bodies of the esophagus and gastrointestinal tract in children", section on 'Coins'.)

The characteristic features of button batteries versus coins are as follows:

•Button batteries have a bilaminar structure, making them appear as a double-ring or halo on plain radiographs. The double-ring shadow helps to differentiate battery from coin ingestions (image 1).

•On lateral view of the foreign body, the button battery has a step-off at the separation between the anode and cathode (image 2) [38]. By contrast, the coin has a sharp, crisp edge (image 2).

Enlargement of the radiograph may help to demonstrate these differences when interpreting the image. Misidentifying the foreign body as a coin when it is actually a battery can have significant adverse consequences. As an example, an 11-month-old infant incurred bilateral vocal cord paralysis when a button battery was misread as a coin on plain radiographs; she remained intubated for six days [39].

●Estimation of battery size – Although size of an object cannot be reliably predicted based upon radiographs, objects greater than 50 mm in length or 20 mm in diameter are less likely to pass into the stomach [40].

●Findings of esophageal perforation – Although rarely seen in children with esophageal button battery impaction, findings suggestive of an esophageal perforation on chest radiograph include mediastinal or free peritoneal air or subcutaneous emphysema. With cervical esophageal perforations, plain films of the neck may show air in the soft tissues of the prevertebral space. Other findings suggestive of an esophageal perforation include pleural effusions, mediastinal widening, hydrothorax, hydropneumothorax, or subdiaphragmatic air. However, plain radiographs are an insensitive means for establishing the presence of esophageal perforation [35].

Esophageal impaction — We recommend that patients with button batteries that are lodged in the esophagus undergo emergent removal with direct endoscopic visualization by an appropriate specialist (eg, in children, a pediatric gastroenterologist, otolaryngologist, or surgeon). These patients should receive nothing by mouth until the battery is removed. General anesthesia with endotracheal intubation usually is recommended to protect the airway during performance of this procedure.

Airway compromise from esophageal edema has been reported as early as three hours post-ingestion, and esophageal injury has occurred in patients with a battery lodged for less than two hours [3,14,25]. Thus, every effort should be made to expedite removal once esophageal impaction has been identified.

The determination of which specialist to perform button battery removal depends upon the presence and type of symptoms as follows:

●Asymptomatic – In asymptomatic patients, removal by any of the above specialists is reasonable and the choice should be based upon who can accomplish removal in the timeliest fashion. In many institutions, specific guidelines determine which specialty manages esophageal foreign bodies based upon a variety of factors including anatomic location and provider expertise.

●Symptomatic with no bleeding – Symptomatic patients without hematemesis have a higher likelihood of esophageal perforation with complications and warrant involvement of a pediatric surgeon. Patients with symptoms of upper airway compromise (eg, drooling, stridor, or respiratory distress) also warrant consultation with an otolaryngologist who can assess and address any airway damage.

●Symptomatic with bleeding – Patients with hematemesis require stabilization and battery removal in conjunction with a surgeon with cardiothoracic expertise as follows [12,41]:

•Patients with a low-volume sentinel bleed in association with an impacted esophageal button battery warrant rapid hemodynamic stabilization and emergent removal in the operating room with surgeons present and prepared to perform a thoracotomy.

•Patients with active bleeding warrant endotracheal intubation, hemodynamic stabilization, and emergent thoracotomy by a surgeon with cardiothoracic expertise in the operating room. Placement of a Sengstaken-Blakemore tube designed to tamponade esophageal sites of bleeding may be a temporizing measure if the tube and clinicians knowledgeable with its use are available.

The disposition after button battery removal is based upon mucosal findings as follows:

●Normal – Patients with normal esophageal mucosa may be discharged home from the post-operative care area.

●Esophageal caustic injury – Based upon expert consensus, hospitalization is warranted in patients with any esophageal injury [2,12]. Additional specialty guidance for ongoing management of these patients is provided in the reference [12]. Esophageal perforation and tracheoesophageal fistula (TEF) with erosion into the aorta or other arteries are rare complications, described in case reports and case series [41-44]. Although these injuries are not necessarily apparent at the time of endoscopy, they have occurred in children with moderate to severe esophageal injury at the time of battery removal. Fatal complications have been described 1 to 18 days after battery removal. (See 'Complications' below.)

Patients with severe injury (grade 2B or 3 [deep ulcers or necrosis]) warrant evaluation for stricture formation. The typical approach is to perform a barium esophagogram four to six weeks after the ingestion or sooner if the patient develops dysphagia (difficulty swallowing). Patients with mild to moderate injury are also at risk for stricture formation and warrant repeat clinical evaluation and imaging if symptoms develop. The peak incidence of dysphagia after corrosive esophageal injury is two months, although it can occur as early as two weeks or as late as years after ingestion. (See "Caustic esophageal injury in children", section on 'Stricture formation' and "Caustic esophageal injury in adults", section on 'Esophageal strictures'.)

Before endoscopy became a standard technique for removal of esophageal batteries, other techniques were used with some regularity. The two most common were Foley catheter removal [4] and retrieval of the battery via insertion of an orogastric tube with a magnet attached to the distal end [45-47]. However, such "blind" techniques do not permit evaluation of the esophageal mucosa surrounding the battery, and may have increased risk for airway compromise, emesis, lodging of the battery in the esophagus, and esophageal perforation compared to endoscopy. These techniques are not recommended [2-4,18,31,48].

Gastric location — Based upon one large prospective study and expert consensus, patients who have a button battery localized to the stomach and signs or symptoms of esophageal or gastric injury at initial presentation, even if minor, warrant emergent endoscopy and removal [2,12,37]. (See 'Signs and symptoms'above.)

As discussed below, two guidelines, the National Battery Ingestion Hotline (NBIH) and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Endoscopy Committee (NASPGHAN), address the approach to asymptomatic patients with a button battery in the stomach and have important differences [2,12]. There is no evidence to indicate that one guideline provides better clinical outcomes than the other.

Because these guidelines differ, we advise consultation with a gastroenterologist for the following situations:

●Any asymptomatic child younger than five years of age who has ingested a button battery ≥20 mm. Consultation should occur at initial presentation and involve a pediatric gastroenterologist.

●Any asymptomatic patient five years of age or older in whom the battery remains in the stomach on follow-up radiograph at 48 hours or longer after ingestion.

The induction of emesis with syrup of ipecac is not recommended for patients with batteries in the stomach because batteries are dense and unlikely to be expelled. In one case series, emetics were administered to 57 patients, but resulted in successful removal of the battery in only four [1]. In addition, induced emesis may cause the battery to lodge in the esophagus.

Indications for endoscopic removal and follow-up of patients with gastric button batteries are summarized by guideline as follows:

●NBIH guidelines – The NBIH guidelines suggest the following approach based upon a large prospective observational experience [1,2,37]:

•Patients with no signs of serious gastrointestinal injury or obstruction should not undergo endoscopy and should be managed at home with a normal diet and activity.

•Obtain follow-up radiographs:

-If the patient becomes symptomatic

-Four days after ingestion in children under six years of age who have ingested a button battery with a diameter ≥15 mm.

-To prove ultimate passage of the battery if not visualized intact in the stool one to two weeks after ingestion.

-Weekly to monitor progression of the battery through the GI tract if it has not been seen in the stool and is present on follow-up radiographs.

•Endoscopic or surgical removal of the battery is suggested if:

-The patient develops signs of gastrointestinal injury, such as occult or visible bleeding, fever, vomiting, severe abdominal pain, or acute abdomen.

-The battery remains in the stomach for more than four days and is unlikely to pass due to large size (eg, ≥15 mm in diameter in a child under six years of age) [17,49].

●NASPGHAN guidelines – The NASPGHAN guidelines also recommend emergent endoscopy and removal in patients who are symptomatic at initial presentation with a button battery located in the stomach or in asymptomatic patients who develop signs of gastrointestinal injury, such as occult or visible bleeding, fever vomiting, severe abdominal pain, or acute abdomen subsequent to the initial evaluation [12].

These guidelines differ from the NBIH guidelines with respect to asymptomatic patients based upon expert consensus as follows [12]:

•Urgent endoscopy (within 48 hours) is suggested for asymptomatic patients who are younger than five years of age and have ingested a button battery that is ≥20 mm. The primary reason for endoscopy in these patients is to exclude concomitant esophageal injury.

•Repeat radiographs at 48 hours are recommended for asymptomatic patients five years of age and older who have ingested a button battery ≥20 mm. Endoscopic removal is advised if the battery remains in the stomach at that time.

•For asymptomatic patients of all ages who have ingested button batteries <20 mm in diameter, repeat radiographs are suggested at 10 to 14 days if button battery passage in the stool has not occurred. Endoscopic removal is advised if the battery remains in the stomach at 10 to 14 days.

Successful endoscopic removal of button batteries from the stomach is less likely than from the esophagus (33 to 66 percent versus 90 percent, respectively) [1,4,5]. In addition, there is a low risk of damage from the battery once it has cleared the esophagus, unless it becomes impacted in the gastric or intestinal mucosa [1,16,17].

Intestinal location — Button batteries that have cleared the stomach usually pass through the gastrointestinal tract within one week without complication [2]. Prolonged battery transit is more common in patients older than 65 years of age.

Patients and their caretakers should be counseled to seek immediate medical attention for emergent radiography if abdominal pain, hematochezia, or fever develops before battery passage in the stool is confirmed. Such symptoms may indicate intestinal perforation or lodging of the battery in the appendix. Although not reported after button battery ingestion, appendiceal impaction of a wide variety of ingested foreign bodies, including smooth foreign bodies, has been described. Prompt surgical consultation for removal is indicated in symptomatic patients with radiographic documentation of a retained intestinal button battery. (See "Foreign bodies of the esophagus and gastrointestinal tract in children", section on 'Clinical manifestations'.)

Follow-up radiographs should be performed in asymptomatic patients who have not passed the battery by 10 to 14 days, regardless of size. In almost all patients, the battery will have passed by this time. If the battery still remains in the intestine, then further evaluation is warranted to determine if the lack of passage reflects a dysfunction of motility or an abnormality of anatomy (eg, intestinal duplication or stricture). Consultation with appropriate specialists (eg, gastroenterologist or surgeon) is warranted.

Increasing GI motility, bowel irrigation, and repeated enemas in patients with an intestinal button battery have been performed in the past with the goal of hastening passage [4,26,50]. However, given the inconsistent benefit of these measures and the limited risk of heavy metal toxicity or intestinal caustic injury, these measures are not recommended.

Mercury toxicity — Although elevated blood mercury levels have occurred after mercuric button battery ingestion, symptomatic mercury toxicity has not been reported and is unlikely [1]. Furthermore, most button batteries in use contain lithium and significant absorption of lithium is also unlikely.

However, because of the potential severity of mercury poisoning, patients with ingestion of batteries containing mercury that have fragmented or who demonstrate radiopaque droplets in the intestines on follow-up radiographs warrant evaluation for toxicity and consultation with a medical toxicologist and/or a poison control center [1]. (See 'Additional resources' below.)

Signs and symptoms of mercury toxicity include intention tremor, ataxia, psychiatric disturbances, anorexia, weakness, hyperreflexia, and paresthesias. Mercury also can impair kidney function, leading to a nephrotic-like syndrome and/or tubular injury with tubular dysfunction. The recognition and management of mercury toxicity is discussed separately. (See "Mercury toxicity", section on 'Treatment' and "Mercury toxicity".)

Complications — Complications from button battery ingestion are rare, but potentially devastating. They include, but are not limited to, tracheoesophageal fistula, vocal cord paralysis, esophageal perforation, esophageal stenosis, mediastinitis, spondylodiscitis, aspiration pneumonia, perforation of the aortic arch, gastric hemorrhage, gastric perforation, and intestinal perforation [2,14,17,31,51-55]. Deaths have been reported and are associated with ingestion of large (≥20 mm) lithium cell button batteries [2].

One case series of 86 patients with major outcomes (esophageal burns, perforations, or fistulas) and 13 deaths after button battery ingestion identified the following risk factors [2]:

●Button battery diameter ≥20 mm

●Patient younger than four years of age

●Ingestion of more than one button battery

●Unwitnessed or unknown ingestion time

●Misdiagnosis of button battery ingestion

●Delayed battery removal

●Coingestion of a magnet

In this series, tracheoesophageal fistula or esophageal stricture were not symptomatic for many days after removal. In one case, fatal bleeding from an aortoesophageal fistula occurred 18 days after battery retrieval [2].

Esophageal stenosis is a late complication of button battery ingestion (image 3). When it occurs, it typically does so weeks to months after endoscopic removal [1,42]. Thus, patients with esophageal injury after button battery ingestion warrant evaluation, as determined by the degree of injury, as described above. (See 'Esophageal impaction' above.)

The diagnosis and treatment of esophageal stricture after corrosive esophageal injury is discussed separately. (See "Caustic esophageal injury in children", section on 'Stricture formation' and "Caustic esophageal injury in adults", section on 'Esophageal strictures'.)

Prevention — As with other ingestions, primary prevention of ingestion is preferable to treatment. Children and their caregivers should be educated about the dangers of button battery ingestion, proper disposal of batteries, and avoidance of the use of one's mouth as a "third hand" while changing batteries.

Other measures that caregivers may consider include the following [9]:

●Check and secure (with tape) battery compartments on household products

●Store batteries out of reach and sight of children

●Do not allow children to play with batteries

In addition, changes in the design of button batteries and/or the products they power could prevent morbidity from ingestion. These include [1,3,9,18,56]:

●Developing child-resistant, unit-of-use battery packaging.

●Providing package warnings regarding the potential for serious injury or death if a button battery is ingested.

●Securing the battery compartment of devices using button batteries so that a tool is required to open them.

●Altering the design of hearing aids and other battery-containing products that are used by children to make the battery less accessible.

●Improving the integrity of the seal and crimp area of button batteries.

●Eliminating button batteries greater than 15 mm in diameter (since these are more likely to lodge in the esophagus).

CYLINDRICAL BATTERY INGESTION — The National Battery Ingestion Hotline (NBIH) (202-625-3333, TDD 202-362-8563) or a Poison Control Center is available to provide guidance for the management of patients with cylindrical battery ingestions.

Most cylindrical battery ingestions occur in patients between 6 and 39 years of age and are intentional [2,9]. Intact cylindrical batteries (eg, AA, AAA, C type batteries) pose a low threat for caustic damage after ingestion but because of their length (>2.5 cm) may become entrapped in the stomach in both children and adults. (See "Ingested foreign bodies and food impactions in adults", section on 'Blunt objects'.)

Leaking batteries do have the potential to cause corrosive injury. As an example, sucking on the fluid from a leaking cylindrical alkaline battery has caused esophageal burns in a child [57].

All patients who ingest cylindrical batteries warrant prompt localization with plain radiography that includes anterior-posterior (AP) and lateral views from the mouth to the anus, and urgent endoscopic removal of batteries located in the esophagus [12]. Depending upon the specific type of cylindrical battery (eg, larger C or D type battery), the presence of leakage, concern that follow-up will be difficult, and/or the age of the patient (eg, young child), some specialists may also choose to remove batteries localized to the stomach at initial evaluation. An alternative approach is to re-evaluate the patient with a radiograph 48 hours after ingestion and remove batteries that remain in the stomach at that time.

Patients with batteries that have exited the stomach may be observed with follow-up radiographs at weekly intervals or until passage in the stool is confirmed. Endoscopic or surgical removal (depending upon the location of the object) is warranted if the battery remains in the same location for more than one week. Patients should immediately seek medical attention for surgical removal if symptoms of perforation and peritonitis (eg, fever, vomiting, and abdominal pain) develop. (See "Ingested foreign bodies and food impactions in adults", section on 'Blunt objects'.)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6thgrade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Swallowed objects (The Basics)")

ADDITIONAL RESOURCES — Regional poison control centers in the United States are available at all times for consultation on patients who are critically ill, require admission, or have clinical pictures that are unclear (1-800-222-1222). In addition, some hospitals have clinical and/or medical toxicologists available for bedside consultation and/or inpatient care. Whenever available, these are invaluable resources to help in the diagnosis and management of ingestions or overdoses. The World Health Organization (WHO) provides a listing of international poison centers at its website: www.who.int/gho/phe/chemical_safety/poisons_centres/en/index.html.

Information specific to button battery exposure and expert guidance on management of serious cases is available at the National Battery Ingestion Hotline (NBIH) (202-625-3333) and at its website: www.poison.org/battery.

SUMMARY AND RECOMMENDATIONS

●The chemical content and diameter of the button battery can be determined from the imprinted code found on the battery case. This code may be known by the caregiver or patient or can be obtained from a spare matching battery. (See 'Battery identification' above.)

●Most button battery ingestions are witnessed, and most patients are asymptomatic at the time of presentation. The clinician should also maintain a high level of suspicion for an esophageal button battery or other foreign body, despite a negative history of ingestion, in young children with abrupt onset of any one of the following: refusal of oral intake, difficulty swallowing, chest pain, drooling, airway obstruction, or wheezing or stridor without typical prodromal symptoms of viral illness. Demonstration of the battery on plain radiographs confirms ingestion. (See 'Clinical features' above and 'Diagnosis' above.)

●Guidelines developed by the National Battery Ingestion Hotline (NBIH, available at its website) and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Endoscopy Committee (NASPGHAN) provide the basis for the approach to button battery ingestion. (See 'Approach' above.)

●Patients with suspected button battery ingestion should have no oral intake until the evaluation is complete. (See 'Approach' above.)

●We recommend emergent evaluation and plain radiography for patients who meet any one of the following criteria:

•All children under 12 years of age who ingest button batteries

•All patients who have ingested a button battery that is ≥12 mm in diameter

•All patients for whom the diameter of the button battery is not known

Plain radiographs should include anteroposterior (AP) and lateral views from the nasopharynx to the anus. (See 'Radiographic localization' above.)

●Asymptomatic, healthy patients over 12 years of age with confirmed ingestion of a solitary button battery that is ≤12 mm in diameter and without coingestion of a magnet may undergo observation for battery passage at home without initial radiographs as long as the patient or caregiver is reliable and able to promptly seek treatment should symptoms develop. Radiographic localization is warranted if battery passage is not confirmed in 10 to 14 days. (See 'Radiographic localization' above.)

●We recommend that patients with button batteries that are lodged in the esophagus undergo emergent removal with direct endoscopic visualization by an appropriate specialist (Grade 1B). Further management is determined by the presence and degree of injury at endoscopy. (See 'Esophageal impaction' above.)

●Symptomatic patients who have a button battery localized to the stomach, even if symptoms are minor, also warrant emergent endoscopy and removal. (See 'Gastric location' above.)

●We advise consultation with a gastroenterologist for the following situations (see 'Gastric location' above):

•Any asymptomatic child younger than five years of age with a gastric button battery that is ≥20 mm. Consultation should occur at initial presentation and involve a pediatric gastroenterologist.

•Any asymptomatic patient five years of age or older in whom the button battery remains in the stomach on follow-up radiograph at 48 hours or longer after ingestion.

●Button batteries that have cleared the stomach usually pass through the gastrointestinal tract within one week without complication. Patients with symptoms of abdominal pain, hematochezia, or fever without confirmed battery passage should seek immediate medical attention for emergent radiography. Prompt surgical consultation for removal is indicated in symptomatic patients with radiographic documentation of a retained intestinal button battery. (See 'Intestinal location' above.)

●Follow-up radiographs should be performed in asymptomatic patients with an intestinal button battery who have not passed the battery by 10 to 14 days, regardless of size. (See 'Intestinal location' above.)

●Cylindrical batteries (eg, AA, AAA, C type batteries) pose a lower threat for caustic damage after ingestion than button batteries but because of their size may become entrapped in the stomach. All patients who ingest cylindrical batteries warrant prompt radiographic localization and urgent endoscopic removal of batteries located in the esophagus. Depending upon the specific situation, cylindrical batteries located in the stomach may be removed at initial evaluation or if they remain in the stomach at 48 hours after ingestion. (See 'Cylindrical battery ingestion' above.)

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