What is the appropriate evaluation and management of a swallowed penny in a patient?

Management of Swallowed Penny

For a swallowed penny, obtain a chest and abdominal radiograph immediately to localize the coin, and if it is lodged in the esophagus, perform endoscopic removal within 24 hours; if the coin has passed into the stomach or beyond, manage conservatively with observation and allow spontaneous passage. 1, 2, 3

Initial Evaluation and Imaging

• All patients with suspected or reported coin ingestion require radiographic evaluation, even if asymptomatic, as 17% of asymptomatic children have esophageal coins that require intervention 4
• Obtain anteroposterior and lateral chest radiographs extending to include the upper abdomen to localize the coin and differentiate esophageal from tracheal positioning 2, 4
• Coins are radiopaque and easily visible on plain films, making CT scan unnecessary in most cases 1, 2
• Approximately 31% of children presenting with coin ingestion have esophageal impaction, with 14% being completely asymptomatic in the emergency department 4

Risk Stratification Based on Symptoms

High-risk features requiring urgent intervention include:

• Inability to swallow saliva (complete esophageal obstruction) 3
• Drooling, choking at time of ingestion, or persistent vomiting 4
• Chest pain or localization of discomfort to the chest 4
• Respiratory symptoms suggesting tracheal compression 1

These symptoms strongly predict esophageal impaction and need for removal (P < 0.05) 4

Management Algorithm Based on Coin Location

Esophageal Coins (Most Common Site: Postcricoid Region)

• Remove all esophageal coins endoscopically within 24 hours to prevent complications including pressure necrosis, aspiration risk, and retropharyngeal abscess 5, 2, 3
• The postcricoid region is the most common impaction site (73% of esophageal coins in one pediatric series) 5
• Endoscopic removal is the standard approach, though some centers use Foley catheter extraction for recent, uncomplicated impactions in cooperative children 2
• Do not delay removal beyond 24 hours, as complications increase with prolonged impaction 5, 3

Gastric or Intestinal Coins

• Manage conservatively with observation once the coin passes into the stomach, as approximately 80% of ingested foreign bodies pass spontaneously through the gastrointestinal tract 2, 3
• Coins that have passed the duodenal sweep should be managed with radiographic surveillance and stool inspection 2
• Repeat radiograph in 2-4 weeks if the coin has not passed in stool to confirm progression 2
• Endoscopic or surgical intervention is indicated only if significant symptoms develop (abdominal pain, vomiting, fever) or if the object fails to progress 2

Special Considerations and Pitfalls

• Coins are the most frequent foreign body ingested by children (87.5% in one series), making this a common pediatric emergency 1, 5
• Choking is a transient event with coins—the coin typically passes into the esophagus or stomach rather than causing airway obstruction 1
• Never assume a negative history rules out ingestion—maintain high clinical suspicion, especially in young children who may not report the event 2, 4
• Asymptomatic presentation does not exclude esophageal impaction—radiographs are mandatory even without symptoms 4
• Surgery is rarely needed (less than 1% of cases) and reserved only for perforation or obstruction 3

Timeline for Intervention

• Urgent (not emergent) endoscopy within 12-24 hours for esophageal coins without complete obstruction 3
• Emergent endoscopy within 2-6 hours only if complete esophageal obstruction with inability to handle secretions 3
• For coins beyond the esophagus, clinical follow-up at 2-4 weeks if not passed in stool 2