Coin in the Esophagus

General Considerations More common in children ( < 5 years old) than adults o Consist of either food-related impactions, or o Ingestion of true foreign body (toy truck, marble, etc) True foreign bodies are more often ingested in those under 40 whereas those over 60 have food-related impactions Most often they impact just below cricopharyngeus at the thoracic inlet (70%) Another 20% impact at the level of the aortic arch Another 10% just above the esophagogastric junction Once past the esophagus, most foreign bodies will pass through the GI tract In children, most often ingested foreign body is a coin, followed by o Chicken or fish bones o Buttons and tacks o Marbles or screws o Button batteries o Straight pins In adults, the most commonly impacted foreign body are food boluses (hot dogs, etc), followed by o Fish bones o Coins o Fruit pits o Straight pins o Dentures Clinical Findings Dysphagia Odynophagia Sensation of foreign body Even if foreign body passes, many complain of pain referable to cervical esophagus Only about half of those with impacted true foreign bodies have symptoms referable to the foreign body In children, symptoms more commonly include drooling, vomiting or gagging Imaging Findings Chicken bones are usually opaque Fish bones contain less calcium and usually are not Conventional radiographs will not demonstrate non-opaque foreign bodies o If impaction in the neck is suspected, then neck radiographs (soft tissue technique) are used first

Classically, coins in the esophagus project en face (round) in the frontal projection whereas those in the trachea project on end in the frontal projection o Otherwise, a PA and lateral chest are obtained o If neither of these studies reveal a foreign body known to have been ingested, then a supine abdominal radiograph can be obtained If negative, then either contrast esophagram or CT if high index of suspicion In adults, rule out an underlying abnormality which narrows the esophagus such as a stricture or carcinoma of the esophagus

Treatment Removal is most often performed using endoscopy Temporization and surgery are other options Glucagon is effective in up to 50% of patients in relieving the esophageal obstruction An ingested button battery lodged in esophagus must be removed immediately o If impacted in esophagus, focal production of a small current may lead to esophageal perforation o Button batteries should be removed endoscopically o Once they pass into stomach, such batteries pose a lower risk Complications Always check for lead lines in children (pica) Longer the FB remains impacted (> 24 hours), higher incidence of perforation Perforation Stricture Diverticulum formation Prognosis Excellent if removed or passed promptly Morbidity rates are high for impacted foreign bodies which remain chronically

Bagan 1. Coin in esophagus. Close-up of a frontal view of the neck and upper chest shows a round metallic foreign body (white arrow) that lies in the midline just above the aortic knob (red arrow). This is a quarter that is impacted in the esophagus. Coins in the esophagus are round in appearance on the frontal view whereas coins in the trachea are usually seen on end and are linear in shape.