Spontaneous passage of coins lodged in the upper esophagus

To the Editor. Soprano and Mandl's decision analytic comparison of 4 esophageal coin management strategies1 is an important contribution toward integrating cost-effectiveness into the management of this common problem. This article suggests that, in low-risk patients, less commonly used alternatives to endoscopic coin removal may be cheaper and have fewer complications, confirming earlier findings.2 However, important limitations in the present study's decision analytic model weaken the authors' conclusions.As the authors state, the Foley catheter method is a leading alternative to endoscopic coin removal; for selected patients, it may be cheaper and safer.2 The omission of consideration of the Foley catheter method from the model, however, leaves those interested in its use without guidance. Also omitted from the model is the sensible strategy of observation to allow spontaneous coin passage, followed by bougienage if the coin remains in the esophagus; in the unlikely event of unsuccessful bougienage, the child would then undergo endoscopy. This strategy combines the safety and cost savings of both observation and bougienage, especially if bougienage is performed in the first 24 hours after coin ingestion.3The study model assumes that patients who are to undergo endoscopy do so instantly. A model more consistent with usual hospital practice would assume a few hours' delay between identifying esophageal coins in low-risk patients and their endoscopic removal. This is important because many esophageal coins will pass spontaneously into the stomach during this interim period,4,5 making endoscopy unnecessary and dramatically reducing the high cost attributed to endoscopy under the study model.Not all complications of removal methods are of equal importance. Although the authors calculate the probability of complications of the removal methods, there is no attempt to categorize them by magnitude. Clinicians would be better informed if minor or transient complications were weighted differently in the study model from more severe ones. A justification for the universal assignment of a cost-to-charge ratio of .72 would also enhance the discussion.Finally, the study model uses a success rate for bougienage of 100%, based on 2 published case series.6,7 A recent report of bougienage for esophageal coin removal in low-risk patients reported a success rate of 83% (10/12); as in previous studies, no complications were reported.8In summary, the model presented by Soprano and Mandl seems overly simplistic, despite their appropriate sensitivity analysis. Results from a more comprehensive model would be more useful when making practice decisions.

To compare clinical outcomes and costs under 4 strategies for the management of esophageal coins in children. We developed a decision analysis model of 4 possible strategies for managing esophageal coins: 1) endoscopic removal under general anesthesia; 2) esophageal bougienage, 3) an outpatient 12- to 24-hour observation period to allow spontaneous coin passage; and 4) an inpatient observation period. Probabilities of success and complication rates for endoscopy and esophageal bougienage were obtained from published data. The probability of spontaneous coin passage was derived from chart review data at our institution. Costs were calculated from charges using a cost-to-charge ratio of.72. Hypothetical patients included in the model were those with a single esophageal coin presenting within 24 hours of ingestion, with no respiratory compromise on presentation and with no previous history of esophageal disease. Strategy-specific outcomes were overall complication rate and total cost in dollars per patient. Sensitivity analyses were performed to account for variations in the data. The esophageal bougienage strategy resulted in no complications and a total cost per patient of $382, which represents a marginal advantage of $2915 per patient compared with the endoscopic removal strategy. On sensitivity analysis over the range of success and complication rates of bougienage, this strategy maintained a considerable decrease in both overall complications and total cost per patient compared with all other strategies. Both outpatient and inpatient observation strategies had overall complication rates of 4.2% compared with the complication rate of 5.8% for the endoscopy strategy. The total cost per patient under these strategies was $2439 for the outpatient and $3141 for the inpatient strategy, representing a marginal advantage of $858 and $156 per patient, respectively, compared with the endoscopy strategy. Both observation strategies maintained a lower overall complication rate compared with endoscopy in the sensitivity analysis. The outpatient observation strategy maintained a marginal advantage of $645 to $1257 per patient compared with endoscopy; however, the inpatient observation strategy total cost per patient surpassed that of endoscopy at a spontaneous passage rate <23%. Given the high success and low complication rates reported for esophageal bougienage, substantial savings in overall complications and costs would be expected with the use of this procedure. With spontaneous passage rates >23%, either an outpatient or an inpatient observation strategy would reduce costs and complications, compared with endoscopic removal of all esophageal coins.

Predictive factors associated with spontaneous passage of coins: A ten-year analysis of paediatric coin ingestion in Australia

Accidental coin ingestion is a common presentation amongst paediatric patients in emergency departments (ED) worldwide, necessitating prompt management to prevent complications. This study aimed to describe the clinical features of paediatric patients with impacted oesophageal coins at Dr. George Mukhari Academic Hospital ED and compare outcomes between the balloon catheter and oesophagoscopic techniques for coin extraction. This was a retrospective review of the medical records of patients aged ≤12 years over 5 years. Data were collected from the hospital records and analysed using SAS® (SAS Institute Inc, Cary, NC), Release 9.3, running under Microsoft Windows. The analysis included 95 patients (51 females, 44 males) with a median age of 3 years, ranging from 0.70 to 10 years. Coins were predominantly located in the upper oesophagus (71.6%). Thirty-five (36%) children presented 8 h after the ingestion of the coin. At presentation, 82 (86.3%) patients were asymptomatic. The most observed symptoms were hypersalivation in 17 (17.9%) patients and vomiting in eight (8.4%) patients. Of the 62 patients for whom the balloon catheter was solely used, it was successful in 77.4% of the cases. Rigid oesophagoscopy was used in 33 patients as the first procedure (34.7%), and its overall success rate was 100% (44 patients). This study contributes valuable insights into the management of oesophageal coin ingestion in a resource-constrained setting, emphasising the safety and efficacy of the balloon catheter and the role of rigid oesophagoscopy in cases of failure or delayed presentation.

Cost analysis in the management of esophageal coins: Endoscopy versus bougienage

Children frequently ingest coins. When lodged in the esophagus, the coin may cause complications and must either be removed or observed to pass spontaneously. (1) To compare relatively immediate endoscopic removal to a period of observation followed by removal when necessary and (2) to evaluate the relationship between select clinical features and spontaneous passage. Randomized, prospective study of children <21 years old who presented to an emergency department with esophageal coins in the esophagus. Exclusion criteria were (1) history of tracheal or esophageal surgery, (2) showing symptoms, or (3) swallowing the coin >24 hours earlier. Children were randomized to either endoscopic removal (surgery) or admission for observation, with repeat radiographs approximately 16 hours after the initial image. Proportion of patients requiring endoscopic removal, length of hospital stay, and the number of complications observed. Among 168 children who presented with esophageal coins lodged in the esophagus, 81 were eligible. Of those eligible, 60 enrolled, 20 refused consent, and 1 was not approached. In the observation group, 23 of 30 (77%) children required endoscopy compared with 21 of 30 (70%) in the surgical group. Total hospital length of stay was longer in the randomized-to-observation group compared with the randomized-to-surgery group (mean: 19.4 [SD: +/-8.0] hours vs 10.7 [SD: +/-7.1] hours, respectively). There were no complications in either group. Spontaneous passage occurred at similar rates in both groups (23% vs 30%). Spontaneous passage was more likely in older patients (66 vs 46 months) and male patients (odds ratio: 3.7; 95% confidence interval: 0.98-13.99) and more likely to occur when the coin was in the distal one third of the esophagus (56% vs 27% [95% confidence interval: 1.07-5.57]). Because 25% to 30% of esophageal coins in children will pass spontaneously without complications, treatment of these patients may reasonably include a period of observation, in the range of 8 to 16 hours, particularly among older children and those with distally located coins.

Coin ingestion is a frequent reason for paediatric radiology referrals, with most cases resolving spontaneously without complications. This imaging case report describes the diagnosis and conservative management of a 2-year-old boy who accidentally ingested a two-Kwacha coin at a public hospital in Zambia. The child remained asymptomatic throughout his hospital and home stay, allowing for a non-invasive approach involving serial plain film radiographs to monitor the coin’s progression through the gastrointestinal tract. Over three days, imaging confirmed the coin’s movement from the oesophagus to the mid-abdomen, culminating in its natural expulsion on the fourth day. This case highlights the crucial role of plain film radiography in both diagnosing and monitoring foreign body ingestion in children, particularly in low-resource settings. It also highlights significant systemic challenges, including the lack of paediatric radiographers, the absence of national paediatric imaging guidelines, a critical shortage of radiologists, and the unavailability of electronic systems for patient data and radiographic image management. Despite these limitations, the successful outcome supports existing evidence that asymptomatic paediatric patients with coin ingestion can be safely managed through careful observation and serial imaging, thus avoiding the risks associated with invasive procedures and sedation.

BACKGROUNDFibreoptic bronchoscopy (FOB) is the usual initial investigation of choice in patients with suspected endobronchial carcinoma, but it is often non-diagnostic. Once a positive diagnosis has been made, many patients...

Thoracic splenosis (TS) is autoimplantation of ectopic splenic tissue in the thoracic cavity that occurs following splenic injury. Most cases of TS are asymptomatic and are diagnosed during the course of an evaluation of incidentally discovered pulmonary lesions. Some cases may be difficult to diagnose, especially if features suggesting TS are not recognized. This may lead to an extensive workup and unnecessary invasive diagnostic procedures including thoracotomy. Multiple, asymptomatic, left-sided pleura-based lesions associated with a history of thoracoabdominal injury and splenectomy are the key points that should alert one to suspect TS, which can then simply be confirmed with a (99m)Tcsulfa colloid radionuclide scan. If TS is suspected and radionuclide imaging studies are performed, further extensive investigations, such as bronchoscopy, biopsy, thoracoscopy, and thoracotomy, are not required as the radionuclide scan is definitive for diagnosis. Most cases are asymptomatic, so further treatment is rarely required; all cases are managed conservatively. We emphasize that all physicians, radiologists, pathologists, and interventionalists should recognize key features that suggest the diagnosis of TS, order appropriate imaging when it is suspected, and avoid unnecessary invasive diagnostic procedures including thoracotomy.

Thoracic splenosis (TS) is autoimplantation of ectopic splenic tissue in the thoracic cavity that occurs following splenic injury. The majority of cases of TS are asymptomatic and are diagnosed in the course of an evaluation of incidentally discovered pulmonary lesions. Some cases may be difficult to diagnose, especially if features suggesting TS are not recognized. This may lead to an extensive work-up and unnecessary invasive diagnostic procedures including thoracotomy. This case report describes a 40-year-old man, who was diagnosed incidentally with TS, several years after the initial injury. Multiple, asymptomatic, left-sided pleural based lesions associated with a history of thoracoabdominal injury and splenectomy are the key points that should alert suspicion of TS, which can then simply be confirmed by a Tc-99m sulphur colloid radionuclide scan. Most patients are treated conservatively unless they are symptomatic. Physicians must recognize the key features suggesting a diagnosis of TS, order appropriate imaging studies and avoid unnecessary invasive diagnostic procedures.

Acute focal bacterial nephritis (AFBN) is a rarely diagnosed interstitial bacterial infection of the kidney. Due to the non-specific clinical presentation of this entity, correct diagnosis can be challenging. In this work, we present three cases of AFBN aiming to stress the diversity of clinical presentation associated with the disease and the fact that patients with AFBN are at risk of undergoing unnecessary invasive procedures. The employment of invasive diagnostic and therapeutic procedures on the management of AFBN should be limited, as the majority of patients respond well to conservative therapy.

Magnetic resonance imaging with magnetic resonance cholangiopancreatography accurately predicts resectability of pancreatic carcinoma

Coins are the most commonly ingested foreign bodies. When they get stuck in the distal esophagus, there is no general agreement about the timing of their removal because some of them may spontaneously migrate into the stomach, no longer requiring removal. We aimed at evaluating the gastric spontaneous passage of esophageal-retained coins, as well as complications. Children admitted for coin ingestion were enrolled. Eight hundred seven children were enrolled. Among the medium-distal esophageal retained coins, we reported a spontaneous gastric dislocation in 65%, with no further need for endoscopy. When coins are trapped in the middle/lower esophagus, we suggest withholding the procedure for at least 6-12 hours, especially for older children, because 2/3 pass spontaneously, not requiring endoscopic removal.

Background: Axillary lymph node (ALN) enlargement with diffuse cortical thickening and conserved echogenic hilum may represent a diagnostic and therapeutic challenge. Sonographic strain elastography may help the characterization of borderline ALN. Aim: To evaluate the strain elastography of borderline ALN and to calculate a cutoff value of strain ratio (SR) that can identify suspicious ALN with the highest sensitivity and specificity to reduce unnecessary invasive procedures. Subjects and Methods: A prospective study included 45 patients who attended the Breast clinic in Oncology Teaching Hospital with borderline axillary lymphadenopathy (intact hilum and diffusely thickened cortex more than 3mm) who had normal ipsilateral breast, suspicious ipsilateral breast lesion, or who had ipsilateral mastectomy. B-mode sonography and elastography were performed for all participants. Four-point elasticity score (ES), and SR were obtained for the targeted lymph node followed by ultrasound-guided fine need aspirate (FNA) biopsy.. Results: Malignant ALN constituted 20% of the cohort. B mode measurements were not able to differentiate between cytologically confirmed benign and malignant ALN in terms of axis ratio (mean ± standard deviation, 0.46 ± 0.08 vs 0.50 ± 0.12) and cortical thickness (4.88 ± 1.93 vs 6.27 ± 2.46). The mean SR of all samples was 2.66 ± 2.25. Metastatic ALN depicted significantly higher SR (P&lt;0.0001), with 88.9% exhibiting ES score 3 and 4. None of the metastatic ALN had ES score 1. ROC curve was used to investigate the utility of SR as a diagnostic tool. The area under the curve (AUC) was 0.906 with a 95% CI of 0.814-0.997, P&lt;0.001. SR cutoff of 2.1 was chosen with 100% sensitivity and 66.7% specificity. Conclusion: High proportion of borderline ALNs are not malignant. Strain elasticity can improve the risk stratification of such cases and prevent unnecessary invasive procedures. We suggested an algorithm that could better tackle borderline ALN which will need further evaluation

Parental home removal of urethral catheters after urological surgery—a prospective benchmarking study