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Complicated Cases of Lithium Battery Ingestion: Delay can be Deadly

  • Indira Gandhi Institute of Medical Sciences, Patna, India
  • Regency hospital, lucknow


Increasing use of button battery (BB) in household products and toys is responsible for the growing incidence of button battery ingestion (BBI). The BBI may cause life-threatening complications. We present a series of three cases of complicated BBI (lithium cell) with delayed presentation; one of them could not survive due to tracheoesophageal fistula and sepsis. Here, we highlight the importance of early endoscopic intervention and careful follow-up in children with lithium battery ingestion.
184184 © 2019 Journal of Digestive Endoscopy | Published by Wolters Kluwer - Medknow
for the growing incidence of button battery ingestion (BBI). The BBI may cause
life-threatening complications. We present a series of three cases of complicated
BBI (lithium cell) with delayed presentation; one of them could not survive due
totracheoesophagealstulaand sepsis. Here, we highlight the importance of early
endoscopic intervention and careful follow-up in children with lithium battery
 Button battery, disc battery, esophageal stricture, lithium cell,
tracheoesophageal stula
Arya Suchismita, Ravish Ranjan1, Ashish Kumar Jha1, Praveen Jha1, Madhur Choudhary1, Vishwa Mohan Dayal1,
Kuldeep Sehrawat1
2.5 kg loss of weight. Clinical examination showed
poor nutritional status, tachycardia, tachypnea, pallor,
fever, and bilateral chest crackles (left > right). Blood
investigations showed hemoglobin of 10 g/dL and
leukocytecount of 16,000/mm≥ (polymorphs88%); the
restofthe parameters werenormal.ChestX-rayshowed
bilateral upper zone opacity suggestive of pneumonia.
Endoscopyrevealed anopening (about1 cm) at the left
esophageal wall just distal to cricopharynx suggestive
ofTEF[Figure 1b].Anasogastric tubewas placed.The
stulawas repaired viaa lateral neck incision ofstula
after 1 week of antibiotics and nutrition support. The
stulous tract was divided, and repair of both trachea
and esophagus was performed with placement of a
muscle ap between them. The patient succumbed to
death on the 4th postoperative day due to uncontrolled
Case 2
An 11-year-old boy presented to the pediatrician
with recurrent vomiting. The symptom was gradually
progressive, and the patients did not improve after
3monthsof symptomatic treatment.Threemonths later,
thepatient developed dysphagia. ChestX-ray showed a
Children constitute around 80% of patients presenting
with foreign body ingestion. Foreign body ingestion
is common in toddler, especially between 6 months and
3 years of age.[1] About one-third of these patients remain
asymptomatic after ingestion of foreign body.[2] Increasing
use of button battery (BB) in household products and
toys is responsible for the growing incidence of button
battery ingestion (BBI).[3] BBI may cause life-threatening
of BBI with delayed presentation; one of them could not
Case 1
An 11-month-old boy with normal developmental
milestones presented to secondary health care center
with a history of BBI a few hours back, while he was
Chest X-ray showed a disc-shaped radio-opaque
shadow at the level of T4 vertebra [Figure 1a]. Serial
radiographs conrmed that the battery migrated to the
lower abdomen near the pelvic brim. One week later,
the child passed battery in the stool. Repeat radiograph
showedno radio-opaque shadow.Atreatment document
Onemonthlater,thepatientreferredtous with2weeks
history of fever, cough, vomiting after feeding, and
Departmentsof Pediatrics
GandhiInstitute ofMedical
Sciences,Patna, Bihar,India
Access this article online
Quick Response Code:
DOI: 10.4103/jde.JDE_86_17
Address for correspondence: Dr. Ashish Kumar Jha,
Department of Gastroenterology, Indira Gandhi Institute of
Medical Sciences, Patna, Bihar, India.
How to cite this article: Suchismita A, Ranjan R, Jha AK, Jha P, Choudhary M,
Dayal VM, et al. Complicated cases of lithium battery ingestion: Delay can
be deadly. J Dig Endosc 2018;9:184-7.
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Suchismita, et al.: Complicated cases of lithium battery ingestion: Delay can be deadly
Journal of Digestive Endoscopy ¦ Volume XX ¦ Issue XX ¦ Month 2018 185
Journal of Digestive Endoscopy ¦ Volume 9 ¦ Issue 4 ¦ October-December 2018
showed a BB in the mid-esophagus. The patient was
referred to us for its removal. We retrieved a lithium
battery (size 20 mm) impacted in the mid-esophagus.
Endoscopy after retrieval revealed a short-segment
mid-esophageal stricture with irregularly thickened
mucosa [Figure 2b]. Endoscopic dilatation of stricture
was performed. The patient was able to swallow
Case 3
A 3-year-old boy presented to us with a history of
BBI 4 days ago, and dysphagia. The patient was
managed conservatively for 3 days before being
referred to us. An urgent endoscopy was performed
which showed a BB embedded in the mucosa of the
upper esophagus. BB (lithium battery, size 20 mm)
was gently retrieved with the use of the foreign body
forceps [Figure 3a and c]. Repeat endoscopy after
retrieval showed a deep esophageal ulcer and mucosal
burn [Figure 3b]. The patient was kept orally for 48 h;
intravenous uids and antibiotics were prescribed. The
patientwas dischargedon postproceduralday 3. During
a month of follow-up, the patient showed no further
BB containing lithium is being increasingly used in
various electronic devices. Various types of BB can be
recognized by their imprint codes (CR2032: lithium,
20 mm diameter, 3.2 mm height; SR516: silver,
5.8 mm diameter, 1.6 mm height; LR1154/SR1154:
alkaline/silver, 11.6 mm diameter, 5.4 mm height). In
two of the three cases of current case series, lithium
body (LB) was identied by their imprint codes.
However, Case 1 presented to us after the passage of
tobring the musicaltoy for conrmationof the typeof
Studies showed worsening outcomes for BBIs,
paralleling the increase in ingestion of 20 mm LB.
Nearly all severe complications of BBI are associated
with lithium cells. In a study, major complications
were noted in 13% of children (<6 years of age) with
LB (>20 mm) ingestion.[4] In a study by Lahmar etal.,
analyzed. Twenty-ve of the 26 batteries had diameters
of ≥20 mm. Esophageal impaction time ranged from
cases were TEF, esophageal perforations, esophageal
strictures, and vocal cord paralysis in 48%, 23%,
38%, and 10% of patients, respectively.[3] Study of 13
severe cases of BBI showed esophageal perforation,
esophageal stricture, and mortality in 31%, 23%,
and 23% of cases, respectively.[6] In a study from the
United States, 12 patients with BBI (all aged <4 years)
expiredmainlybecauseof gastroesophagealhemorrhage
due to aortic-esophageal stula, TEF, and esophageal
perforation.[7] Other complication includes mediastinitis,
aspiration pneumonia, empyema, lung abscess,
pneumothorax, pneumoperitoneum, tracheal stenosis or
Predisposing factors for severe complications include
battery containing lithium, larger battery (>20 mm),
younger age (<4 years), location in the esophagus, and
delayed endoscopy. Ingestion of multiple batteries,
unnoticed ingestion, unknown ingestion time, the
riskfactorsfor serious complications.[3,9]Theabsenceof
endoscopy facility and the migration of battery toward
 (a)A button battery ona lateral viewof chest X-ray,
 Endoscopicimages showing impactedlithium battery (a),
esophagealulcerwithmucosalburn(b),andretrieved lithium battery
 (a) Button battery at level of T4vertebrae (chest X-ray),
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186186 Journal of Digestive Endoscopy ¦ Volume 9 ¦ Issue 4 ¦ October-December 2018
the lower abdomen on serial radiographs were the
possible reasons for the failure to order endoscopy in
case1ofthe present caseseries.BBIwent unnoticed in
The following mechanisms are responsible for the
tissue uids and produces sodium hydroxide at the
battery’s negative pole, (b) leakage of hydroxide ion,
and (c) local pressure effect. Hydroxide is the main
factor for mucosal injury. Hydroxide accumulation
have a higher voltage (3 V), generate more current
and therefore produces more hydroxide. LB can cause
Ina childwith foreignbody ingestion,a carefulhistory
is required to diagnose BBI. The physician should
consider BBI if a toddler presented with symptoms
such as vomiting, dysphagia, coughing, fever, airway
obstruction or wheezing, drooling, chest discomfort,
refusalto eat, choking, or gaggingwith feeding.In two
newstudies fromEurope, vomiting(31.3%), dysphagia/
feeding difculties (31.3%), fever (31.3%), and
fever with a cough (26.42%) were the most common
presenting symptoms; however, 18.8% of the patients
were asymptomatic. In these studies, the batteries were
removed by endoscopic (87.5%) or surgical (12.5%)
methods.[8,10] All patients with suspicion of BBI require
immediate radiograph, except asymptomatic ingestions
of<12-mm sizebatteries inpatients who are more than
12 years of age. Radiographs should be analyzed for
battery’s double-rim or halo effect on anteroposterior
view or step-off on the lateral view, to rule out the
 Endoscopy is indicated to conrm the diagnosis, assess
theseverityofinjury and toremovethe battery.Current
guideline indicates immediate endoscopy and removal
of esophageal ingested batteries >12 mm in size and in
all patients under 12 years of age.[12] Serious mucosal
injuries can occur without esophageal impaction and
symptoms can be observed even after the passage of
battery.[13] The rst case presented with TEF after a
week of passage of battery. North American society
for pediatric gastroenterology, hepatology, and nutrition
endoscopy committee advocates endoscopic retrieval
of all esophageal as well as gastric ingestions of disc
batteries>20 mm and/orin children <5 years of age.[14]
Smaller batteries lodged in the stomach or beyond in
an asymptomatic patient of an older age should be left
to pass spontaneously. Inspection of the stool or repeat
radiograph in 10–14 days is warranted to conrm
Several issues are still not clear such as
frequency of endoscopy or imaging, duration
of hospitalization/observation, duration of
the clinician’s individual decision is very important for
Fistulaformation maybe delayedup to 9–18 days after
batteryremoval;therefore,follow-upisrequired even in
the absence of stula at the time of endoscopy. In our
of BBI. Children with unnoticed BBI may present
several months later with delayed complications such
asesophageal stricture andtracheal stenosis.One of the
three cases of the current case series presented after 3
Lithium battery ingestion can lead to life-threatening
complications. Early endoscopic retrieval of the battery
is required to avoid severe complication in young
children with lithium battery ingestion. Young children
with ingestion of lithium battery of larger size should
receive careful follow-up for early detection of delayed
complication. The patients with unnoticed ingestion of
a BB may present several months later with delayed
Declaration of patient consent
The authors certify that they have obtained all
appropriate patient consent forms. In the form, the
patient has given his consent for his images and other
clinical information to be reported in the journal. The
patient understands that name and initials will not be
published and due efforts will be made to conceal
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Conicts of interest
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Nano-carbon materials are widely used and studied in a new generation of energy storage systems. Lithium batteries are widely used in transportation, power networks, and mobile devices. This paper mainly studies the estimation methods of SOC and SOH of lithium batteries based on nano materials. The SOC state equation and output equation of the lithium battery are established by the ampere integration method, and the parameters in the system are observed to achieve the purpose of observing the charging state of the lithium battery online. Using the internal resistance and SOC of the cell model as state parameters, the nonlinear transfer of equal and covariance is handled. The working voltage was modified using the lithium battery model, and different control methods were implemented for different SOC situations. According to the experimental data, the voltage estimation error is less than 2.1%, which can meet the actual use requirements. It was found that there are different types of lithium-ion batteries, and the model obtained by training samples of lithium-ion batteries reduces the prediction accuracy when predicting other lithium-ion batteries.
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Conclusion: Sixteen serious complications occurred after small and large button batteries ingestion between 2008 and 2016 in both symptomatic and asymptomatic children in the Netherlands. Therefore, immediate intervention after (suspected) button battery ingestion is required. What is Known: • Button battery ingestion may result in serious and fatal complications. • Serious and fatal complications after button battery ingestion are increasing worldwide. What is New: • Sixteen serious complications after button battery ingestion occurred during 2008-2016 in children in the Netherlands. • Serious complications were also caused by small batteries (< 20 mm) in the Netherlands and also occurred in asymptomatic Dutch children.
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Background: Although the ingestion of button batteries is an infrequent situation, it leads to a significant risk of causing serious damage. Objective: This study was carried out to describe all the cases of button battery ingestion recorded by the French Poison Control Centers over 16 years. Patients and methods: All the cases of button battery ingestion were recorded from 1 January 1999 to the end of June 2015, analysed (age, sex, number of ingested button batteries, clinical signs and treatments) and graded for severity according to the poisoning severity score. Results: The incidence of button batteries ingestions was constant over the 16-year period, with an average of 266±98.5 cases per year and a total of 4030 cases. Nevertheless, 21 cases were severe and two deaths occurred. Interestingly, for the two patients who died, the battery was stuck in the oesophagus and they presented anorexia and/or dysphagia, abdominal pain and fever and in one case, a melena 3 weeks after ingestion. Importantly, these symptoms were observed even if the battery was expelled in one fatal case. Conclusion: Ingestions of button batteries still occur and may cause serious damage, especially in children, and if the button battery is stuck in the oesophagus as it might cause severe symptoms. Patients who have ingested a button battery must be directed to the emergency department for medical evaluation, even if the button battery has been expelled from the body and even more if gastrointestinal symptoms are present.
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Over the last 10 years, there has been a dramatic rise in the incidence of severe injuries involving children who ingest button batteries. Injury can occur rapidly and children can be asymptomatic or demonstrate non-specific symptoms until catastrophic injuries develop over a period of hours or days. Smaller size ingested button batteries will often pass without clinical sequellae; however, batteries 20mm and larger can more easily lodge in the esophagus causing significant damage. In some cases, the battery can erode into the aorta resulting in massive hemorrhage and death. To mitigate against the continued rise in life-threatening injuries, a national Button Battery Task Force was assembled to pursue a multi-faceted approach to injury prevention. This task force includes representatives from medicine, public health, industry, poison control, and government. A recent expert panel discussion at the 2013 American Broncho-Esophagological Association (ABEA) Meeting provided an update on the activities of the task force and is highlighted in this paper.
Aim: Button battery ingestion (BBI) in children may cause severe complications. This analysis is a literature review of complications after pediatric BBI. Methods: Literature was searched on PubMed (1995-2015) using the terms "button battery," "ingestion," and "children." End points were age, type and diameter of battery, complications, affected organ, and fatality. Results: A total of 31 publications were analyzed. Patients from 4 months to 19 years old were included (n = 136,191, with n = 102,143 or 75% aged <6 y). In 6262, the diameter of the battery was documented. Batteries of 20 mm or greater in size were more prone to complications (n = 226). With regard to the anatomy, BBI caused complications mainly in the esophagus (n = 88, 38.94%). Sixty-one fatal outcomes were reported. Conclusions: Children younger than 6 years are the most prone to BBI, with lithium batteries of 20 mm or greater in size associated with complications. Complications have been estimated at 0.165%, with lethality of 0.04%. The esophagus is the most affected organ, but vascular involvement is often fatal.
Objectives: To study recent cases of esophageal injury due to button-battery ingestion in children presenting in pediatric ENT emergency departments of the Paris area of France (Île-de-France region), in order to propose appropriate preventive measures. Material and method: A retrospective descriptive single-center study included all children under 15 years of age, presenting in pediatric ENT emergency departments between January 2008 and April 2014 for button-battery ingestion with esophageal impaction requiring emergency removal. Results: Twenty-two boys and 4 girls, with a median age of 25 months, were included. Twenty-five of the 26 batteries had diameters of 20mm or more. Median esophageal impaction time was 7 hours 30 minutes (range, 2 to 72 hours). The complications rate was 23%. Mean hospital stay cost was €38,751 (range, €5130-119,737). The origin of the battery was known in 23 of the 26 cases: remote control without screw-secured compartment (42.3%), open battery pack (15.4%), children's toy (15.3%), camera (7.7%), watch (1 case) and hearing aid without screw-secured compartment (1 case). Conclusion: Esophageal lesions due to ingestion of button-batteries in children are almost always due to batteries larger than 20mm in diameter, mostly from devices with a poorly protected compartment, or batteries that are not individually packaged. These lesions cause serious complications in a quarter of cases and their management entails high health costs. Legislation requiring screw-secured compartments and individual blisters for batteries could have prevented 69.2% of the ingestions.
Gastrointestinal injuries secondary to button battery ingestions in children have emerged as a dangerous and difficult management problem for pediatricians. Implementation of a multidisciplinary team approach, with rapid and coordinated care, is paramount to minimize the risk of negative outcomes. In addition to providing a comprehensive review of the topic, this article outlines the authors' referral center's experience with patients with severe battery ingestion, highlighting the complications, outcomes, and important lessons learned from their care. The authors also propose an algorithm for clinical care that may be useful for guiding best management of pediatric button battery ingestion. Language: en
Foreign body ingestions in children are some of the most challenging clinical scenarios facing pediatric gastroenterologists. Determining the indications and timing for intervention requires assessment of patient size, type of object ingested, location, clinical symptoms, time since ingestion and myriad other factors. Often the easiest and least anxiety-producing decision is the one to proceed to endoscopic removal, rather than observation alone. Due to variability in pediatric patients' size, there are less firm guidelines available to determine which type of object will safely pass, as opposed to the clearer guidelines in the adult population. In addition, the imprecise nature of the histories often leaves the clinician to question the timing and nature of the ingestion. Furthermore, recent changes in the types of ingestions encountered, specifically button batteries and high-powered magnet ingestions, create an even greater potential for severe morbidity and mortality to children. As a result, clinical guidelines regarding management of these ingestions in children remain varied and sporadic, with little in the way of prospective data to guide their development. An expert panel of pediatric endoscopists was convened and produced this review that outlines practical clinical approaches to the pediatric patient with a variety of foreign body ingestions.This guideline is intended as an educational tool that may help inform pediatric endoscopists in managing foreign body ingestions in children. Medical decision-making, however, remains a complex process requiring integration of clinical data beyond the scope of these guidelines. These guidelines should therefore not be considered as a rule or as establishing a legal standard of care. Caregivers may well choose a course of action outside of those represented in these guidelines due to specific patient circumstances. Furthermore, additional clinical studies may be necessary to clarify aspects based on expert opinion rather than published data. Thus these guidelines may be revised as needed to account for new data, changes in clinical practice or availability of new technology.
Recent cases suggest that severe and fatal button battery ingestions are increasing and current treatment may be inadequate. The objective of this study was to identify battery ingestion outcome predictors and trends, define the urgency of intervention, and refine treatment guidelines. Data were analyzed from 3 sources: (1) National Poison Data System (56535 cases, 1985-2009); (2) National Battery Ingestion Hotline (8648 cases, July 1990-September 2008); and (3) medical literature and National Battery Ingestion Hotline cases (13 deaths and 73 major outcomes) involving esophageal or airway button battery lodgment. All 3 data sets signal worsening outcomes, with a 6.7-fold increase in the percentage of button battery ingestions with major or fatal outcomes from 1985 to 2009 (National Poison Data System). Ingestions of 20- to 25-mm-diameter cells increased from 1% to 18% of ingested button batteries (1990-2008), paralleling the rise in lithium-cell ingestions (1.3% to 24%). Outcomes were significantly worse for large-diameter lithium cells (> or = 20 mm) and children who were younger than 4 years. The 20-mm lithium cell was implicated in most severe outcomes. Severe burns with sequelae occurred in just 2 to 2.5 hours. Most fatal (92%) or major outcome (56%) ingestions were not witnessed. At least 27% of major outcome and 54% of fatal cases were misdiagnosed, usually because of nonspecific presentations. Injuries extended after removal, with unanticipated and delayed esophageal perforations, tracheoesophageal fistulas, fistulization into major vessels, and massive hemorrhage. Revised treatment guidelines promote expedited removal from the esophagus, increase vigilance for delayed complications, and identify patients who require urgent radiographs.