What is the management for a coin visible on a stomach X-ray?

Management of Coin in Stomach on X-ray

For a coin visualized in the stomach on X-ray, observation with outpatient follow-up is appropriate, as most coins will pass spontaneously through the gastrointestinal tract without intervention. 1, 2, 3

Initial Assessment and Imaging

• A single frontal chest radiograph including the entire esophagus is sufficient to determine coin location and guide management—full aerodigestive surveys from nares to anus are unnecessary 3
• Plain abdominal X-ray can confirm gastric location when the coin has passed beyond the esophagus 4
• Once a coin is confirmed to be in the stomach (not esophagus), the negative predictive value for requiring intervention is 97.8% 3

Management Based on Location

Coin in Stomach (Your Scenario)

• Discharge home with instructions to monitor stools until passage is confirmed 5, 1
• Expected spontaneous passage occurs within 2-6 days on average (range 1-7 days) 5
• Endoscopic removal is only indicated if:
  • The coin remains in the stomach for 4 weeks without passage 5
  • Patient develops abdominal pain or other concerning symptoms 3
  • Signs of obstruction or perforation develop 4

Coin in Esophagus (For Comparison)

• Symptomatic patients (stridor, respiratory distress, drooling, pain, inability to tolerate oral fluids) require immediate endoscopic removal 1, 2
• Asymptomatic patients with coins below the thoracic inlet can be observed at home with next-day follow-up radiographs—spontaneous passage into stomach occurs in many cases 1, 2
• If coin remains in esophagus on repeat imaging, immediate removal is indicated 1
• Coins above the thoracic inlet in asymptomatic patients warrant repeat radiographs in 2-5 hours, as spontaneous passage may occur 1

Key Clinical Pearls

• Coin diameter matters: Coins with diameter 23.45-26.00 mm are most likely to lodge in the esophagus (73% of retained coins), while smaller or larger coins tend to pass more readily 6
• Age correlation: Larger coins are more likely to be retained in older children, while younger children retain smaller coins 6
• Bougienage (single passage of Hurst bougie dilator) is an effective alternative to endoscopy for esophageal coins with 90% success rate, lower cost ($1210 vs $3100), and shorter hospital time (2 hours vs 8 hours), though this requires gastroenterology expertise 5

Red Flags Requiring Immediate Intervention

• Do not delay intervention if patient develops peritonitis, hemodynamic instability, or signs of perforation—proceed directly to surgical exploration without additional imaging 4
• Contrast-enhanced CT is indicated if there is clinical suspicion of perforation, obstruction, or other complications in stable patients 4

Cost and Time Considerations

• Observation protocols are more cost-effective and convenient than immediate endoscopic intervention for asymptomatic gastric coins 5, 1
• Home observation avoids general anesthesia and procedural risks when spontaneous passage is likely 2