1. Button Battery Ingestion in Children: Experience in KCGH
Dr. Adnan MH Hamawandi
Professor of Pediatrics
School of Medicine
University of Sulaimani
Hamawandi et al., Pediat Therapeut 2015, 5:3

2. What is a Button battery?
A Button battery or button cell is a small single cell battery shaped as a squat cylinder typically 5 to 25 mm in diameter and 1 to 6 mm high—like a button on a garment, hence the name. Lithium cells are generally similar but somewhat larger; they tend to be called either lithium cells or batteries or coin cells rather than button cells.

3. Structure
Button batteries are formed by compacting metals and metal oxides on either side of an electrolyte-soaked separator. The unit is then placed in a 2-part metal casing held together by a plastic grommet The grommet electrically insulates the anode from the cathode. The metal undergoes oxidation on one side of the separator, while the metal oxide is reduced to the metal on the other side, producing a current when a conductive path is provided.

4. Uses
Button cells are used to power small portable electronic devices such as wrist watches, pocket calculators, artificial cardiac pacemakers, implantable cardiac defibrillators, hearing aids and child Toys. 

5. Epidemiology
Button Battery is an increasingly common foreign body ingested by children. The vast majority of disc battery ingestions occur when curious children explore their environment.

6. Cont. Epidemiology
Button batteries contain mercury, silver, zinc, manganese, cadmium, lithium, sulfur oxide, copper, brass, or steel. These are the components of the anode, cathode, and case containing the battery. Disc batteries also contain sodium hydroxide or potassium hydroxide to facilitate the electrochemical reaction through the separator.

7. Cont. Epidemiology
In a series of 56,535 battery ingestions from in which the type of battery was known in 57.7% of the
cases, 42% were manganese dioxide, 32% were zinc-air, 13% were silver oxide, and 9% were lithium.
 In 2008, 24% of the batteries ingested were lithium cells; an upward trend that started in the late 1990s with a corresponding drop in the number of mercuric oxide cells.
Litovitz T, et al. Emerging battery-ingestion hazard: clinical implications. Pediatrics. 2010;125(6):

8. Cont. Epidemiology
Button batteries vary in diameter from mm and in weight from 1-10 g. Known diameters of ingested disc batteries are as follows: 11.6 mm (55% of cases), mm (31% of cases), 20 mm or more (6.7% of cases), 5.8 mm (3% of cases). Cases of large diameter (≥20 mm) disc battery ingestions increased from 1% of cases from to 18% of cases in 2008.
Litovitz T, et al. Emerging battery-ingestion hazard: clinical implications. Pediatrics. 2010;125(6):

9. Cont. Epidem
From , 92% of disc batteries from fatal ingestions or those with major outcomes were 20-mm lithium cells. Most were imprint code CR 2032 (71%) or CR 2025 (21%). "CR" represents the battery chemistry, "20" is the diameter, and "32" indicates the thickness (3.2 mm) of the battery.

10. Pathophysiology
Button batteries do not usually cause problems unless they become lodged in the GI tract. The most common place
disc batteries become lodged, resulting in clinical sequelae, is the esophagus. Batteries that successfully traverse the esophagus are unlikely to lodge at any other location. Liquefaction necrosis may occur because sodium hydroxide is generated by the current produced by the battery.

11. Pathophysiology
Previous experiments have invoked 3 factors, in order of importance: 1. generation of an external electrolytic current that hydrolyzes tissue fluids and produces hydroxide at the battery’s negative pole, 2. leakage of alkaline electrolyte (hydroxide),and 3. physical pressure on adjacent tissue (which, alone, does not cause significant injury). .
Yoshikawa T, et al . Experimental investigation of battery-induced esophageal burn injury in rabbits. Crit Care ed.
1997;25(12):2039 –2044
Yamashita M, et al. Esophageal electrochemical burn by button-type alkaline batteries in dogs.Vet Hum Toxicol
. 1987;29(3):226 –230

12. Pathophysiology
Esophageal damage can occur in a relatively short period of time (2-2.5 h); perforation has occurred as rapidly as 6 hours after ingestion.
If a battery becomes impacted in the esophagus, it may penetrate the esophageal wall and cause a tracheo-esophageal fistula and even fistulization into major vessels with massive hemorrhage.
Injury can continue after endoscopic battery removal for days to weeks due to residual alkali or weakened tissues.
Slamon NB, et al. An unusual case of button battery-induced traumatic tracheoesophageal fistula. Pediatr Emerg Care. 2008;24(5): Mortensen A, et al. Cardiac arrest in child caused by button battery in the oesophagus and complicated by aorto-oesophageal fistula Ugeskr Laeger. 2009;171(43):3098 –3099

13. Clinical presentation
1. Battery ingestion witnessed or highly suspected.
2. Symptomatic patient, NO history of battery ingestion .
Consider battery ingestion if:
Airway obstruction or wheezing
Drooling
Vomiting
Retrosternal discomfort
Difficulty swallowing, decreased appetite, refusal to eat
Coughing, choking or gagging with eating or drinking
Most children who ingest a disc battery remain asymptomatic and pass the battery in their stool within 2-7 days. Only 10% of patients who ingest disc batteries report symptoms.

14. Standard radiologic workup for suspected battery ingestion is the chest X- ray film, in both AP and lateral views.

15. Radiology
In case more than several hours have passed since ingestion, it is recommended to perform a radiographic contrast study to rule out perforation. In some circumstances an esophageal foreign body may cause a meditational mass, which can be diagnosed by chest X-ray.

16. Management
Emergency esophagoscopy is mandated when disc battery is identified on chest radiography. When substantial esophageal erosion is detected, bronchoscopy may be performed to evaluate the tracheal wall, and an esophagogram will assist in evaluating for a perforation.
Grisel JJ, et al. Acquired tracheoesophageal fistula following disc-battery ingestion: can we watch and wait?
Int J Pediatr Otorhinolaryngol. 2008;72(5):

17. Management
In the presence of a contained perforation, conservative measures such as TPN, NG tube placement under fluoroscopy, anti-reflux medication, and intravenous antibiotics should be considered.
Conservative management can be continued if radiologic evaluation suggests that the perforation is getting smaller.
If the perforation persists after several weeks or enlarges or the patient deteriorates, surgical treatment should be considered.
Hamawandi, A.M.H., et al. Esophageal Perforation in Children: Experience in Kurdistan Center for Gastroenterology
and Hepatology/Iraq. Open Journal of Gastroenterology, 2014; 4,

18. Case Reports
Case reports of button battery induced injuries started since There were more than 50 reports of disc battery ingestion causing esophageal injuries, esophageal perforation, Tracheoesophageal fistulae, major vascular injuries and bowel perforation.

20. Case Series
Kimball et al (2010), reported ten pediatric patients who underwent endoscopic retrieval of an esophageal button battery over a 10-year period.
Three patients had minimal esophageal damage; the other 7 sustained severe and extensive esophageal damage involving the muscularis (n=5) or developed a perforation (n=2).
One of these patients had an extensive injury that extended into the trachea resulting in a Tracheoesophageal fistula
Kimball et al; Arch Otolaryngol Head Neck Surg 2010; 136 (9):

21. Case Series
Tabari et al (2011), reported four patients aged between 9 months to 2.5 years with history of button battery ingestion, two boys and two girls.
The common symptoms were cough, cyanosis, and dysphagia, choking and vomiting.The diagnosis was performed through x-ray, barium swallow and CT scan.
All batteries were impacted in the esophagus, they were removed endoscopically, but had (TEF).
All the patients underwent TEF repair surgically. There was no morbidity in three patients, but one patient developed moderate esophageal stenosis.
Tabari A K, et al. Caspian J Intern Med 2011; 2(4): 338

22. Case Series
Mirshemirani et al (2012), reported 22 cases (11 males and 11 females) of button battery ingestion aged 9 months to 12 years.
Common symptoms were vomiting, cough, dysphagia, and dyspnea. The mean duration of ingestion was 2.7 days (4 hours to 1.5 month)
Nineteen patients had histories of disc battery ingestion. Only three cases had batteries impacted in the esophagus.
Twelve batteries were removed endoscopically, 6 batteries spontaneously passed within 5 to 7 days, and 4 patients required surgery due to due to TEF (3) and intestinal perforation (1).
Mirshemirani A, et al. Middle East Journal of Digestive Diseases 2012; 4 (2):

23. Kurdistan Center for Gastroenterology and Hepatology series
There were 20 cases of button battery ingestions within 8 years ( ). Age range was 10 months to 70 months(mean 28 months), 12 males and 8 females. Seven patients passed the batteries spontaneously without harm within 2-5 days. In 13 patients batteries were retrieved endoscopically from the esophagus (7)patients and from the stomach (6) patients.
The endoscopic findings in the 7 patients in whom the button batteries were in the esophagus were; severe injury in 5 patients, mild injury in 2 patients; there was perforation of the esophagus in 4 patients associated with Tracheoesophageal Fistula in three patients. Two patients underwent surgery for TEF repair, two patients undergone repeated endoscopic dilation for stricture and one patient with TEF died as the family refused surgery.

24. Summary of patients’ data undergone endoscopic retrieval of disc batteries.
Age Battery presenting Location Endoscopic Fluoroscopic Treatment Length Outcome and sex size symptoms findings findings of stay
10 M ♀ 10mm dysphagia Upp.Eso. Severe inj Normal Medical d Stricture
48 M ♂ 10mm witness Stomach Normal N/A Observ d Normal
45 M ♀ 23mm cough Mid.Eso. Severe inj Perf.+TEF Surgery d Normal
60 M ♀ 10mm witness Stomach Normal N/A Observ d Normal
24 M ♂ 10mm witness Stomach Normal N/A Observ d Normal
12 M ♂ 20mm dysphagia Mid.Eso. Severe inj Perf.+TEF Surgery d Normal
20 M ♂ 21mm dysphagia Mid.Eso. Severe inj Perf.+TEF Refused d Died
36 M ♀ 10mm witness Stomach Normal N/A Observ d Normal
42 M ♂ 10mm witness Stomach Normal N/A Observ d Normal
18 M ♂ 12mm witness Low.Eso. Mild inj N/A Observ d Normal
16 M ♀ 12mm witness Mid.Eso Severe inj perf Medical d Stricture
17 M ♂ 10mm witness Mid.Eso Normal N/A Observ d Normal
24 M ♀ 10mm witness Stomach Normal N/A Observ d Normal

25. A Safer Disc Battery
A new battery coating could help prevent burns from accidental ingestion of button batteries. The new coating could ward off such damage by stopping batteries from releasing current when they aren’t in devices; using a quantum tunneling composite (QTC), which consists of conductive metal microparticles suspended in an insulating silicone matrix.

26. A Safer Disc Battery
Current flows through the QTC only when enough pressure from the battery compartment is applied to push the microparticles close enough for charge to jump between them. The pressure needed can be changed by adjusting the stiffness of the matrix.
In animal studies, the QTC-coated battery caused no tissue damage.

27. Conclusion
Severe injury can occur rapidly following disc battery ingestion.
A high index of suspicion for an esophageal disc battery is necessary for early diagnosis.
Emergency endoscopic removal is necessary.

28. Thank you
Thank you