Managing Esophageal Coin Foreign Body in Pediatric Patients
Article: IS THERE A NEED FOR REPEAT RADIOLOGIC EXAMINATION OF CHILDREN WITH ESOPHAGEAL COIN FOREIGN BODY?
Dedhia, K., et al, Otolaryngol Head Neck Surg 156(1):173, January 2017
Background: The swallowing of coins accounts for more than 80 percent of all foreign body ingestions. It is generally accepted that coins that pass into a child’s stomach will traverse the rest of the GI tract uneventfully while a coin in the esophagus has a higher likelihood for complication. Coins that do not pass into the stomach are removed endoscopically, typically under general anesthesia in the OR.
Study Question: Is there a need for repeat radiologic examination of children with esophageal coin foreign body? Secondary study question: what factors are associated with increased likelihood of coin passage?
Methods: This was a retrospective cohort of 406 children age 0 to 9 years who had an initial diagnostic CXR showing esophageal coin and an immediate pre-operative repeat CXR. Patients were excluded if there were signs of respiratory distress, significant dysphagia, difficulty managing secretions, or if there was any concern for button battery.
Results: -Avg age: 4yo -Only 7% had a position change on pre-op (repeat) CXR. Average interval between initial and repeat CXR was 9.5 hrs. -For the patients with an esophageal coin for more than 12 hours, 0 passed spontaneously. For the rest of the kids, who had the esophageal coin present for less than 12 hours, only 10% passed spontaneously. In total, 93% of the children in this study had no coin movement on repeat CXR and required endoscopic removal in the OR. -Significant predictors of coin passage were patient age and location in the esophagus. Older patients and distal esophageal coins were more likely to pass spontaneously. Only 1 of the 174 children less than three years of age passed the coin spontaneously. -377/406 went to the OR, 77% had no or minimal esophageal injury. One required thoracotomy after failed endoscopic retrieval.
Discussion: -Using the results from this study, physicians could bypass repeat imaging and proceed to the OR earlier in patients that are less likely to pass the coin spontaneously. This would allow for faster ED throughput and decreased radiation exposure. The argument can be made that even with this information, we should still verify that the coin hasn’t passed into the stomach prior to committing a child to general anesthesia and operative risk. There is growing literature suggesting that general anesthesia in children, especially those less than four years of age, carries neurodevelopmental risk. And while radiation exposure needs to be carefully considered, current literature does not clearly state whether the radiation exposure from one pediatric CXR increases lifetime cancer risk. For those worried about radiation risk, ultrasound and handheld metal detectors can be utilized to determine coin location prior to operative management.
Bottom Line: -A coin in the esophagus >12 hours (or for any length of time in a child less than 3yo) is very unlikely to pass. -Physicians should consider an observation period in cases that have a higher likelihood of coin passage. -In patients with esophageal coin foreign body for less than 12 hours, physicians should confirm esophageal coin location using CXR, alternative modality, or surgery consultant’s modality of choice prior to sending child to the OR.