Disk batteries are small, coin-shaped batteries used in watches, calculators, 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 fistulae). 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.
Fatal cases or those with major sequelae usually involve esophageal or airway battery lodgement.[1]
Disk batteries
Disk batteries are formed by compacting metals and metal oxides on either side of an electrolyte-soaked separator.[2] The unit is then placed in a 2-part metal casing held together by a plastic grommet (see the image below).
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Cross-section of a typical disk battery.
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).[1] 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.
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Changes in chemical systems of ingested disk batteries from 1990-2008.
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.[1] See the image below.
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Changes in the diameter of disk battery ingestions from 1990-2008.
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%).[1] "CR" represents the battery chemistry, "20" is the diameter, and "32" indicates the thickness (3.2 mm) of the battery. See the image below.
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20 mm CR 2032 Lithium Cell Disk Battery shown with a U.S. Quarter: On the left is the Cathode (positive pole) and on the right the narrower Anode (neg....
Disk batteries do not usually cause problems unless they become lodged in the GI tract, nose, or ears. The most common place disk batteries become lodged, resulting in clinical sequelae, is the esophagus. Batteries that successfully traverse the esophagus are unlikely to lodge at any other location.
Batteries pass through the GI 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.
Clinically significant outcomes (moderate, major, or fatal) occurred in only 1.3% cases from 1985-2009.[1] The likelihood that a disk battery lodges in the esophagus is a function of the patient's age (very young or old) and the size (diameter in mm) and type (chemical content) of the battery.
The larger size (20-25 mm batteries) is the most important predictor of a clinically significant outcome. Disk batteries of 16 mm have become lodged in the esophagi of 2 occurred in children who were younger than 4 years old.[1] Older children do not have problems with batteries smaller than 21-23 mm. For comparison, a dime is 18 mm, a nickel is 21 mm, and 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.[1, 3]
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Endoscopic view of disk battery in esophagus of a child demonstrating esophageal burns.
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.[1] 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.
From 1985-2009, 56,535 disk battery ingestions were reported to the National Poison Data System.[1] See the image below.
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Exposures to disk batteries reported to the American Association of Poison Control Centers, 1986-2009.
Mortality/Morbidity
Prognosis
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 image below.
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NPDS button-battery ingestion frequency and severity (for moderate, major, and fatal outcomes), according to year.
Morbidity/mortality
Deaths due to button battery ingestion are rare. From 1985-2009, only 13 of 56,535 reported ingestions were fatal cases (0.02%).[1] Ingestion of a disk battery was initially missed by providers in 7 (54%) of the 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 fistulae occurred in 9 cases (69%), of which 7 were aortoesophageal.
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.[1]
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.[4]
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.[1]
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.
Sex
Male predominance (59%) is observed in disk battery ingestions.
Age
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.[1]
A second peak is observed in adults older than 60 years, with 10.3% of cases occurring in patients aged 60-89 years. 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.
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. 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.[1] 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.[5] 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.[6] Symptoms reportedly associated with the lodging of the battery in the GI tract include the following (in order of decreasing frequency)[6] :
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.
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.
Obtain blood and urine mercury levels only if the mercury-containing cell has been observed to fragment in the GI tract or 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).
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Lateral radiographic appearance of a 7.9-mm disk battery. Photographed by Daniel J. Dire, MD.
Batteries located in the esophagus on initial radiograph frequently (28%) pass into the stomach spontaneously.
Radiopaque droplets in the gut may be found on radiograph in patients with fragmented mercuric oxide cells.
The recommended management algorithm for dealing with the ingestion of disk batteries is shown in the image below.
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Recommended management algorithm for patients with disk battery ingestions. Notes: (1) Serum mercury levels and chelation therapy should be reserved f....
Secure the ABCs, and resuscitate the patient as necessary.
Make the patient is not given anything by mouth and obtain an initial radiograph of the chest and abdomen to determine the battery location. See the image below.
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Disk battery in the stomach of an 18-month-old child.
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 10-16 Fr Foley catheter 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 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.
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Radiograph of child 1 week after ingestion of a disk battery. The battery has passed into the rectum. Photographed by Daniel J. Dire, MD.
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.
Hospitalization for battery ingestion is infrequent (4.5%) and generally brief (< 2 d).
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).
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.
For patient education resources, see First Aid and Injuries Center, as well as Battery Ingestion.
Daniel J Dire, MD, FACEP, FAAP, FAAEM, Clinical Professor, Department of Emergency Medicine, University of Texas Medical School at Houston; Clinical Professor, Department of Pediatrics, University of Texas Health Sciences Center San Antonio
Disclosure: Nothing to disclose.
Specialty Editors
John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals
Disclosure: Nothing to disclose.
Chief Editor
Asim Tarabar, MD, Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.
Additional Contributors
Steven A Conrad, MD, PhD, Chief, Department of Emergency Medicine; Chief, Multidisciplinary Critical Care Service, Professor, Department of Emergency and Internal Medicine, Louisiana State University Health Sciences Center
Disclosure: Nothing to disclose.
Acknowledgements
Eugene Hardin, MD, FAAEM, FACEP Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center
Changes in chemical systems of ingested disk batteries from 1990-2008.
Changes in the diameter of disk battery ingestions from 1990-2008.
20 mm CR 2032 Lithium Cell Disk Battery shown with a U.S. Quarter: On the left is the Cathode (positive pole) and on the right the narrower Anode (negative pole).
Endoscopic view of disk battery in esophagus of a child demonstrating esophageal burns.
Exposures to disk batteries reported to the American Association of Poison Control Centers, 1986-2009.
NPDS button-battery ingestion frequency and severity (for moderate, major, and fatal outcomes), according to year.
Lateral chest radiograph of a child with a nickle and penny adhered to each other in the upper esophagus initially misdiagnosed as a disk battery.
Endoscopic view of a nickle and penny in the esophagus of a child that was initially misdiagnosed as a disc battery.
Lateral radiographic appearance of a 7.9-mm disk battery. Photographed by Daniel J. Dire, MD.
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.
Disk battery in the stomach of an 18-month-old child.
Radiograph of child 1 week after ingestion of a disk battery. The battery has passed into the rectum. Photographed by Daniel J. Dire, MD.
Cross-section of a typical disk battery.
Exposures to disk batteries reported to the American Association of Poison Control Centers, 1986-2009.
Lateral radiographic appearance of a 7.9-mm disk battery. Photographed by Daniel J. Dire, MD.
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.
Radiograph of child 1 week after ingestion of a disk battery. The battery has passed into the rectum. Photographed by Daniel J. Dire, MD.
Disk battery in the stomach of an 18-month-old child.
Changes in the diameter of disk battery ingestions from 1990-2008.
Changes in chemical systems of ingested disk batteries from 1990-2008.
Endoscopic view of disk battery in esophagus of a child demonstrating esophageal burns.
Endoscopic view of a nickle and penny in the esophagus of a child that was initially misdiagnosed as a disc battery.
Lateral chest radiograph of a child with a nickle and penny adhered to each other in the upper esophagus initially misdiagnosed as a disk battery.
20 mm CR 2032 Lithium Cell Disk Battery shown with a U.S. Quarter: On the left is the Cathode (positive pole) and on the right the narrower Anode (negative pole).
NPDS button-battery ingestion frequency and severity (for moderate, major, and fatal outcomes), according to year.
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