Coins are the most common type of foreign body swallowed by children. Coins that reach the stomach and small intestines usually pass uneventfully. However, coins that become lodged in the esophagus often pose a greater problem. Most coins in the proximal and middle esophagus will not pass spontaneously and must be removed by an invasive procedure, while coins located in the distal esophagus can usually be managed by watchful waiting until they pass into the stomach. Soprano and colleagues performed a retrospective review of patients seen in the emergency department of a children's hospital to determine the effect of initial coin location on spontaneous passage.
Researchers performed a retrospective review of consecutive cases in which a radiographic evaluation revealed an esophageal coin. They obtained information regarding patient age, date and time of ingestion, symptoms, physical examination findings, coin location, procedures used in coin removal and final outcomes. The original radiographs of all patients were reviewed to confirm the time of the study and coin location. The location of the coin was considered proximal if it was between the cricopharyngeus muscle and the jugular notch, midesophageal if located in the region of the aortic arch and distal if located between the tracheal bifurcation and the gastroesophageal junction. Cases were classified as “simple” if patients had no history of surgery or esophageal disease, had a single coin lodged in the esophagus for less than 24 hours and had no respiratory compromise on initial presentation to the emergency department. Children whose condition did not meet these criteria were classified as “complex” cases. The two main outcomes measured were: (1) spontaneous passage of the coin, defined as movement through the gastrointestinal junction to the stomach or intestines on follow-up radiographs and (2) the time it took for the coin to pass, defined as the interval between ingestion and spontaneous passage.
The study included 116 patients, with an equal number of boys and girls. The mean age of the patients was 42 months. The average time of presentation to the emergency department was 3.8 hours. There were 84 “simple” cases and 32 “complex” cases. The children with complex presentations tended to be significantly younger, with a mean age of 27 months. Among the simple cases, the coin was lodged in the proximal esophagus in 54 children, the middle esophagus in seven children and the distal esophagus in 22 children. In the complex cases, the coin location was proximal in 27 children and in the middle esophagus in five children.
Among the simple cases, 16 coins passed spontaneously into the stomach. These included seven that were located in the proximal esophagus, two in the middle esophagus and seven in the distal esophagus. The mean age of the children with spontaneous passage of a coin was 57 months; the mean time to spontaneous passage was about five hours. None of the children who were classified with complex cases had spontaneous passage of coins into the stomach. Subsequent removal of the coins by endoscopy under general anesthesia was performed in 68 of the simple cases and in all 32 of the complex cases. While waiting for coin passage or endoscopy, none of the children had an adverse event. Following endoscopy, three children were inadvertently extubated, one had pharyngeal bleeding, one had bronchospasm and one developed stridor and hypoxia.
The authors note several key points from this study. Approximately 30 percent of children have spontaneous passage of a coin if it is lodged less than 24 hours and the child has no history of esophageal disease. The chance of passage does not depend on initial location of the coin. The authors recommend that children with a single coin that is lodged less than 24 hours, who have no history of esophageal disease or surgery, and who are without respiratory compromise on presentation can be safely observed for a period of 12 to 24 hours before undergoing an invasive procedure to remove the coin. During the observation period, the patient should not receive food or fluids by mouth, in the event that endoscopy is required. Although sometimes recommended, it has not been proved that giving fluids or food enhances the spontaneous passage of an esophageal coin. This approach allows for a period of observation and should reduce costs and complications associated with the management of ingested coins.