Coin ingestion

• Chest radiography is recommended for all children who have swallowed coins
• In the esophagus, the flat surface of the coin will be seen on the anteroposterior view, and the edge will be seen on the lateral view.
• The opposite will be true for coins present in the trachea
• The presence of a coin in the stomach allows for expectant observation in the absence of abdominal pain and vomiting.
• The absence of a coin on abdominal radiography that includes the esophagus suggests that the history of ingestion was in error.

• Approximately 20% of coins become lodged in the esophagus and require further intervention (endoscopic removal)
• Coins may become lodged at the level of the cricopharyngeus muscle, aortic arch, and above the lower esophageal sphincter.
• Approximately 75% of coins that do not pass into the stomach are lodged in the proximal esophagus.
• Children who become symptomatic are at increased risk for having the coin remain in the esophagus.
• Common presenting symptoms in young children include drooling, choking, and poor feeding.
• The child may complain of throat or chest pain.
• Rarely, dyspnea and stridor develop as a result of extrinsic compression of the trachea or larynx.
• As many as 44% of children may be asymptomatic despite the presence of a coin in the esophagus.

Management

• Serious complications following a coin ingestion are related to prolonged impaction.
• The change in composition of pennies from copper to zinc in recent years has increased the potential for gastric mucosal corrosion.
• All coins that are lodged in the proximal esophagus should be removed endoscopically as soon as possible.
• Patients who have coins in the mid- to lower esophagus may be observed for 12 to 24 hours if asymptomatic, but should undergo endoscopy if the coin fails to pass in that time period.
• Complications of a coin lodged in the esophagus for greater than 24 hours include
  • esophageal perforation
  • TE fistula
  • esophagoaortic fistula
• Glucagon, which lowers pressure in the lower esophagus, has been used to facilitate  the passage of a lower esophageal foreign body in adults. Its use has not been evaluated critically in children.
  
   
• Because a significant number of children who have a coin lodged in the esophagus are asymptomatic and are at risk for mucosal erosion, expectant observation and inspection of the stool for the coin (which may take 3 to 4 days to pass) are inappropriate.
• The use of emergent endoscopy without confirming the presence and level of the foreign body will result in a significant number of children being brought to the operating room unnecessarily. In anticipation of the possible need for general anesthesia for foreign body removal, children should not be given liquids to drink.

References:
Caravari EM, Bennett DL, McElwee NE. Pediatric coin ingestion: a
prospective study on the utility of routine roentgenograms. Am J Dis
Child. 1989;143:549-551
Conners GP, Chamberlain JM, Ochsenschlager DW. Symptoms and
spontaneous passage of esophageal coins. Arch Pediatr Adolesc Med.
1995;149:36-39
Macpherson RI, Hill JG, Othersen HB, Tagge EP, Smith CD. Esophageal
foreign bodies in children: diagnosis, treatment, and complications.
AJR Am J Roentgenol. 1996;166:919-924