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
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.
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
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