Clinical Question: In asymptomatic children who present with swallowed coins lodged in the esophagus, is it better to remove the coins immediately or wait and remove them if still present 16 hours later?
Setting: Emergency department
Study Design: Randomized controlled trial (nonblinded)
Synopsis: The authors of this study enrolled 60 children who presented to a children’s emergency department after swallowing a coin. They did not study children who had respiratory distress, drooling, or choking, or children who had swallowed the coin more than 24 hours before presentation. They also did not enroll children whose parents managed the ingestion at home. The children, who ranged from 10 months to 13 years of age, were randomized to undergo immediate removal via rigid endoscopy or hospitalization and close observation for 16 hours with repeat radiography to determine spontaneous passage. Children in the observation group had continuous cardiac monitoring with pulse oximetry, received intravenous hydration, and received nothing orally. By the time they reached the operating room (at least two hours later) 30 percent of the children scheduled for immediate removal had spontaneously passed the coin. During 16 hours of watchful waiting, 23 percent of children passed the coin out of the esophagus; the remaining 77 percent underwent endoscopy. Length of hospital stay was higher in the observation group (19.4 versus 10.7 hours).
Bottom Line: Despite waiting 16 hours, fewer than one in four (23 percent) esophageal coins will pass spontaneously. Conversely, 30 percent of children scheduled for removal will have passed the coin by the time they are prepared for surgery. Based on the results of this study (spontaneous passage rate = 23 to 30 percent), eight to 16 hours of observation is appropriate treatment for children with coins in the esophagous, assuming that the child is asymptomatic, the ingestion was recent, and the child has no underlying esophageal or tracheal abnormality. (Level of Evidence: 1b)