Coin ingestion: Difference between revisions

(Created page with "==Background== *Coins are the '''most commonly ingested foreign body''' in children, accounting for the majority of pediatric foreign body ingestion ED visits<ref name="naspghan">Kramer RE, Lerner DG, Lin T, et al. Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee. ''J Pediatr Gastroenterol Nutr''. 2015;60(4):562-574. PMID 25611037.</ref> *Peak age: '''6 months to 3 years''' (exploratory mouthing behavior) *The vast...")
 
(Formatting: removed bold)
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*The primary concern is '''esophageal impaction''', which occurs in approximately 10–20% of pediatric coin ingestions<ref name="waltzman">Waltzman ML, Baskin M, Wypij D, et al. A randomized clinical trial of the management of esophageal coins in children. ''Pediatrics''. 2005;116(3):614-619. PMID 16140700.</ref>
*The primary concern is '''esophageal impaction''', which occurs in approximately 10–20% of pediatric coin ingestions<ref name="waltzman">Waltzman ML, Baskin M, Wypij D, et al. A randomized clinical trial of the management of esophageal coins in children. ''Pediatrics''. 2005;116(3):614-619. PMID 16140700.</ref>
*Esophageal impaction most commonly occurs at one of three anatomic narrowings:
*Esophageal impaction most commonly occurs at one of three anatomic narrowings:
**'''Upper esophageal sphincter (cricopharyngeus)''' — most common site (~70%)
**Upper esophageal sphincter (cricopharyngeus) — most common site (~70%)
**'''Aortic arch / carina level''' (mid-esophagus)
**Aortic arch / carina level (mid-esophagus)
**'''Lower esophageal sphincter''' (GE junction)
**Lower esophageal sphincter (GE junction)
*Serious complications from coin ingestion (perforation, fistula, obstruction) are '''extremely rare''' but can occur with prolonged esophageal impaction<ref name="naspghan"/>
*Serious complications from coin ingestion (perforation, fistula, obstruction) are '''extremely rare''' but can occur with prolonged esophageal impaction<ref name="naspghan"/>
*'''Critical distinction:''' Coins must be differentiated from '''[[Button battery ingestion|button batteries]]''' on radiograph — batteries require emergent removal, coins generally do not
*Critical distinction: Coins must be differentiated from '''[[Button battery ingestion|button batteries]]''' on radiograph — batteries require emergent removal, coins generally do not
*Adult coin ingestions are uncommon and raise concern for underlying esophageal pathology (stricture, eosinophilic esophagitis, Schatzki ring) or psychiatric/developmental conditions
*Adult coin ingestions are uncommon and raise concern for underlying esophageal pathology (stricture, eosinophilic esophagitis, Schatzki ring) or psychiatric/developmental conditions


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==Differential Diagnosis==
==Differential Diagnosis==
*'''[[Button battery ingestion]]''' — '''must be excluded radiographically before observation''' (see Diagnosis for distinguishing features)
*[[Button battery ingestion]] — '''must be excluded radiographically before observation''' (see Diagnosis for distinguishing features)
*Other [[Foreign Body Ingestion|foreign body ingestion]] (magnets, small toys, jewelry)
*Other [[Foreign Body Ingestion|foreign body ingestion]] (magnets, small toys, jewelry)
*[[Esophageal Food Impaction|Food bolus impaction]]
*[[Esophageal Food Impaction|Food bolus impaction]]
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==Evaluation==
==Evaluation==
===Workup===
===Workup===
*'''AP and lateral radiographs''' of the neck, chest, and abdomen — '''standard of care for all suspected coin ingestions'''<ref name="naspghan"/>
*AP and lateral radiographs of the neck, chest, and abdomen — '''standard of care for all suspected coin ingestions'''<ref name="naspghan"/>
**Coins are radiopaque and readily identified
**Coins are radiopaque and readily identified
**Must image from nasopharynx to rectum if location is uncertain
**Must image from nasopharynx to rectum if location is uncertain
*'''Labs:''' Generally NOT needed for uncomplicated coin ingestion
*Labs: Generally NOT needed for uncomplicated coin ingestion
**Obtain CBC, BMP, type and screen if there is concern for perforation, hemorrhage, or the patient requires procedural sedation/general anesthesia for removal
**Obtain CBC, BMP, type and screen if there is concern for perforation, hemorrhage, or the patient requires procedural sedation/general anesthesia for removal


===Diagnosis===
===Diagnosis===
*'''Coin vs. Button Battery on X-ray:'''
*Coin vs. Button Battery on X-ray:
{| class="wikitable"
{| class="wikitable"
|-
|-
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| '''Orientation in esophagus''' || '''Coronal''' (flat face toward AP viewer — appears round on AP) || Also coronal in esophagus
| '''Orientation in esophagus''' || '''Coronal''' (flat face toward AP viewer — appears round on AP) || Also coronal in esophagus
|}
|}
*'''If the object cannot be definitively identified as a coin, manage as a [[Button battery ingestion|button battery]] until proven otherwise'''
*If the object cannot be definitively identified as a coin, manage as a [[Button battery ingestion|button battery]] until proven otherwise
*'''Coin orientation helps localize:'''
*Coin orientation helps localize:
**'''Esophagus:''' Coin is oriented in the '''coronal''' plane (appears round on AP view, thin line on lateral)
**Esophagus: Coin is oriented in the '''coronal''' plane (appears round on AP view, thin line on lateral)
**'''Trachea:''' Coin is oriented in the '''sagittal''' plane (appears thin on AP, round on lateral) — indicates aspiration rather than ingestion
**Trachea: Coin is oriented in the '''sagittal''' plane (appears thin on AP, round on lateral) — indicates aspiration rather than ingestion
*'''Identify the exact location:''' Esophagus vs. stomach vs. beyond — this determines management
*Identify the exact location: Esophagus vs. stomach vs. beyond — this determines management


===Consider Underlying Pathology===
===Consider Underlying Pathology===
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==Management==
==Management==
===Esophageal Coin===
===Esophageal Coin===
*'''Proximal esophagus (cricopharyngeus):'''
*Proximal esophagus (cricopharyngeus):
**Endoscopic removal is recommended — '''urgent''' (within 24 hours)<ref name="naspghan"/>
**Endoscopic removal is recommended — '''urgent''' (within 24 hours)<ref name="naspghan"/>
**Some centers perform removal sooner (within 12–16 hours) if the coin has been lodged for an unknown duration
**Some centers perform removal sooner (within 12–16 hours) if the coin has been lodged for an unknown duration
*'''Mid or distal esophagus in an asymptomatic child:'''
*Mid or distal esophagus in an asymptomatic child:
**A brief observation period of '''12–24 hours''' to allow spontaneous passage into the stomach is reasonable<ref name="waltzman"/>
**A brief observation period of '''12–24 hours''' to allow spontaneous passage into the stomach is reasonable<ref name="waltzman"/>
**65% of mid/distal esophageal coins pass spontaneously within 12–24 hours<ref name="waltzman"/>
**65% of mid/distal esophageal coins pass spontaneously within 12–24 hours<ref name="waltzman"/>
**Repeat radiograph at 12–24 hours; if coin has not passed → endoscopic removal
**Repeat radiograph at 12–24 hours; if coin has not passed → endoscopic removal
**'''Do NOT observe''' if the child is symptomatic, if the duration of impaction is unknown, or if the child has prior esophageal pathology
**'''Do NOT observe''' if the child is symptomatic, if the duration of impaction is unknown, or if the child has prior esophageal pathology
*'''Removal techniques:'''
*Removal techniques:
**'''Endoscopy:''' Preferred method — allows direct mucosal inspection and treatment of concurrent pathology (e.g. eosinophilic esophagitis biopsies)<ref name="naspghan"/>
**Endoscopy: Preferred method — allows direct mucosal inspection and treatment of concurrent pathology (e.g. eosinophilic esophagitis biopsies)<ref name="naspghan"/>
**'''Foley catheter technique:''' Fluoroscopically guided balloon catheter passed beyond the coin, inflated, and withdrawn to pull the coin out. Used at some centers for recently impacted (< 24 hours), smooth, round coins in proximal esophagus of otherwise healthy children with no prior esophageal pathology. Controversial; risk of aspiration; not universally endorsed
**Foley catheter technique: Fluoroscopically guided balloon catheter passed beyond the coin, inflated, and withdrawn to pull the coin out. Used at some centers for recently impacted (< 24 hours), smooth, round coins in proximal esophagus of otherwise healthy children with no prior esophageal pathology. Controversial; risk of aspiration; not universally endorsed
**'''Bougienage (coin advancement):''' Esophageal bougie is used to push the coin into the stomach. Used at some centers for distal esophageal coins. Also controversial; no mucosal inspection possible
**Bougienage (coin advancement): Esophageal bougie is used to push the coin into the stomach. Used at some centers for distal esophageal coins. Also controversial; no mucosal inspection possible
*'''NPO''' in anticipation of procedural sedation/anesthesia for removal
*NPO in anticipation of procedural sedation/anesthesia for removal


===Gastric Coin===
===Gastric Coin===
*'''Observation is the standard of care''' — the vast majority pass spontaneously<ref name="conners"/>
*Observation is the standard of care — the vast majority pass spontaneously<ref name="conners"/>
*No specific dietary modification required; normal diet
*No specific dietary modification required; normal diet
*Parents should monitor stools for coin passage (though this is often missed)
*Parents should monitor stools for coin passage (though this is often missed)
*'''Repeat radiograph:'''
*Repeat radiograph:
**Some guidelines suggest repeat imaging '''only if the coin has not passed within 2–4 weeks'''<ref name="naspghan"/>
**Some guidelines suggest repeat imaging '''only if the coin has not passed within 2–4 weeks'''<ref name="naspghan"/>
**Earlier repeat imaging (at 1–2 weeks) may be considered for larger coins or younger children
**Earlier repeat imaging (at 1–2 weeks) may be considered for larger coins or younger children
*'''Endoscopic removal if:'''
*Endoscopic removal if:
**Coin remains in the stomach > 2–4 weeks
**Coin remains in the stomach > 2–4 weeks
**Patient becomes symptomatic (abdominal pain, vomiting, hematemesis)
**Patient becomes symptomatic (abdominal pain, vomiting, hematemesis)


===Post-Gastric (Intestinal) Coin===
===Post-Gastric (Intestinal) Coin===
*'''No intervention needed''' — will pass in stool
*No intervention needed — will pass in stool
*Return precautions for abdominal pain, vomiting, bloody stools
*Return precautions for abdominal pain, vomiting, bloody stools


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==Disposition==
==Disposition==
*'''Discharge home:'''
*Discharge home:
**Asymptomatic child with coin confirmed in the '''stomach or beyond''' on radiograph
**Asymptomatic child with coin confirmed in the '''stomach or beyond''' on radiograph
**Provide written return precautions: vomiting, abdominal pain, bloody stool, refusal to eat, fever
**Provide written return precautions: vomiting, abdominal pain, bloody stool, refusal to eat, fever
**Follow-up radiograph in 2–4 weeks if passage is not confirmed
**Follow-up radiograph in 2–4 weeks if passage is not confirmed
*'''Discharge home with planned follow-up (12–24 hours):'''
*Discharge home with planned follow-up (12–24 hours):
**Asymptomatic child with coin in '''mid or distal esophagus''' being observed for spontaneous passage
**Asymptomatic child with coin in '''mid or distal esophagus''' being observed for spontaneous passage
**Must have reliable parents/caregivers and ability to return promptly
**Must have reliable parents/caregivers and ability to return promptly
**Repeat imaging in 12–24 hours; return immediately if symptoms develop
**Repeat imaging in 12–24 hours; return immediately if symptoms develop
*'''Admit / procedural intervention:'''
*Admit / procedural intervention:
**Symptomatic esophageal coin requiring endoscopic removal
**Symptomatic esophageal coin requiring endoscopic removal
**Proximal esophageal coin (unlikely to pass spontaneously)
**Proximal esophageal coin (unlikely to pass spontaneously)
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**Coin in the trachea (emergent bronchoscopy)
**Coin in the trachea (emergent bronchoscopy)
**Any concern for button battery rather than coin → treat as battery
**Any concern for button battery rather than coin → treat as battery
*'''Referral to GI:'''
*Referral to GI:
**Recurrent esophageal foreign body impaction (evaluate for eosinophilic esophagitis, stricture)
**Recurrent esophageal foreign body impaction (evaluate for eosinophilic esophagitis, stricture)
**Gastric coin persisting > 2–4 weeks
**Gastric coin persisting > 2–4 weeks

Revision as of 16:12, 19 March 2026

Background

  • Coins are the most commonly ingested foreign body in children, accounting for the majority of pediatric foreign body ingestion ED visits[1]
  • Peak age: 6 months to 3 years (exploratory mouthing behavior)
  • The vast majority of ingested coins pass through the GI tract spontaneously without complication
  • Coins that reach the stomach have a > 95% chance of passing without intervention[2]
  • The primary concern is esophageal impaction, which occurs in approximately 10–20% of pediatric coin ingestions[3]
  • Esophageal impaction most commonly occurs at one of three anatomic narrowings:
    • Upper esophageal sphincter (cricopharyngeus) — most common site (~70%)
    • Aortic arch / carina level (mid-esophagus)
    • Lower esophageal sphincter (GE junction)
  • Serious complications from coin ingestion (perforation, fistula, obstruction) are extremely rare but can occur with prolonged esophageal impaction[1]
  • Critical distinction: Coins must be differentiated from button batteries on radiograph — batteries require emergent removal, coins generally do not
  • Adult coin ingestions are uncommon and raise concern for underlying esophageal pathology (stricture, eosinophilic esophagitis, Schatzki ring) or psychiatric/developmental conditions

Clinical Features

Asymptomatic (Most Common)

  • Many coin ingestions, particularly those past the esophagus, are completely asymptomatic
  • Parents may witness the ingestion or find a coin is missing
  • The child may be entirely well-appearing with a normal exam

Esophageal Impaction

  • Dysphagia, odynophagia
  • Drooling, refusal to eat or drink
  • Vomiting or gagging
  • Chest pain, neck pain, throat discomfort ("something stuck")
  • Irritability, fussiness (nonverbal children)
  • Cough, stridor, or wheezing (compression of the posterior membranous trachea by a proximal esophageal coin)

Post-Esophageal (Gastric / Intestinal)

  • Typically asymptomatic
  • Rare: abdominal pain, vomiting if coin causes gastric outlet obstruction or fails to pass a fixed anatomic narrowing (e.g. pylorus, ileocecal valve, prior surgical site)

Delayed / Missed Ingestion

  • Chronic cough, recurrent wheezing, or feeding difficulties may be the only presentation if the ingestion was unwitnessed
  • Consider coin (or other foreign body) in any child with unexplained respiratory or feeding symptoms[2]

Differential Diagnosis

Evaluation

Workup

  • AP and lateral radiographs of the neck, chest, and abdomen — standard of care for all suspected coin ingestions[1]
    • Coins are radiopaque and readily identified
    • Must image from nasopharynx to rectum if location is uncertain
  • Labs: Generally NOT needed for uncomplicated coin ingestion
    • Obtain CBC, BMP, type and screen if there is concern for perforation, hemorrhage, or the patient requires procedural sedation/general anesthesia for removal

Diagnosis

  • Coin vs. Button Battery on X-ray:
Feature Coin Button Battery
AP view Single uniform disc; no double ring "Double ring" / "halo" sign (step-off between anode and cathode layers)
Lateral view Uniformly thin Step-off (one side wider than the other)
Orientation in esophagus Coronal (flat face toward AP viewer — appears round on AP) Also coronal in esophagus
  • If the object cannot be definitively identified as a coin, manage as a button battery until proven otherwise
  • Coin orientation helps localize:
    • Esophagus: Coin is oriented in the coronal plane (appears round on AP view, thin line on lateral)
    • Trachea: Coin is oriented in the sagittal plane (appears thin on AP, round on lateral) — indicates aspiration rather than ingestion
  • Identify the exact location: Esophagus vs. stomach vs. beyond — this determines management

Consider Underlying Pathology

  • Recurrent esophageal coin impaction or food impaction → workup for eosinophilic esophagitis, esophageal stricture, vascular ring, or other anatomic abnormality[1]
  • Adult with esophageal coin impaction → underlying pathology is very likely

Management

Esophageal Coin

  • Proximal esophagus (cricopharyngeus):
    • Endoscopic removal is recommended — urgent (within 24 hours)[1]
    • Some centers perform removal sooner (within 12–16 hours) if the coin has been lodged for an unknown duration
  • Mid or distal esophagus in an asymptomatic child:
    • A brief observation period of 12–24 hours to allow spontaneous passage into the stomach is reasonable[3]
    • 65% of mid/distal esophageal coins pass spontaneously within 12–24 hours[3]
    • Repeat radiograph at 12–24 hours; if coin has not passed → endoscopic removal
    • Do NOT observe if the child is symptomatic, if the duration of impaction is unknown, or if the child has prior esophageal pathology
  • Removal techniques:
    • Endoscopy: Preferred method — allows direct mucosal inspection and treatment of concurrent pathology (e.g. eosinophilic esophagitis biopsies)[1]
    • Foley catheter technique: Fluoroscopically guided balloon catheter passed beyond the coin, inflated, and withdrawn to pull the coin out. Used at some centers for recently impacted (< 24 hours), smooth, round coins in proximal esophagus of otherwise healthy children with no prior esophageal pathology. Controversial; risk of aspiration; not universally endorsed
    • Bougienage (coin advancement): Esophageal bougie is used to push the coin into the stomach. Used at some centers for distal esophageal coins. Also controversial; no mucosal inspection possible
  • NPO in anticipation of procedural sedation/anesthesia for removal

Gastric Coin

  • Observation is the standard of care — the vast majority pass spontaneously[2]
  • No specific dietary modification required; normal diet
  • Parents should monitor stools for coin passage (though this is often missed)
  • Repeat radiograph:
    • Some guidelines suggest repeat imaging only if the coin has not passed within 2–4 weeks[1]
    • Earlier repeat imaging (at 1–2 weeks) may be considered for larger coins or younger children
  • Endoscopic removal if:
    • Coin remains in the stomach > 2–4 weeks
    • Patient becomes symptomatic (abdominal pain, vomiting, hematemesis)

Post-Gastric (Intestinal) Coin

  • No intervention needed — will pass in stool
  • Return precautions for abdominal pain, vomiting, bloody stools

Airway (Aspirated Coin)

  • Emergent bronchoscopy — coin in the trachea or bronchus requires immediate removal
  • Identified by sagittal orientation on AP radiograph

Disposition

  • Discharge home:
    • Asymptomatic child with coin confirmed in the stomach or beyond on radiograph
    • Provide written return precautions: vomiting, abdominal pain, bloody stool, refusal to eat, fever
    • Follow-up radiograph in 2–4 weeks if passage is not confirmed
  • Discharge home with planned follow-up (12–24 hours):
    • Asymptomatic child with coin in mid or distal esophagus being observed for spontaneous passage
    • Must have reliable parents/caregivers and ability to return promptly
    • Repeat imaging in 12–24 hours; return immediately if symptoms develop
  • Admit / procedural intervention:
    • Symptomatic esophageal coin requiring endoscopic removal
    • Proximal esophageal coin (unlikely to pass spontaneously)
    • Coin that fails to pass after 12–24 hour observation period
    • Coin in the trachea (emergent bronchoscopy)
    • Any concern for button battery rather than coin → treat as battery
  • Referral to GI:
    • Recurrent esophageal foreign body impaction (evaluate for eosinophilic esophagitis, stricture)
    • Gastric coin persisting > 2–4 weeks

See Also

External Links

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Kramer RE, Lerner DG, Lin T, et al. Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee. J Pediatr Gastroenterol Nutr. 2015;60(4):562-574. PMID 25611037.
  2. ↑ 2.0 2.1 2.2 Conners GP. Pediatric foreign body ingestion: complications and patient and foreign body factors. Sci. 2022;4(2):20.
  3. ↑ 3.0 3.1 3.2 Waltzman ML, Baskin M, Wypij D, et al. A randomized clinical trial of the management of esophageal coins in children. Pediatrics. 2005;116(3):614-619. PMID 16140700.
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