Button battery

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Esophageal location

Gastric and intestinal location

BBs exert multiple pathologic effects on the GI tract when ingested. If the battery’s electrodes (the flat sides) closely contact the moist mucosal walls of the GI tract (as commonly occurs in the esophagus), a direct, low-voltage current travels into the adjacent tissues and leads to the creation of hydroxide ions in surrounding tissues and a severe electrical burn. Studies in animal models observed that lithium-ion BBs can cause superficial burns within 15 minutes.$^{44}$ An in vitro study placed BBs in normal saline and observed a release of black-brown precipitate and an alkalinization of the solution within 2.5 hours, where the pH increased from 5.0 to 10.0.$^{45}$ In the same study, in vivo experiments observed mucosal damage in the GI tract of animals within 2 hours of BB placement. 

In human ingestions, these effects can be seen clinically, although only approximately 0.5% of ingestions result in major complications.$^{40}$ A systematic review of 24 case reports and 7 articles demonstrated that complications are most commonly seen with lithium-ion BBs, larger BBs (>2 cm) and BBs that are new or unused.$^{46}$ Complications include ulceration (22%), perforation (18%), and stricture (13%). A devastating complication of BB ingestion, an aorto-esophageal fistula, can present up to 18 days after BB removal, due to ulcerative healing leading to fistula formation and massive GI hemorrhage.$^{47}$ A systematic review found vascular hemorrhage to be the most common cause of death from BB ingestion; only 18% of vascular hemorrhage cases from the National Poison Center registry were deemed survivable.$^{48}$

Treatment

Button batteries in the esophagus should be removed endoscopically as quickly as possible—ideally within 2 hours—regardless of symptoms, battery type, or size. There is more controversy surrounding the treatment of gastric and intestinal button batteries (see below). The National Button Battery Hotline at 1-800-498-8666, based out of the Rocky Mountain Poison Center in Denver, CO, can be a resource in complicated cases and provides 24/7 guidance to clinicians.

If the patient is older than 12 months, honey is one measure that can be taken while awaiting endoscopy. (Honey for infants <12 months is not recommended due to the risk for infant botulism.) Animal studies have shown that honey and sucralfate neutralize the elevated tissue pH that results from alkaline batteries, and decreases the thickness and size of burns in vivo.$^{88}$ Exceptions to the pre-endoscopy nil per os (NPO) rule can be made in the ED in order to give 5 to 10 mL of pure honey or sucralfate to patients who are able to tolerate it if the ingestion was within 12 hours. The National Capital Poison Center recommends up to 6 doses, given every 10 minutes.$^{89}$

A multidisciplinary, team-based approach to definitive management is necessary to address any potential complications that may occur. Published algorithms for BB management include cluster notification of otolaryngology, gastroenterology, and GI surgery.$^{90}$ Endoscopy should ideally be performed in the operating room so that cases of perforation of hemorrhage can be addressed quickly. If clinicians are working at a critical access hospital with limited subspecialty coverage, every effort should be made to transfer the patient directly to the operating room at a referral center.