Button Battery Injury and swallowed foreign objects
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Introduction

Most swallowed foreign objects are harmless and may not need any investigation – just reassurance. Button battery injuries (and to a lesser extent – magents) are uniquely urgent – as the contents can cause burn injuries to surrounding tissues within 15 minutes. Swallowing honey or sucralfate within 12 hours of ingestion can delay the onset of tissue damage whilst awaiting definitive removal (e.g. via endoscopy or surgically).

Button battery injury can occur when a button battery is swallowed (or placed in another orifice – such as the ear, nose, vagina or anus) – usually (but not always!) by a paediatric patient. There are many different types of button battery in many shapes and sizes, but any battery with a voltage of 1.2V or greater can cause injury. Smaller batteries are less likely to cause injury as they can pass through the digestive tract more easily and are less likely to become impacted (get stuck).

Although many cases present as witnessed or suspected ingested button batteries, an unwitnessed event can present with non-specific gastrointestinal and respiratory symptoms, and can be fatal if not recognised.

Most of the damage from button battery injury comes from the electrical current it creates in the tissues that it touches – NOT from leaking of the contents of the battery. Tissue damage occurs within 15 minutes of sustained contact with any piece of tissue.

Therefore – button battery injury is an important time-dependent emergency – tissue damage can occur within minutes when a battery becomes impacted within the gastrointestinal tract (or other tissue).

Less dangerous- but still serious – is when small magnets are swallowed (at least one needs to be swallowed for them to be dangerous). They can stick together with tissue between them causing a pressure injury to the digestive tract. This typically takes much longer than a button battery injury but the consequences can be just as serious. Other foreign objects are generally less dangerous and most can be allowed to make their own way through the digestive tract. It is often appropriate to perform an x-ray to assess the location of the foreign object – large objects that remain in the stomach may need to be retrieved via gastroscope as they will not pass naturally. Objects that have already moved beyond the stomach usually cannot be retrieved and should be allowed to pass naturally, unless an emergency arises. Also consider than some foreign objects may be toxic and consider contacting poisons information.

In Australia (population is about 35% that of the UK) there are about 200 button battery injuries per year (about 5–10% of these are serious) and on average about one death every 3 years.

Monopoly pieces - swallowed foreign object
A selection of metallic monopoy pieces

One particularly memorable clinical incident was when a psychiatric patient swallowed an entire set of metallic monopoly pieces. This made for a great x-ray – Dr Tom Leach

Epidemiology & Aetiology

  • Typically children aged 14-36 months (mean age 23 months)
    • Related to child’s developmental age – which at this stage involves placing a lot of objects in the mouth!
    • Children this age are unable to reliably report what they have eaten
  • M > F (slightly)
  • Most button batteries are lithium based
  • In most button battery injuries the source of the battery cannot be identified
  • Common locations for button batteries in household items include toys, hearing aids, watches, remote controls, car key remotes, medical equipment (thermometer, glucometer)
  • 1/4 of cases of ingestion are unwitnessed

Pathophysiology

  • Tissues in contact with the button battery complete the electrical circuit and are subject to tissue damage
  • This can occur within 15 minutes. Perforation can occur within 2 hours. Fistula formation can also occur
  • As such, button battery injury can be life threatening
  • Usually the battery has to be impacted at the same location for this period of time (or greater) for the injury to occur
  • The injury may also progress after removal of the battery – cases of perforation have been reported to occur after removal
  • The most common location of impaction is in the oesophagus. Batteries that have travelled further into the digestive tract than this are much less dangerous.
  • Objects >6cm long or >2cm can become stuck at the pylorus and may need to be retrieved endoscopically.
  •  Any battery of >1.2V can cause injury – in Australia – this includes ALL commercially available batteries
Button battery injury
Button battery injury demonstrated with a pieces of meat. (A) shows the damage after 15 minutes and (B) after 2 hours. Image from RACGP – https://www1.racgp.org.au/ajgp/2022/july/button-battery-injury

 

Presentation

  • Witnessed button battery ingestion should always be taken seriously
  • Unwitnessed events can difficult to spot. Symptoms may include:
    • Dysphagia
    • Nausea
    • Vomiting
    • Drooling
    • Fever
    • Cough
    • Irritability
  • More serious symptoms that can indicate perforation include:
    • Haematemesis
    • Epistaxis
    • Melaena
    • Altered consciousness
    • Chest pain
  • Remember typical age of presentations around 14-23 months

Investigations

X-ray is the diagnostic imaging modality of choice

  • ”Mouth to anus” AP and lateral x-ray views
  • Circular radio-opaque object will be seen
  • Sometimes described as having a “double ring” or “Halo” sign – caused by the two halves of the button battery
  • Button battery under the diaphragm does NOT exclude oesophageal impaction

Management

Management is time critical. 

  • As soon as the diagnosis is made with x-ray – then involve the relevant teams. This is typically paediatric gastroenterology, but may also include ENT
  • If <12 hours since ingestion and child aged >12 months – give honey / sucralfate 10mls (2 teaspoons) every 10 minutes- maximum of 6 doses
    • Under 12 months – give sucralfate over honey – which carries risk of botulism in those under 12 months
  • If located in the oesophagus – urgent removal by gastro/ ENT is indicated
    • Intraoperative acetic acid can neutralise pH and may reduce level of tissue damage
    • Intraoperative assessment of damage determine post-operative diet and follow-up
  • If in the stomach or small intestine – discuss with specialist team
    • Often these can be monitored and / or discharged
  • Haematemesis or melena may indicate fistulation to the aorta – involve cardio thoracic team urgently
    • This complication is sadly usually fatal

In other orifices

  • Do NOT flush as the fluid can increase the conductivity and thus the tissue damage
  • May require ENT or other specialist team fro removal

Complications

Long-term complications can be significant, although are rate. These are typically strictures or fistula formation – for example oesophageal stricture, tracheo-oesophageal structure, tracheal stenosis.

Prevention

  • Button batteries should be stored out of reach of children
  • Encourage families to send old button batteries for recycling
  • If they cannot be recycled they should be wrapped in tape and put in the bin
  • Since 2020 – all button batteries in Australia must come in secure packaging, and all button battery compartments in products must have a secure battery compartment (require device – such as screwdriver – to be opened)

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Dr Tom Leach

Dr Tom Leach MBChB DCH EMCert(ACEM) FRACGP currently works as a GP and an Emergency Department CMO in Australia. He is also a Clinical Associate Lecturer at the Australian National University, and is studying for a Masters of Sports Medicine at the University of Queensland. After graduating from his medical degree at the University of Manchester in 2011, Tom completed his Foundation Training at Bolton Royal Hospital, before moving to Australia in 2013. He started almostadoctor whilst a third year medical student in 2009. Read full bio

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