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Three Part Question

In [asymptomatic children who have a swallowed coin lodged in the oesophagus] is [watchful waiting better than early active removal] at [achieving safe coin passage]?

Clinical Scenario

A child presents to the Emergency Department with a history of witnessed coin ingestion in the last 24 h. He is asymptomatic and clinical examination is unremarkable. Chest x-ray reveals a coin lodged in the oesophagus. You wonder whether to observe the child, hoping for spontaneous passage into the stomach or to refer him for removal/assisted advancement of the coin.

Search Strategy

Ovid MEDLINE(R) 1950 to January Week 4 2010: [exp eating OR exp feeding behaviour OR ingest$] AND [exp foreign bodies OR coin$] AND [esophag$ OR oesophag$] Limit: Human, Age All Child 0–18, and English Language.
Embase using the NLH interface 1980–January 2010: coin.ti,ab AND exp esophagus foreign body/AND exp emergency/OR exp emergency care/OR exp emergency health service/OR exp emergency medicine/ OR exp emergency treatment/ OR exp emergency ward/ [Limit to: Human and (Human Age Groups Child unspecified age or Preschool Child 1–6 years or School Child 7–12 years or Adolescent 13–17 years) and English Language].

The Cochrane Library January 2010: Coin,ti, ab AND MeSH descriptor Foreign Bodies explode all trees.

Search Outcome

A total of 242 papers were found using these search criteria. Of these eight articles were relevant. Five were studies and the others review articles.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Waltzman et al, 2005, USA	60 asymptomatic patients with oesophageal coins who presented to the Emergency Department from 01/03/2001 - 01/12/2003	Randomised Control Trial Level 2b	Spontaneous passage in observation group (30 children)	7/30 (23%) had spontaneously passed the coin, within 19 hours	Did not randomize according to coin location.
			Spontaneous passage in intervention group (30 children)	Following a delay in going to endoscopy of > 2 hours, 9/30 (30%) had spontaneously passed the coin
			Spontaneous passage of coin by location	Proximal 2/20 (10%) Middle 5/19 (26%) Distal 9/21 (43%)
Sharieff et al 2003 USA	6 asymptomatic patients with coin located in the oesophagus, who presented to the Emergency Department from 01/01/1998 - 31/12/ 2001	Retrospective Case Review Level 4	Proportion of passage of coins in cases with coins above thoracic inlet	Were not due to be included as protocol was for immediate removal, but coin passed into the stomach in 3/3 asymptomatic children within 2 hours	Retrospective case review - cannot be sure that all appropriate information is recorded. Small study group. As most patients were reviewed after 24 hours, there is no good indication of how long coins took to pass.
			Proportion of passage of coins in cases with mid-oesophageal coins	3/3 (100%) spontaneous passage
			Proportion of passage of coins in cases with distal oesophageal coins	3/3 (100%) spontaneous passage
Soprano et al, 1999, USA	84 asymptomatic patients with coin located in the oesophagus who presented to the Emergency Department from 10/1995 – 09/1997	Retrospective case review Level 4	Proportion of passage of coins in cases with proximal oesophageal coins	32/54 children had repeat x-rays. Of these, 7/32 (22%) had spontaneously passed the coin within 6.3 hours	Retrospective case review - cannot be sure that all appropriate information is recorded. Initial location of coin was not recorded in 1 case, hence only 83 children presented. Does not state why the remaining 25 children did not have repeat radiographs, or what the outcome was for these children.
			Proportion of passage of coins in cases with middle oesophageal coins	6/7 children had repeat x-rays. Of these, 2/6 (33%) had spontaneously passed the coin within 12 hours
			Proportion of passage of coins in cases with distal oesophageal coins	19/22 children had repeat x-rays. Of these, 7/19 (37%) had spontaneously passed the coin within 7.5 hours
Conners et al, 1995, USA	73 asymptomatic patients with coin in the oesophagus who presented to the Emergency Department from 12/1991 – 06/1993	Retrospective Case Review Level 4	Proportion of passage of coins in cases with proximal / mid- oesophageal coins (58 children)	Protocol was to remove all coins invasively. Authors noted no coins showed progression whilst awaiting removal.	Retrospective case review - cannot be sure that all appropriate information is recorded. Not all patients counted in the study had a history of coin ingestion <24 hours before presentation. No trial of conservative management for proximal and middle oesophageal coins.
			Proportion of passage of coins in cases with distal oesophageal coins (15 children)	9/15 (60%) had spontaneously passed the coin after 4-24 hours
				Other 6 children scheduled for invasive removal, 2/6 (33%) found to have passed the coin after anaesthetic induction
Schunk et al, 1989, USA	9 asymptomatic patients with coin located in the oesophagus who presented to the Emergency Department from 10/4/1986 - 01/05/1987	Prospective cohort study Level 3b	Proportion of passage of oesophageal coins	3 (33%) spontaneous passage in 3-20.5 hours	Small number of participants to begin with and only 3 patients genuinely treated conservatively. Does not specify location of coins within the oesophagus.
				2 coins removed due to failure to comply with study protocol
				2 removed due to specific referral for removal
				2 removed as parents would not consent to period of watchful waiting

Comment(s)

There are five published studies addressing this clinical question. One of these was a prospective randomised control trial (RCT), the other four were retrospective case reviews. Across these studies, there were a total of 231 cases of asymptomatic children presenting with oesophageal coins. Despite the small number of participants in each study, results were relatively consistent across studies, and show that a significant proportion of these will pass within 24 h. The figures vary with coin location; this is well demonstrated by the results of the only RCT (by Waltzman et al) the results of which showed that 10% of proximal oesophageal coins passed spontaneously, 26% of middle oesophageal coins passed spontaneously and 43% of distal oesophageal coins passed spontaneously within ~16 h of ingestion. None of the papers reported any additional complications attributable to delayed intervention.

Clinical Bottom Line

Best available evidence suggests that asymptomatic children with no previous oesophageal pathology, who present within 24 h of ingestion with a swallowed coin lodged in the oesophagus, can be safely managed conservatively for a period of up to 24 h.

References

1. Waltzman ML, Baskin M, Wypij D, et al. A Randomised Clinical Trial of the Management of Esophageal Coins in Children Pediatrics 2005; 116:614-619.
2. Sharieff et al Acute esophageal coin ingestions: is immediate removal necessary? Pediatric Radiology 2003; 33:859-863
3. Soprano JV, Fleisher GR, Mandl KD. The Spontaneous Passage of Esophageal Coins in Children Am J Dis Child 1999; 153:1073-1076.
4. Conners GP, Chamberlain JM, Ochsenschlager DW. Symptoms and Spontaneous Passage of Esophageal Coins Arch Pediatr Adolesc Med 1995; 149:36-39.
5. Schunk JE, Corneli H, Bolte R. Pediatric Coin Ingestions. A prospective study of coin location and symptoms. Am J Dis Child 1989; 143:546-548.