A 3-year-old boy presents to the emergency department 4 hours after witnessed coin ingestion. He is drooling, refusing food and liquids, and has vomited twice. Chest radiograph shows a single radiopaque, coin-shaped foreign body at the level of the upper esophageal sphincter (C6-T1), appearing circular on the anteroposterior view and linear on the lateral view—classic coronal orientation. There is no double-ring sign, pneumomediastinum, or subcutaneous emphysema. The child is alert, afebrile, with normal respiratory effort and clear breath sounds. Which of the following management approaches marked **A** in the diagram is most appropriate for this symptomatic child with an esophageal coin at the upper esophageal narrowing?
A. Observation with serial radiographs over 12–24 hours to allow spontaneous passage
B. Emergent rigid or flexible endoscopic removal under general anesthesia with airway protection
C. Glucagon administration as first-line therapy to relax the lower esophageal sphincter
D. Empiric proton pump inhibitor therapy with dietary modification and outpatient follow-up
Explanation
Why Emergent rigid or flexible endoscopic removal is right
This child meets criteria for urgent endoscopic removal: he is symptomatic (drooling, dysphagia, vomiting) with an esophageal coin at the upper esophageal sphincter (proximal esophagus). According to NASPGHAN/ESPGHAN guidelines, symptomatic patients require urgent endoscopic removal within 2–24 hours regardless of position. The procedure is performed under general anesthesia with a secure airway using flexible or rigid endoscopy and grasping devices (rat-tooth forceps, alligator forceps, or Roth net). The classic radiographic appearance (circular on AP, linear on lateral—coronal orientation) and absence of a double-ring sign confirm this is a smooth coin, not a caustic button battery, but the presence of symptoms mandates intervention.
Why each distractor is wrong
Observation with serial radiographs: Observation is only appropriate for asymptomatic patients with a coin in the distal esophagus, where up to one-third pass spontaneously. This child is symptomatic with a proximal esophageal coin—observation risks aspiration, airway compromise, and esophageal injury.
Empiric proton pump inhibitor therapy: PPIs are used after endoscopic removal if mucosal injury or ulceration is present. They are not first-line management for an impacted foreign body and do not address the mechanical obstruction.
Glucagon administration: Glucagon relaxes the lower esophageal sphincter and is ineffective for proximal esophageal coins. It has no role in the management of upper esophageal impaction and delays definitive removal in a symptomatic child.
High-YieldNEET PG
Symptomatic esophageal foreign bodies at the proximal or mid-esophagus require urgent endoscopic removal within 2–24 hours; glucagon is ineffective for proximal coins and observation is reserved for asymptomatic distal esophageal coins only.
NASPGHAN Foreign Body Ingestion Guidelines 2015; ESPGHAN/AGES consensus
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