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Am Fam Physician. 1998;57(11):2616-2618

to the editor: A teenager presented to the emergency department with sudden onset of lower chest pain after she had flipped a quarter into the air and caught it in her mouth. The coin was accidentally swallowed, and pain occurred momentarily thereafter. The patient had a completely normal physical examination, other than some evidence of embarrassment and anxiety.

Chest radiograph revealed that the coin was just above the gastroesophageal junction. After discussing the management options, we elected to administer 0.4 mg of nitroglycerin sublingually.

The pain completely disappeared in less than five minutes. The follow-up radiograph indicated that the coin had dropped well below the gastroesophageal junction. The patient was instructed to call if pain recurred or if she experienced any difficulty passing the coin. A follow-up contact with the patient indicated that the coin had passed without any difficulty.

The case described here occurred years ago when I was a young physician. I applied basic medical school knowledge and reasoned that nitroglycerin would cause smooth muscle relaxation. I also knew that an incredible array of objects could pass through the gastrointestinal tract without difficulty once they reached the stomach. It worked!

In recent years, I have seen numerous articles about retrieving swallowed coins endoscopically, with a Foley catheter, or with a bouginage. Each of these methods has associated problems and may be expensive. However, sublingual nitroglycerin costs only pennies. The risks of administering nitroglycerin are quite minimal, even in children. This may prove to be a safe and inexpensive way of getting past a sticky problem and should be studied.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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