Coin ingestion

Background

• Coins are the most commonly ingested foreign body in children, accounting for the majority of pediatric foreign body ingestion ED visits
• 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
• The primary concern is esophageal impaction, which occurs in approximately 10–20% of pediatric coin ingestions
• 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
• 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

Differential Diagnosis

• Button battery ingestion — must be excluded radiographically before observation (see Diagnosis for distinguishing features)
• Other foreign body ingestion (magnets, small toys, jewelry)
• Food bolus impaction
• Epiglottitis, Croup (if airway symptoms)
• GERD, eosinophilic esophagitis
• Esophageal Stricture
• Retropharyngeal abscess (if neck pain, drooling, refusal to eat)
• Swallowed magnets (single magnet = low risk; multiple magnets = surgical emergency)

Evaluation

Workup

• AP and lateral radiographs of the neck, chest, and abdomen — standard of care for all suspected coin ingestions
  • 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
• Adult with esophageal coin impaction → underlying pathology is very likely

Management

Esophageal Coin

• Proximal esophagus (cricopharyngeus):
  • Endoscopic removal is recommended — urgent (within 24 hours)
  • 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
  • 65% of mid/distal esophageal coins pass spontaneously within 12–24 hours
  • 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)
  • 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
• 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
  • 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

• Button battery ingestion
• Foreign body ingestion
• Esophageal foreign body
• Magnet ingestion
• Esophageal food impaction
• Pediatric foreign body

External Links

• Management of Ingested Foreign Bodies in Children - NASPGHAN/ESPGHAN 2015
• Randomized clinical trial of management of esophageal coins in children - Pediatrics 2005
• Pediatric foreign body ingestion: complications and factors - Sci 2022
• National Capital Poison Center: Button Battery Triage and Treatment Guideline