What is the best next management step for a 6-year-old child who ingested a coin (Foreign Body, FB) that is now in the stomach, is stable, and has no respiratory or gastrointestinal (GIT) obstruction?

Management of Coin in Stomach with New-Onset Drooling

The best next step is immediate endoscopy (Option A), because the new-onset drooling strongly suggests a second foreign body in the esophagus that was missed on the initial X-ray. 1

Critical Clinical Reasoning

The key to this case is recognizing the discordance between the clinical presentation and radiographic findings:

• Drooling is a hallmark sign of esophageal foreign body obstruction, not gastric foreign bodies 1
• A coin in the stomach should not cause drooling, as it has already passed through the esophagus 2
• This clinical finding suggests a second, possibly radiolucent foreign body (such as food, plastic, or organic material) lodged in the esophagus 1
• Plain radiographs have a false-negative rate of up to 85% for non-radiopaque foreign bodies 3

Why Immediate Endoscopy is Required

Emergent flexible endoscopy (within 2-6 hours) is recommended for esophageal foreign bodies causing symptoms such as drooling, as they indicate complete or near-complete esophageal obstruction with risk of aspiration and perforation 4, 3

Specific Indications Met:

• Symptomatic presentation (drooling) warrants urgent intervention regardless of what the X-ray shows 1
• The World Journal of Emergency Surgery guidelines state that persistent esophageal symptoms require endoscopic evaluation even when radiographic examination is negative 4
• Esophageal foreign bodies should be removed within 24 hours due to risks of perforation and serious fistula formation 5

Why Other Options Are Inappropriate

Option B (Discharge with stool observation):

• Completely contraindicated given the new symptom of drooling 1
• While coins in the stomach typically pass spontaneously in 80% of cases 6, 2, this only applies to asymptomatic patients
• The drooling indicates an unresolved esophageal problem requiring immediate attention 1

Option C (24-hour observation while fasting):

• Delays necessary intervention for what is likely an esophageal foreign body 3
• Urgent (<24 hour) endoscopy is recommended for esophageal foreign bodies without complete obstruction, but symptomatic cases warrant even faster intervention 4
• Keeping the child fasting without addressing the likely esophageal obstruction increases aspiration risk 3

Management Algorithm

1. Proceed immediately to endoscopy under general anesthesia with endotracheal intubation to protect the airway 4
2. Examine the entire esophagus first before addressing the gastric coin, as the drooling suggests proximal pathology 1
3. Remove any esophageal foreign body identified using appropriate retrieval techniques (grasping forceps, baskets, or snares) 4
4. Then address the gastric coin during the same procedure 2
5. Obtain at least 6 biopsies from different esophageal sites to evaluate for underlying pathology such as eosinophilic esophagitis, which is found in up to 25% of patients with foreign body impaction 3, 7

Common Pitfalls to Avoid

• Never rely solely on radiographic findings when clinical symptoms suggest esophageal obstruction - drooling is a red flag that demands endoscopic evaluation 1
• Do not assume a single foreign body - children may ingest multiple objects, and radiolucent items won't appear on X-ray 1
• Avoid the "wait and see" approach in symptomatic patients - this is only appropriate for asymptomatic esophageal coins, not for patients with drooling or other obstructive symptoms 1