Esophageal Coins in Asymptomatic Children: Watchful Waiting or Early Retrieval?
Abstract & Commentary
By Raemma Paredes Luck, MD Dr. Luck is Assistant Professor of Pediatric Emergency Medicine, Director of Continuing Medical Education, the International Health Program, Temple University Children's Medical Center, Philadelphia. Dr. Luck has reported no relationships with companies having ties to the field of study covered by this CME program.
Source: Waltzman ML, et al. A randomized clinical trial of the management of esophageal coins in children. Pediatrics 2005;116:614-619.
Ingestion of foreign bodies is a frequent reason for seeking emergency care in the pediatric population. Coins, in particular, are commonly encountered, and often are lodged in the esophagus. The management in symptomatic children is immediate removal of the coin, usually by endoscopy. The management of esophageal coin ingestion in the asymptomatic child has been controversial. Some practitioners recommend immediate removal while others advocate observation. This study by Waltzman was undertaken to answer these key issues: to compare the outcomes of two commonly used strategies and to determine which clinical factors can predict spontaneous passage of an esophageal coin in the asymptomatic pediatric patient.
Sixty patients younger than 21 years seen in the pediatric ED were admitted and randomized to equal two groups: 1) defined observation period (~ 16 hours, while remaining NPO) and repeat radiographs afterward; and 2) immediate endoscopic removal. Patients were excluded if they were symptomatic, had previous esophageal or tracheal surgery, or presented more than 24 hours after ingestion (or ingestion time could not be determined). Results showed that the rate of spontaneous passage beyond the esophageal sphincter was similar in both groups (around 27%), with all coins having passed by 19 hours. Nine of 30 patients in the immediate endoscopy group had a delay in their procedure of more than 2 hours. Repeat radiographs just before endoscopic removal showed that all coins had passed spontaneously to the stomach. There were no complications in either group. The authors found that coins located more distally in the esophagus (in the distal third), in males, and in older patients (66 vs 46 months) were more likely to pass spontaneously beyond the esophageal sphincter.
It is interesting to note that in the immediate removal group, where there was a delay in endoscopy of more than 2 hours, approximately the same percentage of patients had spontaneous passage of the coins as in the observation group. One can argue that the percentage could be higher if the patients were observed longer.
The small sample size is probably this study's greatest limitation. However, the findings of the study are similar to other studies and provide further understanding on the natural history of coin ingestions. Previous researchers have shown that coins lodged for less than 24 hours, especially those more distally located and in children without a history of tracheosophageal surgery or pathology, are more likely to pass.1-3 This led to the recommendation that asymptomatic children be observed for 12-24 hours before endoscopic removal.1-4
In an anonymous home-based survey of parents who had children with coin ingestions, Conners5 found that the majority of parents (85%) managed these cases at home, often without calling their physicians or the poison center. Parents did not report any adverse complications. None of the children underwent endoscopic removal. This study suffered somewhat by the possibility of sample bias, in that only 35% of those surveyed responded. This finding was reinforced in a small study by Sharieff and colleagues who also found that asymptomatic patients sent home and followed-up the next day experienced no adverse outcomes.1 Obviously, this strategy is more cost effective and convenient for patients.
A large prospective study comparing inpatient and home observation also may provide better answers to this commonly encountered condition.
1. Sharieff GQ, et al. Acute esophageal coin ingestions: is immediate removal necessary? Pediatr Radiol 2003; 33:859-863.
2. Conners GP, et al. Symptoms and spontaneous passage of esophageal coins. Arch Pediatrics Adol Med 1995;149:36-39.
3. Soprano JV, et al. The spontaneous passage of esophageal coins in children. Arch Pediatr Adolesc Med 1999;153:1073-1076.
4. Conners GP, et al. Conservative management of pediatric distal esophageal coins. J Emerg Med 1996;14: 723-726.
5. Gregory P, et al. Pediatric coin ingestion: A home-based survey. Am J Emerg Med 1995;13:638-640.