Management of Gastric Coin in a 6-Year-Old Child with Drooling
The child requires immediate endoscopy (Option A) because drooling indicates a second foreign body or esophageal pathology that was missed on the initial X-ray, despite the coin appearing to be in the stomach. 1
Critical Clinical Reasoning
The key to this case is recognizing that drooling is a red flag symptom that should not be present if the foreign body has truly passed into the stomach. 1, 2 When a foreign body successfully transits through the esophagus into the stomach, symptoms like drooling, dysphagia, and respiratory distress should resolve immediately. The persistence of drooling in this child suggests one of two scenarios:
- A second undetected esophageal foreign body that was not visible on the initial radiograph (coins can overlap or a radiolucent object may be present) 1
- Esophageal injury or inflammation from the coin's passage that is causing continued symptoms 3
Why Immediate Endoscopy is Indicated
Drooling represents a symptom of complete or near-complete esophageal obstruction and carries significant risk of aspiration and perforation. 1, 2 According to World Journal of Emergency Surgery guidelines, emergent flexible endoscopy within 2-6 hours is recommended for esophageal foreign bodies causing symptoms such as drooling. 1
The endoscopy serves multiple critical purposes:
- Evaluate the entire esophagus for a second foreign body or esophageal injury that explains the drooling 1
- Assess for esophageal mucosal damage from the coin's transit 3
- Remove the gastric coin during the same procedure to prevent any potential complications 4, 5, 6
- Obtain diagnostic biopsies to evaluate for underlying esophageal pathology (found in up to 25% of pediatric foreign body cases) 1, 2
Why Other Options Are Inappropriate
Option B (Discharge with stool observation) is contraindicated because the child is symptomatic with drooling, which demands investigation regardless of where the coin appears on X-ray. 1 Plain radiographs have a false-negative rate of up to 85% for non-radiopaque foreign bodies, and the World Journal of Emergency Surgery guidelines explicitly state that persistent esophageal symptoms require endoscopic evaluation even when radiographic examination appears normal. 1
Option C (24-hour observation while fasting) is also contraindicated because delaying necessary intervention increases aspiration risk and delays removal of any esophageal pathology. 1 The drooling indicates an urgent problem that requires immediate evaluation, not observation.
Management Algorithm for Gastric Coins
For context, if this child were truly asymptomatic with a confirmed gastric coin:
- Blunt gastric foreign bodies <2 cm in diameter (like coins) can be observed for up to 2 weeks in the stomach before requiring removal 4, 5
- Discharge with stool observation would be appropriate for asymptomatic gastric coins 4, 5, 6
- Endoscopic removal is indicated only if the coin remains in the stomach after 2 weeks, or if it's sharp, pointed, >4 cm long, or >2 cm wide 4, 5
However, the presence of drooling completely changes the management and mandates immediate endoscopic evaluation. 1, 2
Procedural Considerations
The endoscopy should be performed:
- Under general anesthesia with endotracheal intubation to protect the airway given the aspiration risk from drooling 1
- By a gastroenterologist as flexible endoscopy is first-line with up to 90% success rates 1
- With appropriate retrieval instruments (W-shape grasping forceps work well for coins) 4, 5
- With complete esophageal inspection and biopsy if any abnormalities are found 1, 2
Common Pitfall
The major pitfall in this case is trusting the X-ray appearance over the clinical presentation. When symptoms don't match the radiographic findings, always investigate further—the symptoms are telling you something is wrong that the X-ray may have missed. 1