Ingestion of a button battery by children is considered an absolute surgical emergency and a dangerous and challenging form of foreign body ingestion that requires a rapid diagnosis and urgent removal [
An increase in button battery ingestion rates in children has occurred in recent years due to the spread of home multimedia devices that use larger batteries that may lead to life-threatening consequences, such as perforation or fistula, particularly in the case of esophageal impaction, even after removal of the battery from the esophagus [
Ingesting a button battery carries the risk of rapidly progressing and potentially life-threatening damage to the esophagus, due to electrical injuries (flow of electrical current from the positive to negative terminals of the battery bridged by the mucosa), mechanical injuries (pressure necrosis by mucosal compression), and caustic injuries (leakage of alkaline electrolytes and coagulative necrosis) [
Given experimental and clinical data that show that coagulative necrosis starts within 15 min of battery-esophageal contact [
This retrospective case series study was designed to present the clinical profiles and outcomes of esophageal button battery ingestion cases treated at our institution over an 8-year period.
A total of 17 children who presented to a tertiary care clinic after ingesting a button battery between January 2011 and December 2018 were included in this retrospective case series study. Data on patient demographics (age and gender), size, and esophageal location of the battery, time from ingestion to admission, symptoms on admission, witnessing of the event, grade of mucosal injury according to the Zargar classification [
Posteroanterior and lateral chest radiographs were taken in all cases. Emergency rigid esophagoscopy was performed under general anesthesia for all patients. Anesthesia was induced with 2 mg/kg propofol or 3 mg/kg pentothal injection, and 1
The median age of the patients was 29 months (range, 2–99 months). Boys comprised (
Overall characteristics (
|
29 (2–99) | |
|
Boy | 11 (64.7) |
Girl | 6 (35.3) | |
|
Hypersalivation | 6 (35.3) |
Vomiting + hypersalivation | 5 (29.4) | |
Dysphagia | 2 (11.8) | |
Dysphagia + vomiting | 2 (11.8) | |
Coughing + hypersalivation | 1 (5.9) | |
Recurrent pulmonary infection + fever | 1 (5.9) | |
|
Witnessed | 7 (41.2) |
Not witnessed | 8 (47.1) | |
|
Proximal esophagus | 10 (58.8) |
Midesophagus | 3 (17.6) | |
Distal esophagus | 4 (23.5) | |
|
6 (3–24) | |
|
18 (14–22) | |
|
0 | 2 (11.8) |
I | 2 (11.8) | |
IIA | 6 (35.3) | |
IIB | 2 (11.8) | |
IIIA | 2 (11.8) | |
IIIB | 2 (11.8) | |
Unknown | 1 (5.9) | |
|
9 (53) | |
Early complication-vocal cord paralysis | 1 (5.9) | |
Late complication-stricture | 7 (41.2) | |
Late complication-surgery | 1 (5.9) |
A 2-month-old boy with a recurrent pulmonary infection and fever was admitted 40 days after ingesting a battery. The battery was located in the proximal esophagus, and surgery was required due to development of a tracheoesophageal fistula (Figure
Images from a 2-month-old boy who was admitted to the hospital 40 days after ingesting a button battery. (a) Anteroposterior chest X-ray with double-contour aspect of the battery lodged in the proximal esophagus. (b) Battery after endoscopic removal. (c) Surgery due to development of a tracheoesophageal fistula.
Case-based characteristics.
Case number | Age (month) | Gender | Location | Symptom | Time from ingestion to admission | Diameter of battery (mm) | Ingestion witnessed | Mucosal injury (Zargar’s grade) | Complication | Follow-up |
---|---|---|---|---|---|---|---|---|---|---|
|
2 | Boy | Proximal | Recurrent pulmonary infection, fever | 40 days | UN | No | UN | Tracheoesophageal fistula | Surgery |
|
77 | Boy | Proximal | Hypersalivation | 4 h | 21 | No | I | Normal | |
|
17 | Boy | Distal | Dysphagia | 6 h | 19 | Yes | IIA | Normal | |
|
14 | Boy | Mid | Vomiting + hypersalivation | UN |
18 | No | I | Normal | |
|
39 | Boy | Proximal | Coughing + hypersalivation | 6 h | 17 | Yes | IIB | Stricture | Dilatation |
|
28 | Girl | Distal | Dysphagia + vomiting | 4 h | 18 | UN | IIA | Stricture | Dilatation |
|
34 | Girl | Distal | Vomiting + hypersalivation | UN | 19 | Yes | IIA | Normal | |
|
39 | Boy | Mid | Dysphagia | 24 h | UN | No | IIIA | Unilateral vocal cord paralysis, stricture | Dilatation |
|
99 | Girl | Proximal | Hypersalivation | 6 h | 20 | No | 0 | Normal | |
|
36 | Boy | Proximal | Vomiting + hypersalivation | 6 h | 17 | Yes | IIB | Normal | |
|
2 | Girl | Proximal | Hypersalivation | 5 h | 14 | UN | IIA | Tracheoesophageal fistula death after 4 days, sepsis | Death |
|
8 | Boy | Proximal | Hypersalivation | 8 h | 15 | No | IIA | Normal | |
|
42 | Girl | Proximal | Hypersalivation | 3 h | 22 | Yes | 0 | Normal | |
|
55 | Girl | Mid | Vomiting + hypersalivation | 24 h | 19 | No | IIIB | Stricture | Dilatation |
|
15 | Boy | Distal | Dysphagia + vomiting | 4 h | UN | No | IIA | Stricture | Dilatation |
|
23 | Boy | Proximal | Hypersalivation | UN | 18 | Yes | IIIB | Stricture | Dilatation |
|
29 | Boy | Proximal | Vomiting + hypersalivation | 6 h | UN | Yes | IIIA | Stricture | Dilatation |
A 39-month-old boy was admitted 24 h after ingesting a battery with a complaint of dysphagia. The battery was located in the midesophagus, and the mucosal injury was grade IIIA. The patient developed unilateral vocal cord paralysis and required a dilatation intervention (Table
A 2-month-old girl was admitted 5 h after ingesting a battery with a complaint of hypersalivation. The battery (14 mm) was located in the proximal esophagus, and the patient developed a tracheoesophageal fistula followed by subsequent sepsis and died 4 days later (Table
None of the grade 0 or grade I cases required dilatation, whereas two (33.3%) of six cases with grade IIA, one of two (50.0%) cases with grade IIB, and all cases (two for each) with grades IIIA and III B required dilatation (Table
Overall, dilatation was needed in two (33.3%) of six girls and five (45.5%) of 11 boys (Table
Four cases with grade 0-I mucosal injuries were admitted to the hospital at a median of 5 h (range, 3–6 h) after ingestion. Six cases with grade IIA-B injury were admitted to the hospital at a median of 5.5 h (range, 4–8 h) after ingestion, whereas three cases with grade IIIA-B injury were admitted to the hospital at a median of 24 h (range, 6–24 h) after ingestion (Table
Two cases with a midesophageal location of the battery were admitted to the hospital at 24 h after ingestion, whereas those with proximal or distally located batteries were admitted to the hospital at 3–8 h after ingestion (Table
Our small group showed us that any delay could lead to serious complications, even to death. We could speculate that an interventional latency in Grade IIA injury that developed even after 5 hours needed future esophageal dilatations and such cases should be dealt with utmost speed.
In the present case series, 64.7% of the children were boys (age 2–99 months), and the initial symptoms were nonspecific. This is consistent with the clinical profile of reported battery ingestion cases in the literature, including male predominance (58.7–84.6%) [
In a case series of 16 children who ingested a button battery, vomiting (33.3%), swallowing and/or feeding problems (27.8%), and fever (27.8%) were the most common symptoms [
The nonspecificity of the initial presentation is important, given that it has been included among the factors leading to a delayed diagnosis together with failure to detect the battery on an X-ray and lack of awareness of the seriousness of the condition by the initial care team [
Button batteries are the second most frequently ingested foreign body after coins [
However, morbidity and mortality associated with ingesting a button battery are not strictly limited to vascular injury and bleeding events, but also include serious complications likely to develop after removing the battery, such as esophageal-tracheal fistulas, esophageal perforations, esophageal stenosis, vocal cord paralysis, pneumothorax, aspiration pneumonia, spondylodiscitis, esophageal-aortal fistulas, and respiratory and circulatory failure [
In a reported series of 13 cases with severe esophageal injury from ingesting a battery, four (30.8%) cases resulted in an esophageal perforation, three (23.1%) developed an esophageal stricture, and two (15.4%) required gastrostomy placement; the mortality rate was 23.1% [
A history of treatment-resistant pulmonary infection in the 2-month-old boy in our case series who was admitted 40 days after ingestion is notable given the presence of a recurrent lung infection and coughing despite medical therapy, which should raise suspicion of an esophageal foreign body, even in the absence of a witnessed ingestion event [
Similarly, a likelihood of complications developing and leading to mortality even after removal of the battery has been described in two case reports [
In our case series, none of the cases with grade 0 or grade I mucosal injury required dilatation, but dilatation was needed in three of eight cases with grade IIA-IIB injury and all four cases with grade IIIA-IIIB injury. Hence, our findings emphasize the impact of the initial mucosal injury on the clinical outcome after endoscopic removal of a battery, with a higher likelihood of dilatation intervention in patients who present with a higher-grade mucosal injury, particularly grade III injury. This seems notable given that cases with grade IIIA-IIIB mucosal injury (range, 6–24 h) in our series were admitted to the hospital later than those with grade IIA-IIB (range, 4–8 h) or grade 0-I (range, 3–6 h) mucosal injury.
The length of time that the battery is lodged in the esophagus (duration of exposure) increases the severity of esophageal damage, leading to mucosal ulceration and perforation [
Nevertheless, delayed admission is not a definite predictor of poorer outcome in cases of button battery ingestion, as severe injuries may also occur in cases admitted early and diagnosed rapidly [
Our findings reveal that the ranges for admission time in boys and girls, battery diameter, and age were similar to the current literature. Hence, the tendency for a greater need for dilatation in boys than in girls in our population seems to be related to the higher rate of grade III mucosal injury in boys than in girls.
Community education and raising awareness are crucial to reduce the incidence of childhood aspiration of foreign bodies, which is a preventable condition [
The present case series study describing the clinical profiles and outcomes of 17 children who ingested an esophageal button battery revealed male predominance, young patient age, and admission at a median 6 hours after ingestion, with nonspecific symptoms at admission. Our findings support the success of rigid endoscopy for urgent removal of an ingested esophageal button battery, but they also indicate the likelihood of severe and potentially lethal complications even after endoscopic removal of the battery and the need for dilatation in nearly half of the cases. Future large-scale clinical studies addressing long-term outcomes in relation to the time from ingestion to admission, esophageal location of the battery, and the mucosal injury grade are necessary to develop a risk stratification model and a well-defined standardized algorithm for postremoval management of children with moderate to severe esophageal injury from ingesting a button battery.
The data used to support the findings of this study are included within the article.
The author declares no conflicts of interest.