What is the treatment for button battery ingestion?

Button Battery Ingestion Treatment

Emergency endoscopy within 2 hours (maximum 6 hours) is the recommended treatment for button battery ingestion, particularly when impacted in the esophagus, due to the high risk of pressure necrosis, electrical burns, and chemical injuries. 1

Initial Evaluation and Diagnosis

• Obtain immediate radiographs (X-rays) of the neck, thorax, and abdomen to confirm:
  • Presence of the battery
  • Location (especially if in esophagus)
  • Size and form of the battery 1
• Do NOT delay intervention for contrast studies, as these are contraindicated and may delay critical treatment 1
• If perforation is suspected, obtain CT scan to evaluate for complications 1

Treatment Algorithm Based on Battery Location

1. Esophageal Impaction

• Immediate emergency endoscopy (within 2 hours, maximum 6 hours) 2, 1
• While awaiting endoscopy (if ≤12 hours since ingestion):
  • Consider administering honey or sucralfate to potentially reduce injury, but this should NOT delay endoscopic removal 3
• For delayed diagnosis (>12 hours after ingestion):
  • Perform CT scan to evaluate for vascular injury before removing the battery 3
  • Proceed with endoscopic removal

2. Battery Beyond Esophagus

• For early diagnosis (≤12 hours) in asymptomatic patients:
  • Monitor with repeat X-ray in 7-14 days if not already evacuated in stool 3
• For delayed diagnosis (>12 hours):
  • Consider endoscopy to screen for esophageal damage and CT scan to rule out vascular injury, even in asymptomatic children 3

Endoscopic Removal Techniques

• Flexible endoscopy is the first-line approach for battery removal 2
• If standard retrieval methods fail due to tight impaction:
  • Consider combined techniques such as endoscopic balloon extraction with forceps retrieval (push-and-pull effect) 4
  • Rigid endoscopy should be considered as a second-line therapy, particularly for batteries located in the upper esophagus 2
• Surgical intervention (1-3% of cases) is required for:
  • Irretrievable foreign body
  • Perforation
  • Proximity to vital structures
  • Other complications 1

Post-Removal Management and Follow-up

• Evaluate for mucosal damage after battery removal
• Monitor for late complications for at least 2-4 weeks after ingestion, even if the battery has been eliminated 1
• Potential complications to monitor:
  • Esophageal stricture formation
  • Tracheo-esophageal fistula
  • Aorto-esophageal fistula
  • Cadmium toxicity (especially if battery casing was compromised) 1
• Follow-up endoscopy may be needed to assess healing and detect stricture formation

Important Clinical Pitfalls

1. Delay in diagnosis and treatment: Tissue damage progresses rapidly, with significant damage occurring within 2 hours and potentially leading to complete esophageal perforation within 24 hours 5

2. Underestimating asymptomatic cases: Even asymptomatic children with delayed diagnosis should be evaluated for esophageal damage 3

3. Inadequate follow-up: Complications can develop weeks after the initial event, necessitating monitoring for at least 2-4 weeks 1

4. Mistaking battery for coin: Button batteries appear as a double-density shadow on X-ray with a characteristic "halo" or "double-ring" sign, distinguishing them from coins 1

The severity of tissue damage from button battery ingestion is related to the electrochemical reaction that occurs in the moist environment, creating an acidic medium at the positive electrode and a basic medium at the negative electrode, leading to coagulation and colliquation necrosis respectively 5. This understanding underscores the urgency of prompt removal to prevent life-threatening complications.