Revisiting Swallowed Troubles: Intestinal Complications Caused by Two Magnets--A Case Report, Review and Proposed Revision to the Algorithm for the Management of Foreign Body Ingestion

Abstract

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-

Perils in the playpen: Duodenojejunal fistula in a child following ingestion of two toy magnets

“…Less than 1% present with complications requiring surgery. 3 Magnet ingestion has been a recent phenomenon with the earliest cases reported from Japan in 1991 where magnets were used for various musculoskeletal therapies 4 . In the recent past there has been an increased incidence of complications related to multiple magnet ingestion.…”

“…MRI of the abdomen should never be used as it can precipitate a perforation 1 . Modern NIB (alloy of Neodymium, Iron and Boron 7 ) toy magnets are 10 times more powerful than traditional magnets 8 capable of producing attractive forces up to 1300 G. 9 These have been known to erode through the intervening bowel wall resulting in perforation, internal enteric fistulae, internal herniation, adhesions, volvulus, obstruction 2 , mesenteric hemorrhage 4 and death 3 . Enteric fistulae reported are jejunoileal, jejuno-caecal, jejuno-colic and ileo-ileal.…”

“…Surgical intervention is advised if the magnetic objects have progressed beyond the stomach. [2][3][4] Laparoscopic removal of the ingested magnets has been reported 12 . In view of the fallacy in relying upon the history or radiological imaging to determine whether the magnet ingested is single or multiple Butterworth et al have suggested treating suspected single magnet ingestions on similar lines of multiple magnet ingestion.…”

“…1 Several algorithms designed to direct clinical decisions are available. [2][3][4] The spectrum of complications is possibly only unfolding. Increased awareness of the problems associated with magnet ingestion is necessary for parents, healthcare givers, toy makers and marketers.…”

Management of gastrointestinal tract perforations

“…11 The location of a tumor in the upper portion of the stomach is a risk factor for perforation during ESD. 12,13 A long operative time is another risk factor for perforation during ESD.…”