Pediatric Button Battery Ingestion

Introduction

Button battery ingestion is a critical pediatric emergency, particularly with the Rising use of high-voltage lithium cells.

Etiology & Risk Factors

· Developmental curiosity: Peak incidence in children aged 6 months to 6 years due to oral exploration behavior.

· Accessibility: Batteries left within reach in toys, remotes, thermometers, or hearing aids.

· High-risk batteries: Lithium cells ≥20mm diameter or ≥3V pose severe tissue damage risks.

· Design flaws: Poorly secured battery compartments in child-friendly devices.

Pathophysiology

1. Electrochemical injury: Current flow between the battery anode/cathode generates hydroxide ions (NaOH), causing liquefactive necrosis.

2. Pressure necrosis: Mechanical compression of esophageal tissue.

3. Thermal injury: Heat from short-circuiting exacerbates tissue damage.

4. Delayed complications: Fibrosis leading to strictures or fistulae (e.g., tracheoesophageal).

Key Insight: Tissue Damage can progress within 2 hours post-ingestion, especially with lithium batteries.

Epidemiology

· Frequency: ~3,500 cases/year in the US; 10% develop severe complications.

· Age: 85% occur in children <5 years (median: 1–2 years).

· Location: Esophageal impaction (60% of severe cases), typically at physiologic narrowings.

· Battery type: Lithium cells (e.g., CR2032) account for >90% of major injuries.

Clinical Presentation

Stage	Symptoms
Early	Drooling, dysphagia, vomiting, chest pain (in older children), coughing.
Advanced	Fever, hematemesis, melena, and respiratory distress (fistula formation).
Unique Signs	Metallic odor ("battery breath"), stridor (laryngeal involvement).

Red Flag: Asymptomatic presentation does not rule out esophageal impaction.

Imaging Features

1. Radiography:

· Frontal view: "Double-ring" or halo sign (circular opacity with peripheral rim).

· Lateral view: Identifies location (proximal/mid-esophagus = higher risk).

2. CT: Assesses complications (perforation, vascular erosion, abscess).

1. Endoscopy: The Gold standard for evaluating mucosal injury post-removal.

Management

Emergency interventions:

· NPO status: Immediate fasting for endoscopic retrieval.

· Honey/Sucralfate: For esophageal lithium batteries, administer 10 mL of honey every 10 minutes (if <2 hours post-ingestion, child ≥1 year). Avoid perforation suspects.

Definitive treatment:

· Endoscopic removal: Mandatory for esophageal impaction (goal: <2 hours). Use Roth nets or grasping tools.

· Surgery: Required for perforation, fistulae, or vascular injury.

Pharmacotherapy:

· Antibiotics: Broad-spectrum coverage if perforation suspected (e.g., Piperacillin-Tazobactam).

· Steroids: Controversial; may reduce stricture risk in select cases.

Prognosis & Complications

Outcome	Risk Factors
Favorable	Gastric location, <15mm diameter, early removal (<2h), non-lithium batteries.
Poor	Esophageal lithium cells, >12h retention, >20mm size, vascular involvement.

Major complications:

· Acute: Esophageal perforation (15–20%), aorto-esophageal fistula (1–2%, often fatal).

· Chronic: Strictures (30–40%), dysphagia, failure to thrive.

Prevention Strategies

1. Childproofing: Secure battery compartments with screw-fastened lids.

2. Public Awareness: Campaigns highlighting risks (e.g., National Button Battery Task Force).

3. Regulation: Advocate for safer battery designs (e.g., coating to reduce current leakage).

Quote: "A button battery in the esophagus is a ticking time bomb." — National Capital Poison Center.

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Case study: 4-Year-Old Girl with Ingested Foreign Body
Button Battery Ingestion

History and Imaging

A 4-year-old girl presented with symptoms suggestive of foreign body ingestion.
According to the reported clinical history, it was suspected that the patient "might have swallowed a coin."
Anteroposterior (AP) and lateral chest radiographs were performed.

Quiz 1:

It is most likely that the ingested object is a coin.
(1) True
(2) False
What is the next step in management?
(1) Reassurance
(2) Outpatient follow-up with radiographic monitoring
(3) Emergency foreign body removal

Additional Imaging
The patient was transferred to the otolaryngology department and subsequently taken to the operating room.
Intraoperative fluoroscopic images are shown below.

The foreign body was successfully removed from the distal esophagus via endoscopy.
Following removal, the patient underwent an esophagogram.

Quiz 2:

Esophageal perforation is observed on the esophagogram.
(1) True
(2) False
Which of the following are known complications associated with the ingestion of this type of foreign body?
(1) Tracheoesophageal fistula
(2) Esophageal stricture
(3) Esophageal perforation
(4) Aortoenteric fistula
(5) (1), (2), and (3)
(6) (1), (2), (3), and (4)

Findings and Diagnosis

Findings:

Radiographs: A disc-shaped metallic foreign body, presumed to be lodged in the esophagus, was observed. On the anteroposterior (AP) view, a characteristic "double-ring" appearance was noted, while the lateral view showed a "step-off" contour.
Intraoperative fluoroscopy: The previously observed metallic foreign body was visualized below the diaphragm.
Esophagogram: No evidence of esophageal leakage or stricture was identified.

Differential Diagnosis:

Ingested coin
Ingested button battery

Final Diagnosis:

Ingested button battery — confirmed via endoscopic removal

Discussion

Ingested Button Battery

Pathophysiology:
Foreign body ingestion is a common occurrence in pediatric patients. The most frequent sites of esophageal impaction are anatomical narrowings, namely the thoracic inlet, the aortic arch level, and the gastroesophageal junction. A lodged button battery can cause tissue injury through multiple mechanisms. The primary mechanism involves electrolysis of sodium chloride (NaCl), resulting in the generation of sodium hydroxide (NaOH), which can cause severe tissue damage.

Epidemiology:
Between 1985 and 2009, over 55,000 button battery ingestion cases were reported to the National Poison Data System.
More than 65% of these cases occurred in children under 6 years of age.

Clinical Presentation:
Most patients are initially asymptomatic. Depending on the location and timing of the battery ingestion, patients may present with nonspecific symptoms such as abdominal or chest pain, cough, difficulty feeding, drooling, stridor, and vomiting.

Imaging Features:
It is crucial to differentiate between coin and button battery ingestion, especially when the clinical history is unclear, as in this case. Failure to distinguish the two can result in severe complications.

Radiographic features: A button battery typically shows a "double-ring" or "halo sign" on AP radiographs and a "step-off" appearance on lateral views. Batteries with a diameter greater than 20 mm are associated with an increased risk of esophageal impaction and injury.
Depending on the extent of soft tissue injury or edema, additional radiographic findings may include anterior displacement or narrowing of the trachea, mediastinal widening, or the presence of gas.
Fluoroscopy: An esophagogram may be performed to evaluate for esophageal irregularity, leakage, stricture, or fistula formation.
Cross-sectional imaging: The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) recommends CT angiography or MRI following removal if there is evidence of esophageal injury during endoscopy, to assess for potential aortic injury.
Major complications of button battery ingestion include tracheoesophageal fistula, aortoenteric fistula, esophageal perforation, and esophageal stricture.

Management:
Ingestion of a button battery lodged in the esophagus constitutes a pediatric emergency. If the battery is located in the esophagus, it should be removed endoscopically as soon as possible.
It is important to note that even if the battery appears to have passed beyond the esophagus on initial imaging, esophageal injury cannot be ruled out.

References:

(1) Jatana KR, Litovitz T, Reilly JS, Koltai PJ, Rider G, Jacobs IN. Pediatric button battery injuries: 2013 task force update. Int J Pediatr Otorhinolaryngol. 2013;77(9):1392-1399.

(2) Leinwand K, Brumbaugh DE, Kramer RE. Button battery ingestion in children: A paradigm for management of severe pediatric foreign body ingestions. Gastrointest Endosc Clin N Am. 2016;26(1):99-118.

(3) Litovitz T, Whitaker N, Clark L, White NC, Marsolek M. Emerging battery-ingestion hazard: Clinical implications. Pediatrics. 2010;125(6):1168-1177.

(4) Semple T, Calder AD, Ramaswamy M, McHugh K. Button battery ingestion in children-a potentially catastrophic event of which all radiologists must be aware. Br J Radiol. 2018;91(1081):20160781.

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