Children, for whatever reason, have a predilection for swallowing coins. Perhaps it’s the taste or that they’re using their stomach as a piggy bank. When these young patients present to the emergency department with a coin lodged in their esophagus, what options do we have? We could call gastroenterology or try to take it out ourselves. One option with few complications is bougienage, where we manually advance the coin into the stomach classically using a Hurst dilator and allow it to pass naturally.

Figure 1. Tongue depressors taped together to act as a bite block

Background

In 2012, there were approximately 93,000 cases of foreign-body ingestions, nearly 4,000 of which were coins.¹ While the feared button-battery ingestion can cause esophageal necrosis in as little as two hours, impacted coins can also cause perforation, obstruction, or fistulas if left untreated.^2,3

The American Society for Gastrointestinal Endoscopy (ASGE) currently recommends an observation period of 24 hours for asymptomatic patients to see if the coin will pass into the stomach without any intervention.⁴ Up to 56 percent of coins lodged in the distal esophagus and 27 percent in the proximal esophagus will pass into the stomach without any complications.⁵ Once in the stomach, most coins will transverse the gastrointestinal

Figure 2. Hurst dilator

tract spontaneously.^5,6 If the coin is retained within the stomach for more than three to four weeks, the patient will likely need endoscopic removal. The same is true for any coin that remains stationary for one week past the duodenum; it will need surgical removal.

For coins that do not spontaneously pass into the stomach, endoscopy has shown to be very successful (100 percent), with a small but measurable rate of complications, which are predominantly airway related (2.5 percent).⁷ An additional method of removal is using the Foley catheter technique. There are variations to the actual procedure, but typically it involves placing a Foley catheter (either orally or nasally) past the foreign body, inflating the Foley balloon, and extracting the foreign body. As you may imagine, the most concerning aspect to this technique is the thought of dragging the foreign body right past the glottis, which is just lying there open and waiting for that coin to drop in as though you are playing the penny slots in Vegas. While the concern is valid, the complication rate is relatively low (0–2 percent), and the success rate is favorable (88–94 percent).^7–12