P0893 - Penny Ingestion: Can We Really Manage Expectantly?

We present a case to open discussion on the guideline regarding the management of coin ingestion in children. A 2-year-old female presented to the ED after mother witnessed her swallowing a penny. An abdominal radiograph showed a round metallic 19 mm object at the left upper quadrant, confirming a penny in the stomach. Given no symptoms and normal physical exam, the family was instructed to observe for abdominal signs, to strain stool, and repeat an abdominal radiograph in two weeks.

Over the following two weeks, the patient developed intermittent abdominal pain with decreased appetite. Serial abdominal radiographs showed persistence of the object in the left upper quadrant. However, the last radiograph showed an irregular appearance of the object’s periphery, more lucent than the prior studies (Figure 1). The decision was made to proceed with upper endoscopy with foreign body removal.

A penny was retrieved successfully from the stomach. An area of gastric mucosal ulceration without evidence of active bleeding was found (Figure 2). The rim of the penny appeared jagged and small broken metallic pieces were noted. Zinc level was 324 ug/dL (normal <120 ug/dL). Complete blood count revealed white blood cells of 23,000/uL (73% neutrophils), normal comprehensive metabolic profile, and normal urinalysis. After the coin removal, her appetite increased and abdominal pain resolved. Repeat labs were not obtained.

Based on a clinical report of the NASPGHAN Endoscopy Committee on the management of ingested foreign body 2015, gastric coins are managed expectantly unless overt GI symptoms are noted, regardless of coin type. However, zinc toxicity from pennies in the stomach is reported. The concern is particularly focused on pennies minted after 1982; these have significantly increased composition of zinc from 5% pre-1982 to 97.6% post-1982, and are coated by only a thin layer of copper. After ingestion, the chemical reaction between gastric acid and post-1982 pennies starts within a few hours, with radiographic changes such as scalloped edge and erosions visible within 24 hours. After the copper shell is eroded, zinc reacts with gastric acid and forms zinc chloride, which is corrosive, highly absorbable, and toxic. Locally, zinc chloride can cause corrosive injury resulting in nausea, vomiting, abdominal pain, ulcerations, and bleeding. Once absorbed, systemic symptoms can occur due to high levels of zinc and associated copper deficiency. Systemic symptoms include anemia, leukopenia, pancreatitis, hepatic necrosis, liver and kidney dysfunction, or even death from multisystem organ failure.

We propose a new approach for the management of coin ingestion in the stomach by early identification of coin type by measuring the diameter and observation of change of the coin radiographically. An object with a diameter of 19 mm would suggest a penny.