Double coin in the upper esophagus mimicking a button battery: a case report

Introduction

Foreign body ingestion (FBI) is frequent in the pediatric emergency department (ED), especially for children under 5 years old, due to their natural inquisitiveness and oral exploration. The estimated annual incidence is around 1%, with a noted male preponderance of 2:1 (1). The variety of objects ingested spans from lower-risk coins and toy parts to higher-risk button batteries (BBs). Coins account for most pediatric FBI cases, approximately 60% to 80% (2). In contrast, BBs represent only about 7% of ingested objects yet can cause rapid tissue damage and potentially life-threatening complications (1,3).

Treatment options available will vary based on the type of object ingested and the patient’s presentation. Prompt and precise imaging takes the highest priority; delays in diagnosis and treatment can result in life-threatening consequences such as mucosal necrosis, perforation, or tracheoesophageal fistula (4). Some authors have described how superimposed coins may simulate the appearance of BBs on radiographs, which may confuse diagnosis (2,5-7). Very few have focused on the overlooked potential for severe esophageal damage, such as necrosis, eschar, or early fistula formation, caused by stacked coins.

Here, we present an 8-year-old boy who ingested two coins, which, upon imaging, were thought to be BBs. The patient was symptomatic and required an endoscopic evaluation. This case demonstrates the need to consider the diagnosis of stacked coin ingestion and illustrates the need for timely intervention. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-70/rc).

Case presentation

An 8-year-old boy with no significant past medical history came to the ED with excessive drooling, vomiting, and complete dysphagia. He was not in respiratory distress, with no relevant abnormal auscultatory findings, and his vital signs were stable. The family was uncertain if he had eaten something he should not have.

Although the boy was entirely of verbal age, he did not report ingesting anything or clarify when the symptoms began. His parents brought him to the ED immediately after the onset of symptoms.

We obtained chest X-rays (CXRs) in anteroposterior (AP) and lateral views. The AP image revealed a round radiopaque object below the cricopharyngeal area with a denser internal ring, raising suspicion of a halo sign (Figure 1). The lateral view showed a bulging outline in the upper esophagus, positioned anterior to the trachea. On closer inspection, we identified a double thick line and a step-off sign (Figure 2), a feature that further raised concerns about either a BB or two stacked coins lodged together.

Figure 1 Anteroposterior chest radiograph showing a round radiopaque object below the cricopharyngeal area. The object demonstrates a denser central ring resembling a “double-rim” or “halo” sign (arrow), raising suspicion for a button battery or stacked coins.

Figure 2 Lateral radiograph of the neck displaying a step-off contour (arrow) and bulging outline in the upper esophagus, anterior to the trachea. These features suggest a multilayered foreign body, further supporting the possibility of stacked coins.

Given the child’s symptoms and the uncertainty of the object’s nature, we proceeded with an urgent rigid esophagoscopy under general anesthesia. Using grasping forceps, we identified and removed two stacked coins from the upper esophagus (Figure 3). The esophageal mucosa showed circumferential eschar, necrosis, and patchy ulceration, but we observed no signs of perforation or bleeding.

Figure 3 Intraoperative images of the retrieved foreign bodies. (A) Frontal view of the stacked coins. (B) Identification of the upper coin as a 1-SAR coin and the lower as a 2-SAR coin, highlighting the size difference. (C) Lateral view showing the coins perfectly aligned, contributing to the double-rim radiologic mimicry. SAR, Saudi Riyal.

Due to the depth of injury and the object’s proximity to major vessels, we performed a postoperative computed tomography angiography (CTA) to rule out vascular-esophageal fistula. Although such fistulas typically emerge during the healing phase, we ordered early imaging as a precaution, given the circumferential necrosis (8). The CTA revealed no abnormalities. We maintained the patient on nasogastric feeding for 10 days. A follow-up esophagogram confirmed no perforation or leakage. After 2 weeks of hospitalization, we discharged him in stable condition. Figure 4 illustrates the clinical timeline from the patient’s initial presentation to discharge. We present the symptom onset, imaging studies, prompt esophagoscopy with ‘coin stack’ visualization, postoperative imaging, inpatient management, and discharge chronologically. This sequence underlines the team’s decisive actions and collaborative multidisciplinary approach during the child’s acute presentation and subsequent mucosal injury.

Figure 4 Timeline illustrating the patient’s clinical course from initial presentation to discharge. It includes symptom onset, radiologic evaluation, esophagoscopy, postoperative imaging, inpatient management, and follow-up. AP, anteroposterior; CT, computed tomography; CXR, chest X-Ray; ED, Emergency Department; GA, general anesthesia.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient’s legal guardians for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal

Discussion

FBI is a common pediatric emergency, with coins representing the most frequently ingested objects in children (3). While most cases involve a single coin, stacked coin impactions are less common, making up an estimated 5–7% of cases (5,6). When two coins of identical size align in the esophagus, they may produce a radiographic appearance that mimics a BB, raising diagnostic and management challenges (2,5).

Radiographic differentiation plays a critical role in initial management. BBs typically show a double-rim or “halo” sign on AP views and a step-off on lateral views. These features may also appear with stacked coins (1,5,8). Several reports have documented cases where stacked coins mimicked BBs, leading to diagnostic uncertainty (2,5,6). However, most of these cases involved minimal mucosal damage, whereas in our case, the stacked coins caused circumferential necrosis, a finding more commonly associated with BB injury. This case adds to the literature by demonstrating that even inert objects like coins can occasionally cause significant tissue damage when stacked and impacted in the esophagus, even when the exact duration of impaction is unknown. Table 1 summarizes key distinguishing features.

In our case, the patient’s symptoms and radiographic findings prompted an immediate esophagoscopy. The procedure revealed two coins, one on top of the other, that had resulted in severe mucosal necrosis. Although we ultimately identified the foreign body as coins, the decision to proceed with urgent endoscopy was based not only on the clinical presentation but also on the need to rule out a BB, which is a critical differential diagnosis in such cases.

BBs pose a distinctive danger because they can generate an external electrolytic current when lodged in a moist esophageal environment, which produces hydroxide ions at the battery’s negative pole, causing rapid liquefactive necrosis of surrounding tissue in as little as two hours (9,10). In addition to mucosal burns, delayed removal increases the risk of life-threatening complications such as esophageal perforation, tracheoesophageal fistula, and aorto-esophageal fistula formation (9). Therefore, BB ingestion is a true emergency requiring early recognition and prompt action, even when there is uncertainty regarding the object’s definitive nature.

Conclusions

This case illustrates how stacked coins can mimic BB on imaging and cause significant esophageal injury when impacted. While symptoms alone warranted urgent endoscopy, radiologic ambiguity reinforced the need for immediate intervention. Recognizing this mimicry is essential for accurate triage. Future protocols should emphasize combined AP and lateral imaging and highlight stacked coins as a distinct diagnostic consideration in symptomatic children with radiopaque esophageal foreign bodies.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-70/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-70/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-70/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient’s legal guardians for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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