Review Question - QID 104581

Patients who are asymptomatic following ingestion of a coin and know the point in time of ingestion may be observed until it passes with serial radiographs.

After a suspected foreign body ingestion, the first step in management is to ensure that the object is not causing respiratory compromise through a thorough physical examination and appropriate imaging studies. If a patient has swallowed a coin and is either symptomatic or the time of ingestion is unknown, flexible endoscopy with attempted retrieval of the foreign body should be attempted.

Uyemura reviews foreign body ingestion in children. The majority of ingested objects will pass spontaneously. If an object is lodged in the esophagus, removal should be attempted via endoscopy. For large or sharp objects swallowed, endoscopic retrieval should be attempted when possible. For small, smooth objects that have advanced past the duodenum, conservative management with radiographic observation and stool inspection is appropriate. Surgical or further endoscopic management is needed for objects that cause severe symptoms or fail to progress through the GI tract.

Waltzman discusses the management of esophageal coins. The best treatment for esophageal coins causing symptoms such as stridor, respiratory distress, pain, cough is widely agreed upon as being immediate removal via either endoscopic retrieval or advancement of the object further through the GI tract commonly with bougienage. However, the management of asymptomatic coins is more controversial; this author recommends, based on literature review, expectant management for 12 - 24 hours with the hope of spontaneous passage to avoid more invasive measures.

Figure A is a radiograph showing a radio-opaque coin inferior to the patient's left diaphragm, likely located in the stomach. Illustration A gives an overview of a management algorithm for foreign body ingestion. Illustration B depicts a management algorithm for radiopaque foreign body ingestion. Illustration C shows a similar algorithm for radiolucent objects.

Incorrect Answers:
Answer 1: This patient should be observed for 24 hours or until the coin passes, as the coin may potentially obstruct or cause symptoms more distally in the GI tract that would necessitate retrieval.
Answer 3: With a known time-point of ingestion and an asymptomatic clinical presentation, observation should be pursued over endoscopic retrieval at this point.
Answer 4: Bronchoscopy would not be appropriate; the imaging shows that the coin is inferior to the diaphragm.
Answer 5: Surgical removal should only be attempted in cases necessitating removal of the foreign body, where prior attempts at endoscopic retrieval have failed.