doi:10.1111/j.1440-1754.2007.01121.x
CASE NOTE
Ingested magnets and gastrointestinal complications Abdulrahman M Alzahem,1,2 Soundappan SV Soundappan,1,2 Heather Jefferies1,2 and Daniel T Cass1,2 1
Department of Academic Surgery, The Children’s Hospital at Westmead, Westmead and 2University of Sydney, Sydney, New South Wales, Australia
Abstract: Multiple magnet ingestion is an unexpected health hazard in children that can lead to significant gastrointestinal morbidity. The magnets are attracted to each other across the bowel wall and this may lead to pressure necrosis, resulting in perforation, fistula formation, and/or intestinal obstruction. We report herein a case of small bowel obstruction following ingestion of two magnets. The public and clinicians should be aware of the health hazard of such devices. Key words:
fistula; foreign body; gastrointestinal obstruction; magnet; perforation.
There have been several reports describing foreign bodies (FBs) ingestion in children including coins, pins and batteries.1–3 On the other hand, the reports describing magnet ingestion and its significant gastrointestinal complications are sparse despite the increased accessibility of small magnets to the reach of young children.4–6 Despite these occasional reports, there is still a lack of awareness of this potentially serious problem. In particular, there have been few publicity campaigns to alert the public and manufacturers. Therefore, we report herein the unusual case of a child who ingested magnets and the resultant gastrointestinal morbidity, with review of the literature.
Case Report A 4-year-old boy presented to a local hospital with a 4-day history of non-bilious vomiting, crampy abdominal pain and constipation. The abdomen was distended with no obvious peritoneal signs or hernias. A diagnosis of gastroenteritis was made and he was sent home. The child continued to vomit and represented to the same hospital where an abdominal radiograph performed, showed small bowel obstruction. Subsequently, he
Key Points 1 The availability of magnet devices among children has increased. 2 Ingestion of multiple magnets could lead to serious gastrointestinal complications. 3 Awareness among clinicians and public about the health hazard of magnet devices may improve the preventative and therapeutic strategies to address this problem. Correspondence: Dr Soundappan SV Soundappan, Department of Academic Surgery, The Children’s Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145, Australia. Fax: +61 2 9845 3346; email:
[email protected] Accepted for publication 18 February 2007.
was transferred to our tertiary care children’s hospital. On arrival, he was ill and dehydrated. His heart rate was 112 beats per minute and the body temperature was 37.7°C. His abdomen was distended but soft with tinkling bowel sounds. He was noticed to have a right hydrocele. The haematological and biochemical parameters were normal. The abdominal radiograph showed a disk-shaped radio-opaque FB, 7.5 × 10 mm in the mid-abdomen along with dilatation of small bowel and multiple air-fluid levels (Fig. 1). On further questioning the parents thought that he might have swallowed magnets from a badge from school. Following a brief period of resuscitation, he underwent a laparotomy which revealed adhesions between two ileal loops. Upon releasing the adhesions, two ileal perforations (7 cm and 35 cm from ileocaecal valve) were found (Fig. 2) and the FBs turned out to be two pieces of magnets, one in each opposing ileal loop. The FBs were removed and the perforations were oversewn. The patient’s post-operative recovery was uneventful. He was discharged from the hospital on the fourth post-operative day.
Discussion More than 111 000 ingestions of FBs by people aged 19 years and younger were reported to American Poison Control Centres in 2003.7 In the state of Victoria (Australia), the annual admission rate for FB ingestion was 31.7 per 100 000.8 Most FBs pass spontaneously through the gastrointestinal tract.1 Complications from FB ingestion in children are uncommon. A great variety of interesting FBs are reported from different cultural and geographical backgrounds. Among the commonly ingested FBs are coins, needles and pins, fish bones, and batteries. About 10–20% of patients may be subjected to endoscopic retrieval of FBs from the oesophagus or the stomach. Surgical intervention is required in only 1% of patients for complications, namely, obstruction, perforation, or fistula formation.5 The use of small magnets made from neodymium iron boron or other compounds in toys has become common over the last
Journal of Paediatrics and Child Health 43 (2007) 497–498 © 2007 The Authors Journal compilation © 2007 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
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Ingested magnets and gastrointestinal morbidity
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Fig. 1 Abdominal roentgenograph showing radio-opaque foreign body along with small bowel dilatation.
or more) magnets or a single magnet and another metallic FB are ingested, and divided into groups, they can attract each other through the bowel wall. This would lead to pressure necrosis, resulting in bowel perforation, fistula formation, and/ or bowel obstruction secondary to kinking, inflammatory reaction, and/or internal herniation.5,6 Single magnet ingestion warrants close observation. However, multiple magnets in the oesophagus or the stomach should be removed using the same techniques used in the removal of other FBs, or using the steel wire basket to take advantage of the strength of magnet.5 If the magnets have passed the pylorus, an attempt should first be made to evacuate them non-invasively using laxatives before the symptoms and signs of gastrointestinal complications appear. However, if their position become fixed on serial radiographs then an emergent laparotomy for removal of FBs will be required before the symptoms and signs occur.6 In conclusion, multiple magnets ingestion can lead to serious gastrointestinal complications. Public and clinicians likewise should be aware of the health hazard of such devices.
References
Fig. 2 Two ileal perforations (black arrows) and the foreign body are evident on laparotomy.
few years.9,10 They are cheap to manufacture and are put into everything from building sets to toys.4,9,10 The morbidity from magnet ingestion can be serious. Individually, magnets are usually smooth and small enough to pass through the gastrointestinal tract without any problem. However, when multiple (two
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1 Blaho KE, Merigian KS, Winbery SL et al. Foreign body ingestion in the emergency department: case reports and review of treatment. J. Emerg. Med. 1998; 16: 21–6. 2 Arana A, Bruno H, Hachimi-Idrissi S et al. Management of ingested foreign bodies in childhood and review of the literature. Eur. J. Pediatr. 2001; 160: 468–72. 3 Henderson CT, Engel J, Schlesinger P. Foreign body ingestion: review and suggested guidelines for management. Endoscopy 1987; 19: 68– 71. 4 Tay ET, Weinberg G, Levin TL. Ingested magnets: the force within. Pediatr. Emerg. Care 2004; 20: 466–7. 5 Lee SK, Beck NS, Kim HH. Mischievous magnets: unexpected health hazard in children. J. Pediatr. Surg. 1996; 31: 1694–5. 6 Honzumi M, Shigemori C, Ito H et al. An intestinal fistula in a 3-year-old child caused by the ingestion of magnets: report of a case. Surg. Today 1995; 25: 552–3. 7 Conners GP. Pediatrics, Foreign Body Ingestion. EMedicine (updated 28 February 2005). Available from: http://www.emedicine.com/ [accessed 10 January 2007]. 8 Altmann AE, Ozanne-Smith J. Non-fatal asphyxiation and foreign body ingestion in children 0–14 years. Inj. Prev. 1997; 3: 176–82. 9 Tiny Strong Magnets in Toys Hazardous for Tots. Available from: http:// www.msnbc.msn.com/id/16096422/ [accessed 4 January 2007]. 10 Study Warns of Dangers of Small Magnets to Children. Available from: http://www.wstm.com/global/story.asp [accessed 19 December 2006].
Journal of Paediatrics and Child Health 43 (2007) 497–498 © 2007 The Authors Journal compilation © 2007 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
