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Battery Ingestion: Overview

Battery ingestions are reported approximately 3,500 times annually across the US, primarily in children younger than 13 years old, with 56 percent identified as button batteries.² Adults with pica are also at risk. Children often obtain batteries from remote controls, or household products with unsecured battery compartments.⁴ These batteries can cause GI injury due to electrical discharge, caustic chemical release, and pressure necrosis, even in patients who initially have minimal symptoms. Complications including esophageal burns, perforation, hemorrhage, fistula development, and death occur in 3 percent of battery ingestion. The majority (94 percent) of deaths occur after ingesting button batteries with specific characteristics: (1) lithium containing, and (2) less than 20 mm in diameter.⁵ The mucosal injury is caused by both the formation of hydroxide radicals and electrothermal injury, with mucosal necrosis shown experimentally within 15 minutes.⁶ Human injury progresses rapidly, with esophageal burns occurring within two hours, necessitating rapid intervention with battery removal to avoid those injuries. About half of patients who require battery removal have minimal or no symptoms.⁵

A national Battery Ingestion Hotline (800-498-8666) is available for assistance in battery identification and patient management.

Cylindrical Battery Ingestion: Overview

Cylindrical battery ingestion occurs less frequently than button battery ingestion but is reported in children and adults with pica and mental illness. Because these cylindrical batteries are larger, ingestion is less common and primarily occurs in people who intend to ingest them.⁷ A multi-year study from the National Capital Poison Center reported nationally that button battery ingestions far outnumbered cylindrical battery ingestions: 2,320 versus 62, respectively.⁴ With fewer cases reported, no clear practice guidelines have been developed for management of cylindrical battery ingestion.⁸

Most household cylindrical batteries are alkaline, and may contain such metals as zinc, manganese, lithium, and mercury bathed in an alkaline electrolyte solution of potassium hydroxide.⁹ This caustic mixture leaks out if the battery’s casing is damaged, resulting in corrosive injuries. Electrical related tissue damage is less likely than with button battery ingestions as the voltage is lower–1.5 volts compared with button batteries that have up to 3 volts.

There are two case reports of ST elevation in an inferior MI pattern that resolved with removal of the gastric located batteries; this was considered likely artifactual from electrical interference from the ingested batteries.^10,11

Although most intact cylindrical batteries pass through the GI tract without complication, physical obstruction or lack of advancement through the enteral tract over time may necessitate endoscopic or surgical intervention.

Evaluation of battery ingestion:

1. ABCs: Address airway first. Are there signs of respiratory distress (drooling, stridor, tripoding, or inability to speak)?
2. History: Suspected acute ingestion of batteries requires immediate evaluation, so timing is key; number of items ingested, prior similar events, and pica history.
3. Symptom assessment: Complaints of chest or abdominal pain, vomiting, shortness of breath, refusal to eat, bloody saliva, or hematemesis are red flags.¹² Presence of these symptoms indicate need for emergent assessment.
4. Differential: Ensure the object is indeed a battery and not a coin or magnet or lead object. Each has its own complications.^5,13
5. Examination: Look for oral or throat injury; respiratory distress; abdominal tenderness, distension, or any other signs that might indicate GI obstruction or perforation.
6. Imaging: Biplane radiographs (neck, chest, abdomen) are critical to identify the battery type, location, number, orientation, and complications (e.g., free air, perforation). Batteries are radio-opaque. Advanced imaging (CT) may be indicated for suspected perforation.
7. Laboratory: consider pre-operative lab work in cases of a confirmed foreign body that might require removal.

X-ray Findings

Image 4. (Photos Dr. Hack. Click to enlarge.)

1. Confirm radiopaque foreign body and determine the presence of specific characteristics. If it has a “double-ring” or “halo” sign, has varying density, or has indents along the edge (Image 4; green arrows), these are all consistent with button battery (see red arrows).
2. Cylindrical batteries—specific characteristics include consistent width down its length, may have increased density at the ends (metal caps), blunt at both ends (whole battery) or smooth on one end and jagged at the other (bisected; cut or bitten battery; Image 1,2, blue arrows).
3. Identify location: esophagus, trachea, stomach, intestines. For these locations, in addition to interval movement, determine intervention planning and timing.
4. Assess for additional objects or complications, e.g., obstruction.

Location and Management

Image 1. (Click to enlarge.)

1. Batteries in the stomach/intestines:
   • Often both button and cylindrical batteries can be allowed to be egested spontaneously out of the GI tract if the battery is small, there is progression of transit, and the patient remains asymptomatic.
   • Monitor with serial X-rays and stool checks.
   • Button batteries or cylindrical batteries remaining within the stomach for 48 hours require endoscopic removal. Any development of symptoms during the observation period should trigger earlier intervention.
   • If appropriate for discharge, patients and families must be given warnings and instruction regarding the need to return immediately to the hospital for signs of obstruction, bleeding, or any worsening abdominal pain.
     

     Image 2. (Click to enlarge.)

2. Batteries in the esophagus:
   • Emergent (within 2 hours) removal of button batteries is required due to high risk of mucosal injury and perforation.¹⁴ Almost all the button battery deaths were from those located in the esophagus.²
   • Symptomatic patients (pain, vomiting, drooling, dysphagia, dysphonia, respiratory symptoms) with any battery require immediate intervention.
   • Asymptomatic patients with cylindrical batteries (full or sharp edged) may be monitored and should undergo urgent (within 24 hours) endoscopy if the battery remains in place.¹⁴

Interventions

Button Batteries

• Endoscopic removal: Emergent (within 2 hours) for esophageal batteries or symptomatic gastric batteries. Urgent (within 24 hours) endoscopic removal for gastric button batteries with symptoms. Delayed (within 48 hours or longer) endoscopic removal for asymptomatic button batteries retained in the stomach for more than 48 hours for fear of battery leakage or mucosal adherence.
• Supportive care: IV fluids, pain control, monitor for perforation or bleeding.
• Acid mitigation: Some protocols recommend honey or sucralfate in children with recent esophageal battery ingestion to reduce mucosal injury before endoscopy.
• Surgical consultation: Indicated for perforation, obstruction, fistula formation, with battery location beyond endoscopic reach.

Cylindrical Batteries

• Current guidelines only briefly address cylindrical battery ingestion.¹⁵
• Overall, intact cylindrical batteries pose a low threat for electrical (low voltage) or caustic damage after ingestion, but because of their length (less than 2.5 cm), they may become entrapped in the stomach in children and adults and should be removed if delayed imaging does not show forward migration after 48 hours. Cylindrical batteries with open casing (cut, chewed, etc.) should have urgent (within 24 hours) endoscopic removal because of the risks of caustic injury.
• The recommendation for urgent or delayed retrieval (or surgical intervention) of these batteries includes if (1) the battery has remained in the stomach more than 48 hours, (2) if the patient develops signs of injury or obstruction (3) or if evidence (or history) suggests that the battery casing had been compromised^.8

Back to the Case

The patient’s imaging revealed multiple button batteries (red arrows) in the stomach and intestines. Because of the upper abdominal tenderness on examination, the findings of a distal esophageal coin that did not pass with observation (yellow arrow), and the irregular-ended cylindrical objects in his stomach (blue arrows), he underwent urgent endoscopy. Objects removed included three coins, one button battery, three AA batteries that had been cut in half and one additional object (purple arrow). The patient did well post-procedure.

If you have a guess what the purple arrow is indicating, write to us at acepnow@acep.org. The first person to send me the correct answer will be acknowledged in my next column!

Please note: The patient gave verbal and signed consent for the use of his images and case.

National Resources

National Button Battery Ingestion Hotline: 1-800-498-8666

Dr. Hack is chief of the division of medical toxicology and vice chair for research at East Carolina University in Greenville, N.C.

References

1. Hack JB. What Is Safer to Toss Than Swallow? ACEP Now. 2026; 45(5):3-4.
2. Centers for Disease Control and Prevention. Button battery injuries in children—United States, 1995–2021. Morbidity and Mortality Weekly Report. 2022;71:125-131.
3. Litovitz T, Schmitz BF. Ingestion of cylindrical and button batteries: an analysis of 2382 cases. Pediatrics. 1992 Apr; 89(4 Pt 2):747-757.
4. Litovitz T, Whitaker N, Clark L. Preventing battery ingestions: an analysis of 8648 cases. Pediatrics. 2010 Jun;125(6):1178-83. doi: 10.1542/peds.2009-3038. Epub 2010 May 24. PMID: 20498172.
5. Rogalidou M. Ingestion of foreign bodies and caustic substances in children: a narrative review on clinical evaluation and management update. Clin Exp Pediatr. 202669(1):11-21. doi: 10.3345/cep.2025.01823. Epub 2025 Dec 10. PMID: 41381079; PMCID: PMC12790899.
6. Tanaka J, Yamashita M, Yamashita M, Kajigaya H. Esophageal electrochemical burns due to button type lithium batteries in dogs. Vet Hum Toxicol. 1998;40:193-6.
7. Hindley N, Gordon H, Newrith C, Mohan D. The management of cylindrical battery ingestion in psychiatric settings. Psychiatric Bulletin.1999;23(4):224-226. doi:10.1192/pb.23.4.224
8. Hammami MB, Alkaade S, Piraka C, Taylor JR. Endoscopic Retrieval vs. Observation in Cylindrical Battery Ingestion. Ochsner J. 2019;19:157-165. doi: 10.31486/toj.18.0020
9. Dunphy L, Maatouk M, Raja M, O’Hara R. Ingested cylindrical batteries in an incarcerated male: a caustic tale! BMJ Case Rep. 2015;2015. doi: 10.1136/bcr-2014- 208922
10. Ordoobadi AJ, Allar BG, Orhurhu V, Keith S, Cocchi MN. ST Segment Elevation Caused by Artifact From Cylindrical Battery Ingestion. J Emerg Med. 2020;58(4):673-676. doi: 10.1016/j.jemermed.2019.12.027. Epub 2020 Jan 27. PMID: 32001122.
11. Chang H, Hu SC, Tsai MJ. Cylindrical battery ingestion with electrocardiogram mimicking ST-segment elevation myocardial infarction. J Am Coll Cardiol 2012;59:2387.
12. Dipasquale V, Romano C, Iannelli M, Tortora A, Melita G, Ventimiglia M, Pallio S. Managing Pediatric Foreign Body Ingestions: A 10-Year Experience. Pediatr Emerg Care. 2022;38(1):e268-e271. doi: 10.1097/PEC.0000000000002245. PMID: 32970025.
13. Quitadamo P., Anselmi F., and Caldore M. et al. Foreign body ingestion in children: Beware of disk batteries and multiple magnets. Acta Paediatr. 2021 Oct;110
14. ASGE Standards of Practice Committee; Ikenberry SO, Jue TL, Anderson MA, Appalaneni V, Banerjee S, Ben-Menachem T, Decker GA, Fanelli RD, Fisher LR, Fukami N, Harrison ME, Jain R, Khan KM, Krinsky ML, Maple JT, Sharaf R, Strohmeyer L, Dominitz JA. Management of ingested foreign bodies and food impactions. Gastrointest Endosc. 2011;73(6):1085-91. doi: 10.1016/j.gie.2010.11.010. PMID: 21628009.
15. Boccia M, Pugliese M, Cantelli M, et al. Pediatric cylindrical battery ingestion. Endosc Int Open. 202526;13:a25260108. doi: 10.1055/a-2526-0108. PMID: 40018076; PMCID: PMC11866037.