Accidental ingestion of foreign bodies and its management is a common problem seen more in the pediatric population than in adults. A review of the literature suggests that endoscopic removal of foreign bodies is curative for objects located in the cricopharynx or upper esophagus. Foreign bodies passed into the stomach can usually be observed for development of symptoms, because 80% of them would be spontaneously passed.However, ingestion of metallic foreign bodies involving coins or button-type batteries may require an aggressive approach. A few cases of intestinal obstruction due to magnet ingestion have been reported in Japan, China, and Korea where magnets are used for treatment in traditional medicine.1-5 When more than one magnet is ingested they can be attracted to each other through the intestinal wall, causing necrosis and intestinal perforation or fistula, so they should be removed while they are still accessible with endoscope.We report a case for the first time in the United States of intestinal obstruction and fistula formation due to ingestion of more than one magnet. We feel that early endoscopic removal of magnets or a magnet along with a magnetic foreign body is safe and should be the choice of management. The author proposes an algorithm for management of foreign body ingestion focusing on early retrieval of magnetic foreign bodies. CaseAn 11-year old boy presented with a three-week history of nausea, vomiting, and burning epigastric pain. He had been treated for Streptococcus A pharyngitis by his pediatrician and had been seen in the emergency department previously with a negative work-up. At admission, vital signs were stable but the patient was visibly uncomfortable, lying on his left side with bilateral lower extremities flexed. Physical examination revealed abdominal tenderness with light palpation and decreased bowel sounds in the right and left lower quadrants. Leukocyte count was 13,900/mm 3 , hemoglobin and hematocrit were slightly elevated, and all other laboratory findings were within normal limits. Radiograph and CT scan of abdomen and pelvis confirmed the presence of two foreign bodies in the pelvis with bowel obstruction (Figures 1 and 2). After multiple rounds of questioning, the patient revealed that he had swallowed two magnets from a toy approximately 1 month before. A surgical consult was called that resulted in an exploratory laparotomy. Operative report of our patient describes fistulae formation at ileoileal level involving a "U" turn region of ileum and proximal jejunum and distal ileum that fistulized through the mesentery of terminal ileum. The procedure involved division, debridement to healthy bowel and closure of jejunoileal fistula, enterotomy for foreign body removal, and reinforcement at ileoileal fistula after division. The specimens were examined by the pathologist and confirmed to be consistent with fis-

We report this case of effort thrombosis of the upper extremity (Paget-Schroetter syndrome) caused by hypertrophied muscles. This unusual cause of extrinsic venous compression and intimal injury leading to thrombosis was treated uniquely with good outcome. Untreated symptomatic patients can sustain long-term disability from venous obstruction resulting in significant loss of occupational productivity and quality of life. For the same reason, early catheter directed thrombolysis followed by anticoagulation and surgical intervention are recommended in much of the recent literature. Thrombolysis is the most common form of treatment, followed by surgery, if needed, after careful diagnostic approach. A majority of the literature supports a multimodal approach, but there is no definite consensus on management. This highlights the need for randomized clinical trials to guide management as well as to assess the safety and efficacy of anticoagulants commonly used and to define the optimal duration of therapy after thrombolysis. (J Am Board Fam Pract 2005;18:314 -9.)