Podcast – Button Battery Ingestion

I’m going to start with a couple of confessions and disclosures. First disclosure, my husband is a pediatric radiologist. This is an x-ray that he kindly passed on to me, which he was asked to report on one month ago. The request card stated that this two-year-old had a witnessed ingestion of a single button battery, a small one for a watch, at midday. They hadn’t swallowed anything else, definitely hadn’t swallowed anything else. They had vomited twice since, but there was no sign of the button battery in the vomit. The query was about a foreign body on the x-ray, and I think you might be able to see more than one foreign body in this x-ray.

The next confession/disclosure is that this button battery was found at the weekend, albeit on a high shelf, but a high shelf in my three-year-old’s bedroom. Nobody in the house has any idea how it got there, no idea whatsoever. He doesn’t know, I don’t know, his big brother doesn’t know, my husband doesn’t know, and our nanny doesn’t know. We are clueless. The only things in his bedroom that have button batteries are really secure. He’s got one thing, a remote for his bedside light, and it is very secure, requiring a screwdriver to open it. But there you go.

Another similar anecdote: a friend of mine, who is an ENT surgeon, when she woke one of her daughters up one morning, found no less than seven button batteries under the pillow where her daughter had been sleeping. So this is real, it happens. It happens to those of us, you know. I mean, my children think that I spend half of my time at work removing batteries and magnets from naughty children who have swallowed them, and the other half creating new bottom holes. They’re not far wrong. There’s a lot of ingrown toenails, hernias, orchidopexies, and circumcisions to deal with in between, but I don’t chat so much about those at home.

So despite a lot of our chat at home being about the dangers of things like magnets and batteries, how they should be safely secured and stored, I still found one at this weekend—terrifying. The other thing about this picture is that I don’t know what anyone else thinks, but I’m not entirely sure that a bright red sticker on it that says “Harmful if swallowed” is of any use to the children, certainly. And really, the adults should already know that. If anything, this red sticker makes the battery look slightly more interesting and inviting than it did without it.

There are lots of different types of button batteries around. I think there are about 85 different button batteries available either on the market or in use in toys, watches, hearing aids, etc., in the UK. These are just ones that I could find at home, and you can see the sizes compared to a 10-pence coin and a five-pence coin. In the batteries, the active agent varies from lithium, alkaline, silver oxide, mercury, and all sorts of different things. They range in size from 2.8 to 30 millimeters and in thickness from 1.2 to 16 millimeters. The code on the battery, the most common battery that is used, the button battery that’s likely to cause problems, is the CR2032. The CR lead means that it’s lithium manganese oxide, and the 2032 means the diameter is 20 millimeters and the thickness is 3.2 millimeters.

So how do ingested button batteries cause trouble? You’ve seen the video of the battery that was inserted, just sort of wedged in that chicken breast, and in a very, very short period of time, it caused significant necrosis. The three N’s stand for negative, narrow, and necrotic, which means that the negative battery pole is on the narrowest side, which you can see on the lateral x-ray and causes the most severe necrotic injury. The larger the battery and the smaller the esophagus, the more likely the battery is to get stuck. It’s really the batteries that are in the esophagus that we’re worried about, and that’s because they stick against the mucosa of the esophagus. Whereas if the button battery has passed through the esophagus down the rest of the GI tract, it is unlikely to be in contact with the mucosa for any prolonged period of time. It’s moving around, so it’s much, much less likely to cause any significant injury.

The esophagus has three particularly narrow points: at the level of the thoracic inlet, the aortic arch, and the gastroesophageal junction. Those are the places where you’re most likely to get the button battery stuck. Essentially, what happens is the mucosa bridges the electrodes, the circular rim that you can see on the narrower side of the battery, and that allows generation of an electric current, which causes hydrolysis of the tissue fluid. That generates hydroxide at the negative pole, and that hydroxide is basically extraordinarily strong alkali. It’s like pouring oven cleaner into the esophagus. You very, very rapidly get this alkaline corrosive injury that causes tissue liquefaction and necrosis, as you saw in that chicken breast video right at the beginning. That happens really quickly, within two hours you’ve got significant injury. Later on, there might be the risk of leakage of the battery contents, especially from the alkaline electrolyte, but that usually doesn’t happen for at least two hours onwards. In all of the studies that they’ve tried to do, there’s been varying degrees of how much the battery has leaked or not. Obviously, in the situation when you’ve already got the tissue necrosis, the liquefaction, and you’ve got this fluid, the alkaline fluid and the necrotic tissue, you’re probably more likely to get some leakage. But most of the injury is from the corrosive alkaline effects of the hydroxide that is produced.

So when might you suspect a battery ingestion? Some really important things to think about here are that the vast majority of the time, button battery ingestion is not witnessed. You don’t have to have a child who’s big enough to wander and get hold of a button battery to ingest it. We all know the dangers of having an older sibling, and they will feed things to their younger siblings. I remember a child who presented with a magnet ingestion, and their older sibling very proudly said, “Oh look, Mummy, look what little Johnny can do,” and put a magnet on the outside of little Johnny, and it stuck. The mum was like, “What’s happened here?” and realized that the older sibling had fed the magnet to the baby. Great party trick, but I don’t recommend it.

It may not be witnessed. It’s unlikely that the child is going to offer up, “Oh yes, I’ve just swallowed a button battery,” because they probably don’t even know what it is. It could be that parents thought that they’ve witnessed the swallowing of a coin. We will talk in a moment about the signs to look for on an x-ray, but they are not always there. So if there is any hint of suspicion that this could possibly be a battery, then treat it as a battery ingestion. They may present with airway obstruction. They may present with drooling, difficulty swallowing, regurgitation. The history may be quite insidious and have been going on for several days. Some children have presented weeks after ingestion of a battery and still have a battery lodged somewhere in their esophagus. They may be refusing to eat or drink, and you’ve got no idea why. They may have chest pain, coughing, choking, gagging, lots of different things. Sometimes they present with recurrent upper respiratory tract infections, but they’re not so unwell as to warrant a chest x-ray for this presumed upper respiratory tract infection. I remember a patient who had presented daily to the local emergency department for seven days with cough and with food refusal, low-grade temperature, and generally not quite right. It was only on the eighth day that somebody took a chest x-ray and saw the button battery lodged in the esophagus. The patient was blue-lighted to us in Leeds many years ago, and on arrival, as they were wheeled in onto the ward with the paramedics, she essentially just started to sanguinate out of her mouth at huge high pressure because of an esophageal-tracheal fistula. She had been presenting repeatedly, and nobody had thought about it because there was no suggestive history and no one had thought about it.

So it’s very, very simple. What do you do when a button battery ingestion is suspected? Even the slightest bit of suspicion? Get a chest x-ray, and if you need to, a lateral to confirm a double rim, a halo, or a step off. A couple of x-rays here, so we go back to that one from earlier. You can see the step-off sign; you can see that drop down onto the negative electrode of the button battery and the double rim or halo sign.

I’ve talked a little bit about magnets and mentioned them here and there. The talk is not about magnets, but beware the possibility of a battery plus magnet ingestion. With these batteries, we wouldn’t be worried about one that’s below the diaphragm. It’s a little bit harder when you’ve got this many batteries in a patient because who knows what’s going to happen. Is that sort of, you know, more dangerous because you’ve got so many? You’re going to be keeping a close eye on them, but it’s not quite the same as if it’s stuck in the esophagus. But you would want to think about what you’re going to do and get your surgical colleagues involved if there are either this many or if there’s any suspicion that there’s a magnet in there as well, even if they are below the diaphragm.

Continuing on the theme of what to do when a button battery ingestion is suspected is pre-arrival in hospital. The advice is over the age of one year to give honey, a teaspoon every ten minutes, and that can be repeated six times. If they’re under the age of one,

there’s limited evidence that you can give jam. We don’t want to worsen the situation of the button battery ingestion by giving honey to a child under the age of one, so we use jam instead. In hospital, sucrose syrup suspension, a gram every ten minutes, and you can do that three times. Neither of those things should delay the patient from getting to the hospital, nor should those things delay the patient from getting to the theatre. The key thing here is that we need to get the battery out as quickly as possible.

Who’s going to do that is going to depend upon where you are. It may be that you’re in a tertiary centre with pediatric surgical services, in which case somebody like Erica or myself will be around and will be able to get the patient to the theatre and get the button battery out. But it may be that you’re somewhere that doesn’t have pediatric surgery, but you might have an ENT surgeon who would be happy to get the battery out. There’s usually this kind of, if something’s above the level of the clavicles, then ENT will remove it, and if it’s below, then pediatric surgery will. But if you ask your local ENT surgeons, even if it is below the level of the clavicles, they will appreciate that actually, time saves lives in this situation. Even after you’ve removed the button battery, that alkaline injury does continue to occur, so you do need to get that button battery out as quickly as possible.

When they go for endoscopy to remove the battery, you’re not just doing this to remove the battery. That is a key point. The other things you want to do is note the extent of the injury, see if there’s any obvious evidence of perforation, and document where the battery was lying, where the injury was, which side the negative pole was on. If there’s no evidence of perforation, then we would irrigate with 150mls of 0.25% acetic acid with the hope that that will neutralize some of the alkali and prevent or reduce the amount of ongoing consequences from the alkaline burning. We would also pass a nasogastric tube and a bridle, which would allow enteral feeding to start early and also, if they’ve got a significant injury, particularly if it looks circumferential, you’re really worried about the risk of stricturing later down the line. That nasogastric tube is going to allow some patency or at least help you to find the esophagus and the way through the esophagus in the future should that be needed.

As discussed, the injuries can continue for long after the button battery has been removed. So if the button battery has been removed in a DGH by an ENT surgeon, that patient will need to be admitted and they’ll most certainly need to be transferred to a pediatric surgical centre. Ingested button batteries can cause massive and wide and varying problems afterwards. Apart from the obvious esophageal perforation, it can fistulate through into the trachea, into vessels, and perforation may present as late as 28 days down the line. Fistulas have been reported to present as late as 48 days down the line. You can get recurrent laryngeal nerve injuries, tracheomalacia, mediastinitis and empyema, lung abscesses, strictures which present later on and may need multiple repeat general anesthetics for dilatations. We’ve seen patients present with spondylodiscitis several weeks down the line as well. And of course, we all know about the risk of death.

When death occurs in this situation, it usually occurs because of an aorto-esophageal vascular fistula. If there is a herald bleed and that occurs within the hospital, all you can do is get that patient to the theatre, get cardiothoracic surgeons, get the patient on bypass, and then operate to see what you can do and if you can salvage them. If the herald bleed happens outside of the hospital, it is almost certain that the patient is not going to survive.

What do you do with the patient once they’ve been admitted? I’ve kept patients like this in for three weeks, and really, if you get bored, that’s a good thing in this situation. You have to work out if you need to do any further imaging based upon their symptoms. But how you interpret that imaging and what you do about it is really difficult. Whether a CT or an MRI is going to help, and what the degree of inflammation that you see means, it’s very difficult to manage these patients until something happens and then you deal with it surgically, essentially.

Thank you very much.