Think

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Think !

• Jack CF Chong, MD

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????

• Simulating
• Epiglottitis
• Croup
• Nonspecific vomiting
• Feeding abnormalities

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????

• 2y Boy
• ABC OK, no stridor
• 37.3 C, PR 100, RR 24
• BS Clear
• Abd Soft, flat, nontender

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The swallowed coin

• Routinely !

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Simple cases

• Single
• lt 24 hr
• Minimal / no symptoms
• No underlying esophageal pathology

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Clinical

• No symptoms
• Coughing
• Gagging
• Respiratory distress
• Drooling, unable to swallow

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Management
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Management

• Endoscopy
• Foley catheter
• Bougienage
• Observation / feeding

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• If the coin is in the stomach / intestines, the
  patient can be sent home for elective follow-up

• 1 week

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• Any child with respiratory distress should have
  the coin promptly removed, if time permits, in
  the OR

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Asymptomatic coins
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Asymptomatic coins

• Management
• Foley / endoscopy
• Observe / feeding re-evaluate in 12-24 hr
• Locations
• Upper esophagus
• Middle / lower esophagus

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Endoscopy

• Well-controlled
• Successful, few complications
• Complex cases
• Known esophageal pathology
• Multiple coins
• gt 24 hr
• Requires OR and ETGA
• Repeat X-ray just before OR

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• Repeat X-ray just before OR

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Foley

• Pediatric / Radiology
• Upper esophagus
• Single coin
• lt 24 hr
• Chocking may occur

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Bougienage

• Least common
• Esophageal dilator
• Single coin
• lt 24 hr

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Observation / Feeding

• Simple
• Proximal 64
• Middle 8
• Distal 26

• Complex
• Proximal 84
• Middle 16
• Distal 0

• Spontaneous passage
• 25 (n116), regardless of the location
• Arch Ped Adol Med. 1999 1531073

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Observation / Feeding

• Carbonated soft drink
• Small amount of bulky food (bread, crackers,
  banana) Repeat X-ray in 4-6 hr (sooner if Sm ?)
• NTG / glucagon (?)
• Home observation (?)

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12- to 24-hour
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?
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Conclusion

• Respiratory distress
• Endoscopy / Foley
• History PE - X-rays
• Complex cases ? Endoscopy
• Simple cases
• Observe / feeding, re-evaluate in 12-24 hr
• Endoscopy

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30Y F, no stool for 2 days
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24 hr later .

• Coma
• Cyanosis
• BP 70/40, PR 50, RR lt 10

• OP findings
• 54 packets of heroin in colon

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Post-OP

• Persisted coma, shock, and apnea
• Responsive to high-dose naloxone

• CT scan ? 2 additional packets in sigmoid colon
• Re-open

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19Y M, abdominal pain

• Abd pain and distension for 4 days
• Alert, vital signs stable

• Emergent laparotomy ? 45 intact cocaine packets

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Post-OP

• Persisted hypertension, tachycardia, diaphoresis,
  and fever x 4 d
• R/O Intra-abdominal abscess formation

• CT scan ? 1 additional packets in stomach
• Re-open ? 2 packets in stomach

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Body Packer (mule)

• Heroin, cocaine
• Asymptomatic / symptomatic
• Management
• GI decontamination (Active charcoal)
• Whole bowel irrigation (WBI) with polyethylene
  glycol (PEG-ELS)
• PES / Colonoscopy
• Surgery ? Gold standard (?!)

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No unified and systematic approach !

• No available control studies
• Active charcoal ? Peritoneal spillage if bowel
  perforated
• WBI ? Packet rupture
• Cocaine ? No antidote

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Surgery -- Indications

• Symptoms of cocaine toxicity
• Peritonitis
• Hollow-organ perforation
• Mechanical ileus
• Medical treatment failed

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Packets remaining ?

• Intra- or post-OP radiography
• Intra- or post-OP endoscopy
• Post-OP UGI series with bowel follow-through with
  water-soluble contrast
• Abdominal CT with contrast

• Intra- or post-OP radiography
• Intra- or post-OP endoscopy
• Post-OP UGI series with bowel follow-through with
  water-soluble contrast
• Abdominal CT with contrast

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?
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Conclusion

• Heroin ? Surgery ??
• Cocaine ? Surgery !!
• History
• CT scans Not reliable !
• Surgery
• Post-OP UGI series with bowel follow-through with
  water-soluble contrast