Hemoptysis Identifies An Esophageal Coin
Radiology Cases in Pediatric Emergency Medicine
Volume 2, Case 1
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawaii John A. Burns School of Medicine
     This is a two-year old Chinese female with a chief 
complaint of coughing up some blood.  There has been 
a one-month history of coughing and wheezing.  She 
has seen her pediatrician three times in the past month.  
The child has been treated with albuterol syrup and 
amoxicillin.  Some improvement had been noted.  She 
is currently taking amoxicillin-clavulinic acid since her 
symptoms did not resolve after 10 days of amoxicillin.  
Up until this time, the wheezing and coughing have 
been mild, but tonight, her parents were alarmed 
because she coughed up some blood for the first time.
     Her parents are concerned about tuberculosis since 
an elderly relative suffered from this in Hong Kong.  
Prior to this, there was no history of wheezing or 
prolonged respiratory illness.  There is no family history 
of wheezing.
     Examination:  VS T37.7R, P130, R44, BP 
95/60, oxygen saturation in room air 99%.  She is active 
and alert in no acute distress.  She does not appear 
toxic or irritable.  Eyes normal.  Ears normal.  Oral 
mucosa moist.  Normal pharynx and tonsils.  No 
hemorrhaging in the mouth noted.  Neck supple.  No 
adenopathy.  Heart regular without murmurs.  Lungs 
good aeration, mild wheezing.  No retractions.  She is 
coughing occasionally, but the cough does not sound 
moist.  She does not expectorate any secretions while 
being examined.  Abdomen benign.  Good color and 
perfusion.  No bruising or petechiae noted.
     A chest radiograph is obtained.

View CXR.

     An esophageal coin is noted on the AP view.  An 
ENT surgeon is called to extract the coin.  Further 
history to determine the duration that the coin may have 
been in the esophagus is not able to identify any 
episodes of choking or playing with coins.  Therefore, 
the duration of the coin's presence is still uncertain.
     Esophageal coins come to rest at the three areas of 
esophageal narrowing: the cricoid, the tracheal 
bifurcation, and the gastroesophageal junction.  The 
majority of coins will become lodged in the esophagus 
at the level of the cricoid ring.  This patient's 
esophageal coin is unusual in that it is located near the 
tracheal bifurcation.
     The child is taken to the operating room where the 
coin is removed under general anesthesia.  At the time 
of removal, some hemorrhaging within the esophagus 
is noted.  This was followed by extensive 
hemorrhaging and hypovolemic shock refractory to fluid 
and blood resuscitation.  Before a vascular team could 
be called in, the child arrested and could not be 
     Post-mortem studies identified an esophageal 
perforation overlying an ulcerating aortic perforation.

Teaching Points and Discussion
     The presence of an esophageal foreign body and 
any sign of hemorrhaging should alert one to the 
possibility of a vascular injury.  Foreign bodies which 
cause vascular injury are usually sharp objects (most 
commonly fish or chicken bones), but coins have 
reportedly resulted in vascular injuries as well.  This 
condition has a high mortality rate even if it is properly 
recognized before removal of the foreign body.
     The longer the foreign body remains in the 
esophagus, the greater the likelihood of esophageal 
ulceration, perforation, and extension of injury to the 
mediastinum, trachea, or great vessels.
     "Aorto-Esophageal" syndrome is classically 
described as a painful esophageal injury, followed by a 
symptom-free interval, then a "signal hemorrhage", 
followed by hours to days until a fatal exsanguinating 
hemorrhage occurs.  The "signal hemorrhage" which 
should alert one to the possibility of a vascular injury 
can include any sign of hemorrhage.  Most typically, 
this manifests as hematemesis, melena, or hemoptysis.  
The "signal hemorrhage" may precede fatal 
exsanguination by hours to days.  If one is lucky 
enough, promptly arranging a vascular team prepared 
to deal with the possibility of an aortic injury may be life 
     In the case presentation, the history of wheezing 
and coughing may have been due to the presence of 
the esophageal coin, or it may have been due to 
recurrent viral infections or an occult pneumonia 
refractory to amoxicillin.  The presence of hemoptysis 
does not necessarily indicate tracheal injury since one 
could hemorrhage into the esophagus and have some 
of this blood mixed with expectorated mucus from an 
unrelated respiratory infection.
      Significant esophageal edema at the site of the 
foreign body may begin to occur within 48 hours of 
impaction.  Thus, whenever an esophageal foreign 
body of uncertain duration is seen on the AP view, one 
should generally obtain a lateral view to look for a 
widening of the tracheoesophageal interspace which 
would be an indirect sign of significant esophageal 
edema.  Whenever there is any suspicion of significant 
esophageal edema, the foreign body should be 
removed under controlled conditions via endoscopy and 
not blindly removed via the Foley catheter method.

     1.  Sloop RD, Thompson JC.  Aorto-esophageal 
fistula:  Report of a case and review of literature.  
Gastroenterology 1967, 53(5):768-777.
     2.  Tectmeyer CJ, McLean WC.  Vascular injury 
following foreign body perforation of the esophagus.  
Ann Otol Rhinol Laryngol 1990;99:698-702.
     3.  Vella EE, Booth PF.  Foreign body in the 
Oesophagus.  Br Med J 1965;2:1042.
     4.  Turner GG.  Death from perforation of the aorta 
by a halfpenny impacted in the oesophagus.  Lancet 
     5.  Lovett T.  Ulceration into aorta due to foreign 
body in the oesophagus:  Fatal hemorrhage.  Br Med J 

     This case described is not an actual case.  
However, such cases have occurred in many centers 
with a similar course of events.  The purpose of 
describing this sequence of events as a hypothetical 
case is to alert one to this possible pitfall.

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Web Page Author:
Loren Yamamoto, MD, MPH
Associate Professor of Pediatrics
University of Hawaii John A. Burns School of Medicine