Fatal Button Battery Ingestions: 44 Reported Cases

Case #  Year Reported  Author
(or MMWR
case # if
Age  Sex  Imprint  Diam (mm)  Chemistry  Intended Use  Time to Removal  Battery Location 
Complications  Signs & Symptoms  Procedures and Treatment 
 1 1977 Blatnik  2.5 y  PX 825  23.0 MnO2  movie camera  ≥26 hours  upper esophagus at thoracic inlet massive hematemesis, shock, cardiac arrest 8 days post removal (≥9 days post ingestion); tracheoesophageal fistula; erosion of inferior thyroid arteries and veins; exsanguination into bronchi and lungs  vomiting, fever, lethargy, aphonia, inability to swallow, tender swelling suprasternal notch, tracheal shift, increased WBC endoscopic removal from esophagus; steroids (presumed to have masked progression) 
 2 1979 Shabino  16 mo  PX 825  23.0  MnO2  camera flash  ≥4 days  upper esophagus  Perforation of esophagus and right tension hydropneumothorax (~4 days post ingestion); widened mediastinum - drain inserted (~5 d post ingestion); aortoesophageal fistula - perforation of posterior aspect of aortic arch near origin of left subclavian (~5 d post ingestion); massive exsanguination; cardiac arrest   vomiting, fever, irritability, abdominal distention, tachypnea, 10% dehydration, acrocyanosis  tube thoracostomy (~4 days post ingestion); battery removal by esophagoscopy (~4.5 days post ingestion); mediastinal drain and gastrostomy feeding tube inserted (~5 days post ingestion) 
1991 Peralta 11 mo  unk  15  unk  watch  >30 hours  upper esophagus  extensive bilateral pneumonia, anemia requiring transfusion; tracheoesophageal fistula 3x2.5 cm diameter  fever, cough, vomiting, rejecting food and fluids; respiratory distress; cyanosis; pallor  endoscopic removal 
4 1994 Sigalet 3 y  unk  unk  unk  unknown  unknown  upper esophagus 
aortoesophageal fistula (presumed, no post done); presumed mediastinal abscess (air at impaction site and sepsis)  dysphagia; fever; dehydration; elevated white blood cell count; sepsis; massive bright red bleeding from mouth 5 days post removal  endoscopic removal; granulation tissue seen 
2004 Chang YJ  unk  unk  unk  unk  unknown  ~2 days
(not removed) 
esophageal perforation leading to pneumothorax and pneumoperitoneum; died suddenly in ER  intractable cough; poor appetite  none 
6 2004 BBC
13 mo  unk  unk  unk  camera  11 days in
or removed

upper esophagus or hypopharynx with damage to trachea (presumed tracheoesophageal fistula) 
ulcerated esophagus with tracheoesophageal fistula and bleeding; respiratory failure; death  repeated vomiting, breathing difficulty; wheezing, difficulty drinking and eating, weight loss; misdiagnosed as viral infection  no x-ray done thus diagnosis missed despite hospitalization 
7 2004 NBIH
(MMWR 3) 
2.5 y  CR 2032  20.0  lithium  remote control
of portable
≥10 days
upper esophagus   aortoesophageal fistula (estimated 10 days post ingestion); massive exsanguination; cardiac arrest  unresponsive, dyspnea, hematemesis, melena  battery removal by rigid esophagoscopy; emergency thoracotomy for massive bleeding uncontrolled by ET and balloon catheters in esophagus; open cardiac massage 
2005 Hamilton
(MMWR 4)
19 mo  unk  unk  lithium  garage door opener  1 day  2 batteries ingested: one in stomach, one in mid-esophagus 2 cm aortoesophageal fistula at proximal descending aorta; massive bleeding and death 10 days after battery removal  presented with 1 day of abdominal pain, shallow respirations, lethargy, anorexia, cough; massive bleeding from aortoesophageal fistula 10 days post battery removal  battery removal by esophagogastroscopy; contrast swallow post-op day 4 suggested walled off tract along distal esophagus; child discharged; developed cyanosis and lethargy suddenly at home; CT showed IV contrast in esophagus & stomach; thoractomy - cross-clamped hypovolemic aorta 
9 2008 NBIH &
15 mo  CR 2032  20.0  lithium electric candle  not removed;
in place 2
esophagus at level of tracheal bifurcation aortoesophageal fistula - child exsanguinated 2 weeks after ingestion; blood in stomach and first part of duodenum on post; erosions in esophagus at level of tracheal bifurcation; fistula a few mm in diameter
fussy, crying, dark stools with suspected blood; respiratory problems  battery never removed as diagnosis not made until post mortem done 
10 2008 NBIH &
(MMWR 7)
16 mo  CR 2025  20.0  lithium  unknown  suspect
ingested 7-13
days prior to
mid-esophagus; moved spontaneously to stomach esophageal erosions with small amount of blood in paraesophageal and para-aortic tissues; child arrested (from blood loss) in OR and could not be resuscitated
hematemesis  vomited blood a second time just prior to planned endoscopic removal - exploratory laparotomy done instead; clot and battery evacuated from stomach; clotted blood formed cast of distal esophagus and stomach 
11 2009  NBIH &
(MMWR 9) 
2 y  CR 2032  20.0  lithium  Yahtzee toy  10 hours  distal esophagus aortoesophageal fistula
projectile vomiting of blood 18 days after battery removal  endoscopic removal of battery from esophagus 
12 2009  NBIH
(MMWR 8) 
2.5 y  unk  unk  unk  receiver unit
for remote
light switch 
4-5 days  upper esophagus 
exsanguinated; fistula between esophagus and right subclavian artery
vomiting only with solid food x 4-5 days; tolerated liquids; otherwise acting normally; hematemesis 4-5 days post ingestion, then into shock  resuscitation; balloon in esophagus to attempt to control bleeding 
13 2009 NBIH
(MMWR 10) 
13 mo  CR 2032  20.0  lithium  unknown  10 days  removed from stomach; suspect lodged in mid esophagus then dropped to stomach aortoesophageal fistula with massive exsanguination 2 days post removal and 12 days post ingestion  coughing; gagging; chest congestion; vomiting; refusal to eat; guaiac positive, tarry stools; massive hematemesis 2 days after battery removal  endoscopic removal of battery from stomach 10 days post ingestion; battery presumed to have moved to stomach from esophagus 
  Fatalities 1 to 13 above were included in the publication:
 Litovitz T, Whitaker N, Clark L, White NC, Marsolek M: Emerging battery ingestion hazard: Clinical implications.  Pediatrics 2010;125(6): 1168-77. epub 24 May 2010.
 Cases below occurred or were identified after compilation of data for this publication.
14 2010  NBIH
(MMWR 14) 
2 y  CR 2025  20.0  lithium  unknown  not removed
time of
mid-esophagus aortoesophageal fistula 5 cm above gastroesophageal junction
hematemesis; exsanguinated  orogastric tube placed and battery dislodged to stomach 
15 2010  Soerdjbalie-
2 y  CR 2032  20.0  lithium  unknown  11 days  mid-esophagus
aortoesophageal fistula between aberrant right subclavian artery (arteria lusoria) and esophagus; hemothorax, blood throughout gut on post mortem; focal mediastinitis; esophageal perforation and esophagitis  sore throat, high fever, cough, diarrhea, vomiting after every drink or meal, seizure, hypotension, anemia, melena, hematemesis, collapse  thoracotomy 
16 2010  Baeza
3 y  unk  20.0  lithium  remote
for video
1 day  mid-esophagus
aortoesophageal fistula developed 11 days post ingestion (10 days after removal); liquid diet started on day 6 and child was asymptomatic; sudden hematemesis occurred and child exsanguinated from hemorrhagic shock in the hospital despite attempts to resuscitate; autopsy showed burns throughout esophagus and 3 cm perforation in distal third of esophagus into the thoracic aorta; large amounts of blood were found in the stomach and the cardiac chambers were empty  initial abdominal pain and vomiting; asymptomatic by day 6; hematemesis 11 days post ingestion (10 days post removal) endoscopic removal of battery from esophagus; repeat diagnostic endoscopy on day 10 
17  2011 LaFrance
(MMWR 11) 
3 y  CR 2032  20.0  lithium  unknown  unk, <3 weeks  upper esophagus, at thoracic inlet
hemoptysis, exsanguination and aspiration of blood; tracheoesophageal fistula
T&A 3 weeks prior to death obscured determination of time of onset of symptoms; 10 days post T&A evaluated for fever and refusal of solid foods; 3 weeks post T&A presented with respiratory distress and vomiting, O2 sat 94% on room air, tachypnea; CXR showed diffuse bilateral infiltrates and coin-like foreign body in esophagus at thoracic inlet; removal scheduled for next day but patient developed coughing spells and marked hemoptysis requiring intubation and transfusion; acute bradycardia and bleeding from mouth, nose, and ET tube followed  intubation, transfusion, unsuccessful resuscitation attempts (stabilized after 30 mins of resuscitation but pupils fixed and dilated, then another episode of massive hematemesis occurred and resuscitation was unsuccessful) 
18 2011  NBIH &
4 y  unk  20  lithium   unknown unknown  distal esophagus  aortoesophageal fistula  child vomited blood and collapsed at home; unresponsive with no pulse or breath sounds on arrival in ED; CPR initiated; pH dropped to 6.9; hemoglobin undetectable; regained spontaneous circulation with fluids and blood; no prior symptoms; ingestion not witnessed; apneic and pulseless on arrival at ED   thoracotomy showed aortoesophageal fistula; aorta cross-clamped but child continued to bleed; arrested in OR and could not be resuscitated; battery not removed
19 1998  MMWR 1  16 mo  unk  unk  unk  unknown  unk  esophagus exsanguination from arterio-esophageal fistula    unknown unknown 
20 2002  MMWR 2  15 mo  CR 2016  20.0  lithium  toy watch?  >24 hours  proximal esophagus  exsanguination from aortoesophageal fistula
vomiting, melena, hemorrhaging; symptoms developed > 5 hours post ingestion  battery identified on x-ray 19 hours after symptoms developed (>24 hours post ingestion) 
21  2006  MMWR 5   1 y unk  unk  alkaline  remote
car alarm 
≥4 days
esophagus  tracheoesophageal fistula; anoxic encephalopathy secondary to TE fistula
fever, decreased appetite, suspected croup  child taken to hospital after 2 days of fever; diagnosed with croup and discharged. Returned 2 days later at which point a radiograph showed a battery in the esophagus. Battery removed but child died 6 days later. 
22 2007  MMWR 6  7 mo  unk  unk  unk  unknown  unk  proximal esophagus  acute fistulous erosion of esophageal ulcer into carotid artery  massive hematemesis  battery removed endoscopically 
23  2010  MMWR 12  2 y  unk  unk  unk  unknown  ≥5 days
upper thoracic esophagus  esophageal perforation; bleeding  sore throat, dysphagia, choking, dyspnea, tachypnea, dark stools, listless  child treated for strep by pediatrician; taken to ED 5 days later where an x-ray identified foreign body in esophagus. Battery removed in hospital where child died 2 days later. 
24 2010  MMWR 13  2 y  CR 20xx  20.0  lithium  unknown  unk  esophagus  esophageal damage, necrosis and hemorrhage; esophageal tear  vomited blood, cardiovascular collapse  Unknown time of ingestion. Child "became ill" and vomited blood. Condition deteriorated after transfer from initial hospital. Died at hospital. 
25 2011  MMWR
13 mo  F unk  20.0  lithium  watch  unk  esophagus  unknown unknown  unknown 
26 2011  MMWR
3 y  unk  unk  unk  unknown  unk  esophagus  aortoesophageal fistula hemorrhage  unknown 
27 2012  MMWR
4 y  AAA
AAA unk  unknown  4 days  mid esophagus  two fistulas: esophagus to aorta and esophagus to pulmonic artery
initial choking and vomiting; refusal to eat, abdominal pain and fever developed over next day or so; throat pain reported 4 days after swallowing battery; child had multiple pre-existing medical problems (DiGeorge syndrome, right aortic arch with aberrant origin of left subclavian artery, arthritis treated with NSAIDs); 32 days post ingestion he developed nose bleed and hematemesis then arrested and could not be resuscitated due to massive bleeding  battery removed from esophagus by rigid esophagoscopy with the aid of a balloon catheter; child died 32 days post ingestion (28 days post battery removal) 
28  2012  CPSC;
2 y  unk  20  lithium  unknown  ~8 days  esophagus  esophageal-carotid fistula; battery removed from upper esophagus; 3 weeks later child presented with gastric bleeding and seizures; large necrotic mass in neck on MRI and peptic ulcer with blood clot; transfused and placed on ventilator; one day after admission began to vomit blood, went into cardiac arrest and could not be resuscitated  gastric bleeding; seizures; necrotic mass in neck; peptic ulcer with blood clot; hypotension  battery removed from upper esophagus 
29 2012  NBIH  13 mo  DL 2032  20.0  lithium  unknown  unk  battery in stomach; bleeding site identified on post mortem  gastric erosions; massive upper GI bleed followed several hours after a sentinel single episode of hematemesis  sentinel episode of hematemesis preceded massive upper GI bleed none 
30 2013  Martinez  23 mo  unk  20.0  lithium  unknown  unk  proximal esophagus (thoracic inlet)  esophageal ulceration; aortoesophageal fistula in upper esophagus   odynophagia, sialorrhea, stridor x 2 weeks prior to presentation without improvement with steroids; repeated hematemesis following attempted battery removal; hemorrhagic shock treated with blood and pressors and CPR
endoscopic removal of battery from esophagus attempted but battery displaced to stomach; unable to cauterize bleeding in esophagus on repeat endoscopy
31 2013  NBIH;
4 y  unk  20.0  lithium  unknown  ≥2 weeks  mid esophagus
aortoesophageal fistula at aortic arch near origin of left subclavian artery; death from hemorrhage  presented with epistaxis following 2 weeks of abdominal pain and melena; discharged home; vomited a cup of fresh blood at home and brought back to the ER in shock; massive hematemesis and coma followed  intubated; chest x-ray performed to confirm ET tube position showed mid-esophageal battery; transfusions; CPR; thoracotomy showed large, tense mediastinal hematoma 
32 2010  NBIH 735607
(this case is duplicated on Severe Cases list, case 89; child died nearly 2 years and 10 months after ingestion) 
10 mo  unk  20.0  lithium  unknown  >8 hours  cervical esophagus  tracheoesophageal fistula; died (found unresponsive) nearly 2 years and 10 months after the battery ingestion  initial gasping and choking; cyanosis. Stridor developed  tracheostomy required; unknown other procedures 
33 2013  NBIH  16 mo  M CR 2025 20.0  lithium  unknown  ~7 days  proximal esophagus  massive upper GI bleed of undetermined origin; possible concomitant acetaminophen toxicity (used to treat child prior to removal); child died approximately 3 days after removal; there was evidence of pulmonary edema, pneumonia, uncontrollable esophageal bleeding and mediastinitis in addition to renal and liver failure  presented initially with cough and congestion; later developed profoundly elevated INR, PTT, AST, ALT; Hct dropped to 17; hypotensive with hematemesis, melena, and acidosis exploratory lap done to decompress abdomen due to massive bleeding with prolonged intraoperative arrest; bright red blood in lower esophagus and stomach 
34 2013  NBIH  23 mo  M unk unk  unk  camera  unk  esophagus  GI bleed, laceration of the  esophagus, collapsed lung, gastric irritation   hematemesis unknown 
35 2014  Takesaki  5 y  M unk ~20   lithium  unknown  ~10 days or
injury in distal esophagus; battery passed   to lower colon spontaneously deep ulceration of lower esophagus; presume esophageal-vascular fistula but not confirmed; massive hematemesis; profound hypotension; two cardiopulmonary arrests  abdominal pain x 10 days followed by hematemesis, pallor, tachycardia (150 beats/min), hypotension (60 mm Hg), and Hct 27%  UGI endoscopy demonstrated deep ulcerated lesion in distal esophagus; additional profuse hematemesis followed the endoscopy accompanied by severe hypotension; Sengstaken-Blakemore tube inserted; cardiopulmonary arrest followed, resuscitated with CPR and epinephrine; subsequent exploratory laparotomy showed a large amount of blood in the stomach; child arrested again and could not be resuscitated; battery removed manually per rectum 
36 2014  Hama-
28 mo  M unk unk  unk  unknown  ≥5 days  esophagus  esophageal perforation; child died at home on 7th day (family refused surgery and discharged child)  unknown family refused treatment 
37 2013  Connor L
1 y  F unk  unk  unk  torch  ~1 day  esophagus   aortoesophageal fistula  massive bleeding  battery removed from esophagus; child discharged from hospital; returned 8 days post ingestion (6 days after removal) with massive bleeding; heart abnormality detected on post mortem 
38 2014  News  4 y unk  20 (suspected due to
(suspected due to
unknown  unk  esophagus   massive upper GI bleed, presumed to be an esophageal-vascular fistula
presented with difficulty breathing; hematemesis developed about 7 days later
battery removed; child died about 7 days post removal; massive hematemesis developed when NG tube was removed
39 2014  Mercer RW  4 y  CR 2032  20  lithium  unknown  ≥2 days  upper esophagus, at level of aortic arch child with trisomy 21, diagnosed with a vascular ring at the time of button battery ingestion; died 9 days after presentation due to massive upper GI bleeding from a vasculoesophageal fistula; patient found unresponsive in hospital room; during intubation, massive amounts of bright red blood emerged from esophagus; hypotension and acidosis followed; resuscitation unsuccessful; post mortem showed a necrotic transmural ulceration of the esophagus; blood found in stomach and small intestine; the vascular ring caused esophageal narrowing due to external compression   presented with 2 days fever, difficulty breathing and decreased oral intake; no known cardiovascular history but reported longstanding intolerance of solid foods with frequent vomiting  endoscopic removal reviewed extensive avascularity, blanching and necrosis on posterior, left lateral and anterior esophageal walls; obstructed esophageal lumen; microlaryngoscopy and bronchoscopy showed no tracheal involvement; post-op CT angio showed right aortic arch with an aberrant left subclavian artery originating from a Kommerell diverticulum consistent with a vascular ring; Kommerell diverticulum adjacent to a contained esophageal perforation (3.3x2.9 cm air fluid collection); repeated flexible and rigid endoscopy with NG tube placement and bronchoscopy 2 days post removal 
40 2014  Times
2 y  F unk  unk  unk  unknown  ~2 weeks  esophageal-vascular fistula (unspecified artery involved)  massive upper GI bleed, presumed to be an esophageal-vascular fistula  sore throat and chest over 2 weeks; began vomiting blood Oct 19, 2014; rushed to hospital; died hours later   unknown
41 2014  BBC News  3 y  unk  unk  unk  unknown  unk  unk  unknown  severe hemorrhage  unknown 
42 2015  Barabino  22 mo  CR 2032  20  lithium  unknown  unk  mid esophagus aortoesophageal fistula due to lithium battery lodged in mid esophagus (found on autopsy) bloody emesis occurred once an hour prior to admission; slight pallor, mild tachycardia and Hgb 7.7 g/dL  on presentation; Hgb dropped to 6.2 g/dL 5 hours later without evidence of ongoing bleeding; almost 8 hour after presentation, sudden severe hematemesis occurred followed by cardiorespiratory arrest; resuscitation attempted over 2.5 hours but upper GI hemorrhage was uncontrollable  resuscitation attempted (transfusion, ventilation, cardiac massage); battery not removed prior to death 
 43  2015 Chow  14 mo  CR 2025  20.0  lithium  unknown  unknown  distal esophagus  aortoesophageal fistula due to lithium battery lodged in the esophagus  3 weeks of nonspecific symptoms (vomiting, lethargy, refusal of food and fluids, fever, abdominal pain, difficulty settling, dark green stool) diagnosed as urinary tract infection, including 3 ED presentations; acute onset hematemesis with large clots was followed by cardiac arrest; resuscitation was successful but further hematemesis resulted in a second cardiac arrest and she could not be resuscitated battery not removed prior to death
 44 2015  NBIH  17 mo  unk  20.0  lithium  unknown  not removed prior to death   mid esophagus death due to exsanguination from fistula from esophagus to aberrant right subclavian artery  exsanguinated on arrival to emergency department; presented with hematemesis and hemoptysis; sentinel bleed: melena 7 days prior to presentation; unrelenting hematemsis progressed to cardiac arrest  crash thoracotomy; unsuccessful attempt to repair injury 


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