See the original question here.

A 42-year-old man was brought to the emergency department (ED) for abdominal pain. EMS stated he has a history of pica. The patient stated that his stomach hurt because he “ate some stuff” over the last two days, but he would not disclose what he ate.

Physical examination revealed normal vital signs: alert and oriented, speaking comfortably, and in no distress. He had clear lungs and normal heart rate and rhythm. He was obese and had a moderately tender abdomen primarily in the epigastric area, no peritoneal signs, no rebound, normal bowel sounds, and no surgical scars. A normal neuro examination—labs, chest X-ray (CXR), and kidneys, ureters, and bladder radiograph (KUB)—was ordered.

CXR AP [image 1] and Lateral [image 2] revealed a round, flat, radiopaque foreign body (FB) in the distal esophagus, consistent with a metal coin. His KUB revealed multiple other foreign bodies. [image 3]

Coin Ingestion

Lateral revealed a round, flat, radiopaque foreign body (FB) in the distal esophagus, consistent with a metal coin. (Photos Jason Hack | Oleander Photography) (Click to enlarge.)

Coin ingestions are the most swallowed non-food FB seen in children brought to emergency departments.^1,2 Once in the stomach, they usually result in no, or minimal, mucosal harm and typically pass spontaneously. However, in some circumstances, FBs can cause injury or even mortality due to gastrointestinal (GI) bleeding, ulcerations, perforation, mediastinitis, peritonitis, abscess, fistula formation, or obstruction if not properly addressed. About half of patients who end up requiring FB removal (including coins) have minimal or no symptoms.

Evaluation

1. ABCs. Address airway needs immediately. What does the patient look like? Are they in respiratory distress? Tripoding? Drooling? Unable to speak?
2. Is the patient complaining of severe chest or abdominal pain? Be aware that 51 percent of children needing FB removal had no symptoms.³
3. Is there a history of nausea or vomiting? Feeding refusal? Cough? Unexplained crying? Blood-stained saliva? Dysphagia? ²
4. Is it really a coin? Could it be something else? How do they know it was a coin? You want to make sure it was not a lead (Pb) item, which can lead to potential poisoning,⁴ a button battery [severe mucosal burns], or more than one super-magnet [severe mucosal damage, and fistulization].^3,5
5. Examination. Stridor? Lung sounds? Abdominal tenderness or distension? Look in the mouth!
6. Imaging. Biplane radiographs including chest X-ray and KUB are most commonly used. These allow identification of type, size, and location of radiopaque FBs; free mediastinal or peritoneal air. Make sure the chest X-ray includes the neck to the level of the jaw. Some patients may require advanced imaging such as CT scans, depending on clinical picture and severity of symptoms—to evaluate for perforations, etc.

X-ray Findings

His KUB revealed multiple other foreign bodies.

1. Is there an FB? Metal coins are radiopaque and should be able to be located and identified in the GI tract with X-ray.⁶ If not present, look in ears and nose.
2. Identify where the coin is: larynx, trachea (coins typically lie in the sagittal plane with edges front and back;⁶ think of the vocal cords as a coin slot*), esophagus (coins typically lie in the coronal plane with edges left and right*⁶), stomach, distal to stomach. (*Rarely sagittal oriented coins are seen in the esophagus, typically in older pediatric patients in the distal section.)
3. Is the FB consistent with a coin? Is it round? Is it flat? Is it thin? Does it have only one density? If so, it is likely a coin.

Location and Management

1. Coins in the stomach or beyond. More than 93 percent of 807 children presenting with coin ingestions have them in the stomach or beyond.¹ These patients, if they have no other symptoms, can go home with “stool sifting” for the next two weeks. If the coin is not recovered, repeat X-ray in two weeks for location. Good warnings and instructions for discharge are the development of abdominal pain, signs of obstruction, etc.
2. Coins in the esophagus. Most common narrowed areas for coins to pause within the esophagus are at the thoracic inlet, in the mid-esophagus at the level of the aortic arch, or at the lower esophageal sphincter of the gastroesophageal junction. There is debate in the management of these patients. Quitadamo found that coins in the middle to distal esophagus spontaneously passed within a “few hours” in 65 percent of the children they monitored, avoiding the need for endoscopy¹, and Rozier reported 30 percent advance into the stomach from the esophagus. Coins found in the proximal one-third often require urgent endoscopy and removal because of symptoms.⁶

There are no firm guidelines about the timing of esophageal coin removal. Coins may spontaneously migrate into the stomach and be allowed to pass. Research to determine a reliable number for the rate of spontaneous esophagus retained coins moving to the stomach is limited.

The Coin

Tander et al., reviewed 62 pediatric patients (median 4 years old), and found the coins were lodged in upper esophagus in 80 percent of them. The size of the coins ranged from 17 mm to greater than 26 mm. Of all the children included, they found that 2- to 5-year-olds had most esophageal impacted coins, and 75 percent of the coins were in the “danger” size, 23.45 mm to 26 mm. They found no relationship between the coin size and where in the esophagus it lodged.⁸

Endoscopic Retrieval

The timing of the endoscopy, if needed, is determined by where the coin is lodged and symptomatology. Patients with signs of distress (including inability to swallow) require emergent GI consult and endoscopy. Patients with proximal esophageal coins and symptoms typically undergo urgent endoscopic retrieval within four hours. Patients with middle or distal esophageal coins (or sometimes proximal without distressing symptoms) are often observed for 12 to 24 hours for migration into the stomach before endoscopic intervention is considered.¹⁰

Back to the Case

The patient underwent emergent endoscopy because of his imaging findings and his abdominal pain. Items found and retrieved from his esophagus and stomach included three coins (yellow arrows): one in the distal esophagus and two laying on top of each other in his stomach. He also had several other types of objects (red arrows, blue arrow, purple arrows) that we will discuss in our next column. Be sure to tune in!

Dr. Hack is chief of the division of medical toxicology and vice chair for research at East Carolina University in Greenville, N.C.

References

1. Quitadamo P.,o; Di Napoli L.,; Lerro F., et al. et al. Insert-Coin: A Prospective Study of Coin Ingestion in Children of Southern Italy. Am J Gastroenterol. 2025;120(6):1388-1390. | 10.14309/ajg.0000000000003270
2. Dipasquale V., Romano C., Iannelli M., et al. Managing Pediatric Foreign Body Ingestions: A 10-Year Experience. Pediatr Emerg Care. 2022 Jan 1;38(1):e268-e271. 10.1097/PEC.0000000000002245. 32970025.
3. Quitadamo P., Anselmi F., and Caldore M. et al. Foreign body ingestion in children: Beware of disk batteries and multiple magnets. Acta Paediatr. 2021 Oct;110(10):2862-2864. 10.1111/apa.15957. Epub 2021 Jun 8. 34048089.
4. Rozier B, Liebelt E. Lead Pellet Ingestion in 3 Children: Another Source for Lead Toxicity. Pediatr Emerg Care. 2019 May;35(5):385-388. 10.1097/PEC.0000000000001469. 30095594.
5. Centers for Disease Control and Prevention (CDC). Gastrointestinal injuries from magnet ingestion in children—United States, 2003-2006. MMWR Morb Mortal Wkly Rep. 2006 Dec 8;55(48):1296-300. 17159831.
6. Rogalidou M. Ingestion of foreign bodies and caustic substances in children: a narrative review on clinical evaluation and management update. Clin Exp Pediatr. 2026 Jan;69(1):11-21. 10.3345/cep.2025.01823. Epub 2025 Dec 10. PMID: 41381079; PMC12790899.
7. Schlesinger AE., Crowe JE. Sagittal orientation of ingested coins in the esophagus in children. AJR Am J Roentgenol. 2011 Mar;196(3):670-2. 10.2214/AJR.10.5386. 21343512.
8. Tander B.,Yazici M., Rizalar R., et al. Coin ingestion in children: which size is more risky?
9. ASGE Standards of Practice Committee; Ikenberry SO., Jue TL., Anderson MA, et al. et al. Management of ingested foreign bodies and food impactions.
10. Lee SM, Baek SE, Lee CW, Kim YC, Kim MJ. Foreign Body Ingestion: Radiologic Evaluation, Findings, and Management. Korean J Radiol. 2025 Jul;26(7):638-649. https://doi.org/10.3348/kjr.2025.0118

Please note: The patient gave verbal and signed consent for the use of his images and case.