Button battery ingestion is a serious medical concern in pediatric patients due to the potential for rapid tissue injury. Batteries lodged in the esophagus can cause damage within hours through electrical discharge, pressure necrosis, and leakage of caustic substances. While some children exhibit early symptoms such as dysphagia,

vomiting, drooling, or chest pain, others may remain asymptomatic, leading to delayed diagnosis and an increased risk of severe complications. In some cases, even asymptomatic children may develop significant esophageal ulceration, perforation, or stricture formation, highlighting the importance of early detection and management.

Radiological imaging, particularly chest X-rays, plays a crucial role in the initial evaluation of suspected foreign body ingestion. Endoscopy is the gold standard for both diagnosis and removal, allowing direct visualisation of mucosal damage. Here, we report a case of a 10-year-old girl who presented after button battery ingestion, with significant esophageal injury confirmed by endoscopy despite minimal symptoms.

A 10-year-old girl, accompanied by her mother, presented to the emergency department on November 1, 2022, with a history of accidental ingestion of a button battery from a watch toy six hours earlier. Unlike initially suspected, the child was aware of the ingestion and immediately informed her mother. She was asymptomatic except for mild abdominal discomfort, with no nausea, vomiting, dysphagia, drooling, chest pain, or respiratory distress..

On clinical examination, the child appeared alert and hemodynamically stable, with no signs of respiratory distress or abdominal tenderness. Her vital signs were within normal limits, and systemic examination revealed no abnormal findings. Given the history of ingestion, a chest X-ray (posteroanterior and lateral views) was performed. The X-ray revealed the presence of a button battery in the esophagus, confirming the ingestion. Due to the high risk of esophageal injury, the case was prepared for emergency endoscopic removal under short general anesthesia.

During upper gastrointestinal endoscopy (OGD scopy) under general anesthesia, a button battery was identified in the lower esophagus, embedded within the mucosa. Surrounding the site of impaction was deep ulceration with severe sloughing, consistent with Grade 3A esophageal injury based on the Zargar classification.

Fortunately, no perforation, fistula formation, or significant bleeding was observed.

The button battery was carefully removed using forceps, ensuring minimal additional trauma.

Following the successful removal of the button battery, the child was admitted to the Pediatric Intensive Care Unit (PICU) for close observation. Intravenous antibiotics were administered to prevent secondary infection, and proton pump inhibitors (PPIs) were initiated to facilitate esophageal healing. Routine blood investigations were performed, all of which were within normal limits

To further assess the extent of esophageal injury and rule out complications, a contrast-enhanced computed tomography (CECT) scan of the upper abdomen was performed. The scan revealed a normal esophagus, with no signs of perforation, stricture, or fistula formation. Given the absence of any alarming features, the patient was managed conservatively with supportive therapy, pain management, and dietary modifications.

The child was initially kept nil per oral (NPO) to allow for esophageal mucosal recovery. After 24 hours of observation, she remained clinically stable, with no worsening of symptoms. She was subsequently discharged in stable condition on a soft diet, oral PPIs, and close outpatient follow-up with a pediatric gastroenterologist.

Foreign body ingestion is a common occurrence in infants, with button batteries posing a significantly higher risk compared to other foreign objects. They are associated with more frequent and severe complications, including full-thickness burns, esophageal perforation, and the formation of tracheoesophageal or even esophago-aortic fistulas, all of which can develop within hours of ingestion (1).This risk underscores the need for urgent removal.

Despite the lack of symptoms in this case, endoscopic evaluation revealed a Grade 3A esophageal ulcer, emphasising the importance of early intervention. Previous studies indicate that at least 30% of children with an esophageal foreign body may remain asymptomatic. Therefore, any history of foreign body ingestion should be taken seriously and thoroughly investigated(2).Although chest X-rays are the first- line imaging modality, they may not always provide a clear diagnosis. In this case, the button battery was successfully identified on X-ray, prompting early endoscopic intervention. This highlights the importance of rapid radiological assessment followed by endoscopy when necessary.

One significant finding in this case is the rapid onset of severe esophageal damage within just six hours of ingestion. Normally, severe sloughing and deep ulceration are expected after 12 to 24 hours, but in this patient, Grade 3A injury developed within six hours, making it particularly dangerous.

This rapid degradation can be attributed to the poor quality of button batteries used in certain toys. Low-quality button batteries may lack proper protective coatings, leading to faster chemical leakage and severe esophageal injury within a short time.

The sudden degradation and exposure of caustic substances cause accelerated tissue damage, reinforcing the importance of ensuring strict quality control in manufacturing and usage of such batteries.

Esophageal coins are most commonly lodged in one of three locations: the upper esophageal sphincter (60–70%), the mid-esophagus at the level of the aortic notch (10–20%), and just above the lower esophageal sphincter (20%)(3).The incidence of button battery ingestion is rising in India. R. Banerjee et al. reported evidence of esophageal mucosal ulceration within 48 hours of ingestion.(4).

Management of button battery ingestion includes immediate removal, preferably via endoscopy, hospital observation, and aggressive medical therapy with proton pump inhibitors (PPIs) and antibiotics. In cases with extensive mucosal injury, long-term follow-up is required to monitor for complications such as esophageal strictures or motility disorders.

This case underscores the critical need for early endoscopic intervention in cases of suspected button battery ingestion, even when symptoms are minimal. The presence of severe esophageal ulceration despite mild symptoms highlights the potential for silent but progressive tissue damage.

An important observation in this case was the rapid progression of severe esophageal injury within six hours, which is unusually fast compared to typical cases where such damage is seen after 12 to 24 hours. This accelerated injury is likely due to the poor quality of button batteries used in toys, where low-grade materials and inadequate protective coatings result in faster chemical leakage. The sudden release of caustic substances leads to rapid mucosal damage, making these low-quality batteries particularly hazardous when ingested.

This finding highlights the urgent need for stricter regulations on the manufacturing and quality control of button batteries, especially those used in children’s toys.

Ensuring proper safety standards can significantly reduce the risk of severe esophageal injuries in accidental ingestions.

Clinicians should maintain a high index of suspicion, and early endoscopy should be strongly considered even when imaging is inconclusive. Timely removal and close post-removal monitoring remain the key to successful management and improved patient outcomes.

1. Semple T, Calder AD, Ramaswamy M, McHugh K. Button battery ingestion in children-a potentially catastrophic event of which all radiologists must be aware. Br J Radiol. 2018 Jan;91(1081):20160781. doi: 10.1259/bjr.20160781. Epub 2017 Oct 26. PMID: 28830198; PMCID: PMC5966199.
2. Khan Seema, Orenstein Susan R. Nelson textbook of pediatrics. 19th edition. Philadelphia: Elsevier; 2012. Foreign bodies in esophagus; p. 1271
3. Kay M, Wyllie R. Pediatric foreign bodies and their management. Curr Gastroenterol Rep. 2005 Jun;7(3):212-8. doi: 10.1007/s11894-005-0037-6. PMID: 15913481.
4. Banerjee R, Rao GV, Sriram PV, Reddy KS, Nageshwar Reddy D. Button battery ingestion. Indian J Pediatr. 2005 Feb;72(2):173-4. doi: 10.1007/BF02760705. PMID: 15758543.