Overview
Definition:
A button battery is a small, disc-shaped battery commonly found in toys, remote controls, and electronic devices
Ingestion of a button battery into the upper gastrointestinal tract (esophagus, stomach, duodenum) in children poses a significant medical emergency due to the risk of serious chemical and electrical burns, leading to mucosal damage, perforation, or stricture formation.
Epidemiology:
Button battery ingestions are a leading cause of foreign body injuries in children, with peak incidence in children aged 6 months to 3 years
Estimates suggest hundreds of thousands of ingestions occur annually, with a substantial proportion involving the upper GI tract requiring urgent intervention
Factors include increased availability of electronic devices and developmental stage of children.
Clinical Significance:
Button battery ingestions are a true medical emergency
The discharge of electrical current and leakage of alkaline electrolytes from the battery can cause rapid tissue necrosis, esophageal or gastric perforation, tracheoesophageal fistula, vocal cord paralysis, and even death
Prompt recognition and management are critical to prevent severe morbidity and mortality, making it a high-yield topic for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Vomiting, often bilious
Drooling and dysphagia
Refusal to eat or drink
Chest pain or abdominal pain
Cough or stridor, suggestive of airway compromise or tracheoesophageal fistula
Fever
Symptoms can be non-specific or absent initially, especially if the battery is in the stomach.
Signs:
Retained secretions or aspiration
Stridor or hoarseness
Abdominal tenderness
Visible or palpable foreign body on digital rectal examination (less common for upper GI)
Vital sign abnormalities like tachycardia or hypotension may indicate severe complications like perforation or sepsis.
Diagnostic Criteria:
Diagnosis is confirmed by radiographic evidence of a radiopaque, circular foreign body in the upper gastrointestinal tract on plain radiographs (anterior-posterior and lateral views of the neck, chest, and abdomen)
Clinical suspicion based on history of ingestion and characteristic symptoms in a child is paramount, even if radiographs are initially equivocal.
Diagnostic Approach
History Taking:
Detailed history is crucial: exact type of battery if known (size and voltage matter), circumstances of ingestion (witnessed or suspected), time of ingestion, and any prior symptoms
Inquire about underlying medical conditions, neurological status, and any history of prior GI surgery or abnormalities
Identify red flags such as sudden onset of respiratory distress or copious secretions.
Physical Examination:
A systematic head-to-toe examination focusing on the airway (stridor, retractions), oropharynx (visual inspection for foreign body), neck (tenderness, crepitus), chest (breath sounds), and abdomen (tenderness, guarding)
Assess vital signs thoroughly and monitor for signs of distress or shock.
Investigations:
Plain radiography (AP and lateral views of neck, chest, and abdomen) is the cornerstone investigation to confirm the presence, location, and number of button batteries
Esophagography with water-soluble contrast may be useful if perforation is suspected or to delineate mucosal injury
Endoscopy is both diagnostic and therapeutic
Laboratory investigations (CBC, electrolytes, liver function tests) are generally not helpful for initial diagnosis but may be indicated if complications arise.
Differential Diagnosis:
Other esophageal foreign bodies (coins, food boluses, magnets)
Tracheoesophageal fistula from other causes
Epiglottitis or croup presenting with stridor
Esophageal spasm
Gastroesophageal reflux disease (GERD) causing vomiting and feeding refusal
Upper GI bleeding from other etiologies.
Management
Initial Management:
Immediate consultation with pediatric gastroenterology or surgery
Maintain NPO status
If the battery is in the esophagus, emergent endoscopic removal is mandatory
If the battery is in the stomach or duodenum and symptomatic, removal is generally recommended
If asymptomatic in the stomach/duodenum and radiographically confirmed not to be in the esophagus, close monitoring with serial radiographs may be considered, but removal is often preferred due to potential delayed complications.
Medical Management:
Prophylactic antibiotics (e.g., amoxicillin-clavulanate or clindamycin) may be considered for esophageal batteries or if perforation is suspected, to cover oral flora
Proton pump inhibitors (PPIs) can be used to reduce gastric acidity, though their role in preventing battery-induced injury is less established compared to immediate removal.
Surgical Management:
Endoscopic removal is the primary management
Flexible or rigid endoscopy can be used
Techniques include grasping forceps, snares, or specialized retrieval baskets
If endoscopic removal fails or if complications like perforation or fistula are present, open surgical intervention or laparotomy may be necessary, but this is rare
The goal is rapid removal before significant tissue damage occurs.
Supportive Care:
Strict monitoring of vital signs and respiratory status
Intravenous fluid resuscitation if dehydrated or in shock
Management of pain and anxiety
Nutritional support via nasogastric or intravenous routes if oral intake is compromised
Post-removal, monitoring for signs of esophageal or gastric perforation, stricture formation, or fistula development
Discharge planning should include parental education on safe storage of batteries and electronics.
Complications
Early Complications:
Esophageal or gastric perforation
Tracheoesophageal fistula
Vocal cord paralysis
Mediastinitis
Pneumonia or aspiration
Hemorrhage
Stricture formation within days of injury.
Late Complications:
Esophageal stricture formation requiring dilation or surgery
Chronic dysphagia
Recurrent aspiration pneumonia
Vocal cord dysfunction
Malnutrition
Long-term gastrointestinal dysfunction.
Prevention Strategies:
Educate parents and caregivers about the dangers of button batteries, especially in children under 6 years
Store batteries and battery-containing devices securely away from children
Use child-resistant battery compartments on toys and devices
Promptly dispose of used batteries
Ensure proper functioning of battery compartment latches
Public awareness campaigns about the risks associated with button battery ingestion.
Key Points
Exam Focus:
Button batteries in the esophagus require IMMEDIATE endoscopic removal due to rapid mucosal damage and perforation risk
Batteries in the stomach or duodenum also warrant urgent removal, especially if symptomatic or large
Radiography is key for diagnosis
Tracheoesophageal fistula and vocal cord paralysis are critical complications.
Clinical Pearls:
Always assume ingestion if symptoms are present and a battery-powered device is accessible to the child
Radiographs can differentiate esophageal (requires urgent removal) from gastric/duodenal location
Mucosal burns can continue even after removal, necessitating careful monitoring and potential early endoscopy for follow-up evaluation
Consider battery voltage and size as factors influencing severity.
Common Mistakes:
Delaying endoscopic removal of esophageal batteries
Underestimating the severity of potential complications
Inadequate follow-up imaging or endoscopic evaluation after removal
Misinterpreting radiographs (e.g., confusing a swallowed coin with a battery)
Failure to consider airway compromise in symptomatic children.