My four-year-old swallowed a quarter 10 days ago. An X-ray showed the coin is still in his stomach. His pediatrician has recommended that we wait another two weeks and X-ray to determine if the coin is still in his digestive tract. Wouldn't it be better to try and retrieve the coin by introducing a tube through his mouth, rather than waiting to see if it will make it through the intestines, colon and rectum?

B.

Accidental swallowing of small objects, including coins, is common among young children. In some cases, the coin will lodge in the esophagus. This may lead to complete obstruction, making it impossible for the child to swallow saliva and posing a risk of perforation of the esophagus. In such cases, doctors immediately remove the coin using a tube called an endoscope.

However, most often, the coin safely passes through the esophagus after it is swallowed. In these cases, it is the size of the coin that determines how the situation is handled. The most common sites of obstruction are the pylorus (the opening that connects the stomach to the upper intestine, or duodenum) and the ileocecal valve (the connection between the small intestine and the large intestine). It has been shown that objects smaller than 2.5cm (one inch) in diameter usually pass from the stomach and through the small intestine, colon and rectum without complications. Doctors typically monitor the passage of the object through a series of X-rays. A quarter is less than 2.5 centimeters in diameter, thus any coin of this size or smaller can be watched and not immediately removed.

Endoscopic removal from the stomach should be attempted if the coin stays in the stomach for three weeks, as it is unlikely to pass if it has not done so in that time. The reasoning behind this policy relates to the risks and benefits of endoscopy. Before three weeks have passed, the risks of the procedure (including sedation and the removal of the object) outweigh the benefits of removing the coin.

Keep in mind that even after the coin passes beyond the stomach, it can still cause problems in the small intestine or colon. If it is not advancing in the small intestine for two straight weeks, then surgical removal is strongly considered (endoscopy cannot reach most of the small intestine). Also, if the coin stays in the colon for three weeks, endoscopic (colonoscopic) removal would also be indicated. If signs of intestinal obstruction occur (severe abdominal pain, distention or fever) then urgent surgical intervention is usually necessary.