The Poison Review

Emerging Battery-Ingestion Hazard: Clinical Implications.  Litovitz T et al.  Pediatrics June 2010;125:1168-1177.

Abstract

This must-read article points out that with the growing popularity of 20-mm lithium batteries, the percentage of button battery ingestions involving major outcomes or fatalities is increasing.  The authors, from the National Capital Poison Center in Washington, DC, analyzed data from 3 major sources concerning these ingestions.  They make the following important points:

• A button battery stuck in the esophagus can cause significant injury if not removed within 2 hours.

• Complications of button battery ingestion include tracheoesophageal fistula or other perforation, esophageal stricture and stenosis, vocal cord paralysis, aspiration pneumonia, and — most devastatingly -- exsanguination from erosion into arteries.

• Especially if the ingestion is not witnessed, initial presentation can be nonspecific with symptoms such as vomiting, dysphagia,  fever, lethargy, cough, wheezing, and/or dehydration.

• Button batteries are often mistaken for coins on radiographs. A way to avoid this pitfall is to get a lateral view of the object, and look for a narrow side and a wider side.

• The narrow side will be the negative pole, which is where tissue necrosis will tend to occur secondary to hydroxide formation. (The rule of the 3-Ns).

• Even after treatment these patients must be watched carefully, since life-threatening hemorrhage has been reported as late as 18 days after removal.

• Risks factors correlated with poor outcomes include ingestion of large-diameter (> 20-mm) lithium cells and age < 4 years.

There were some confusing and unresolved points made in the article.  The authors state that: “Endoscopic removal of esophageal batteries (rather than blind retrieval by balloon catheter or magnet) is essential . . .”  Unfortunately, the authors do not suggest how to proceed if it is impossible to arrange for endoscopy within the 2 hour window.  Also, their graphic treatment guideline (Figure 4) is quite confusing, with arrows seemly coming from and going nowhere.  Nevertheless, this is an essential article.

The following is a CBS news story about button battery ingestion, including an interview with Dr. Toby Litovitz, the main author of this article: