Pediatric ingestion of multiple ball magnets leading to intestinal perforation: A case report

Abstract

Introduction and importance

Ingestion of foreign bodies is a relatively common cause of abdominal pain in the emergency department among pediatric patients. A less common but potentially life-threatening ingestion is that of magnets.

Presentation of case

Here, we report the case of a 6-year-old female who ingested 7 ball magnets in a rural town in Brazil and presented with a 4-day history of abdominal pain.

Surgical approach was necessary in this case. It consisted of midline laparotomy that revealed one small intestinal perforation of the antimesenteric aspect of the small bowel. The magnets were attached to each other and were retrieved through the perforated intestinal wall. Resection of the necrosed borders of the perforated wall was followed by single-plan extra-mucosal enterorrhaphy of the lesion.

Clinical discussion

The magnets took on a linear configuration which led to the overlap and obstruction of a loop of the small bowel, with ischemia and perforation of the intestinal wall.

Conclusion

Ingestion of magnets is an unusual event that can lead to increased risks of intestinal mechanical obstruction, and intestinal perforation. Previous research shows that other complications such as fistulas and volvulus can also occur and that patients with this presentation might develop peritonitis, resulting in death if not timely treated.

Highlights

• •The number of magnets ingested may change severity of outcomes.
• •Ingestion of multiple magnets is a potentially serious medical condition.
• •Ingestion of multiple magnets may require operative treatment.

1. Introduction

Foreign body ingestion is relatively common among children, especially in those younger than 5 years of age. That age group accounted for 54.7 % of magnetic foreign body ingestions in the US [1] between 2002 and 2011. A study of endoscopies performed in 12 Latin American countries showed that 1.05 % of endoscopies performed in children due to foreign body ingestion had single or multiple magnets as the causative agents [2]. The ingestion of a single magnet is generally uncomplicated, whereas the ingestion of multiple magnets is related to increased risk of intestinal perforation and need of operative treatment [3].

Our objective is to report a case of ingestion of several ball magnets by a 6-year-old girl in a community hospital in Brazil.

2. Methods

This work has been reported in line with the SCARE criteria [4].

This case report was approved by the regional ethics committee of FUTO – Faculdades Unificadas de Teófilo Otoni, MG, Brazil.

3. Presentation of case

A 6-year-old female patient was referred by her family physician to the community hospital with a 4-day history of abdominal pain, constipation, and reduced appetite, with no vomits, fever or peritoneal signs. Abdominal ultrasonographic studies from the primary healthcare institution were reported to be normal. No relevant past medical history, family history or psychosocial history were reported.

She had significant abdominal distension and diffuse pain at admission. The patient disclosed having ingested 7 magnets when playing with one of her cousins.

Initial investigations consisted of blood work and abdominal radiographies. White blood cells were elevated (12.900/mm³), as well as C-reactive protein levels (149 mg/L). Abdominal radiography showed a linear metallic foreign body in the small bowel, and gas distension of the proximal gastrointestinal tract, as reproduced in Fig. 1, Fig. 2.

Fig. 1.

Orthostatic radiography showing signs of intestinal obstruction and a linear metallic foreign body in the ileum.

Fig. 2.

Supine radiography showing gas distention of the small bowel and linear metallic foreign body in the ileum.

A nasogastric tube was inserted to decompress the stomach and address the abdominal distention. The patient had a bowel movement later that day, with no foreign bodies found upon stool inspection.

She was hospitalized and started on daily oral lactulose to facilitate evacuation of the magnets, as well as intravenous gentamicin and ampicillin. She remained under clinical surveillance by Pediatrics, and radiographs were repeated on the two following days, with no considerable changes, as depicted in Fig. 3, Fig. 4, Fig. 5.

Fig. 3.

No significant radiographic changes on day 2 of hospitalization.

Fig. 4.

Magnified image of the seven spherical magnets shown on Fig. 3.

Fig. 5.

No significant radiographic changes on day 3 of hospitalization.

Other imaging studies (Computed Tomography, Ultrasound) are not routinely available in our hospital. The radiographic findings of foreign bodies and bowel distention, associated with the patient's signs of surgical acute abdomen were indicative of the need of a surgical approach.

Given the lack of improvement and worsening abdominal symptoms, the patient underwent a midline laparotomy on the third day of hospitalization, under general anesthesia, by two staff surgeons. Surgical findings showed a small perforation (0.8 cm) on the antimesenteric aspect of the small bowel covered by fibrin approximately 30 cm distal to the ligament of Treitz (Fig. 6). The radial margins of the perforation were friable and necrotic, but the surrounding tissue was viable, as was the rest of the intestines. No abscesses or adhesions had formed at this site nor elsewhere in the abdominal cavity. Seven ball magnets firmly connected to each other in a linear pattern were found partially exteriorized through the perforated site and their retrieval was completed manually, through the intestinal perforation (Fig. 7, Fig. 8). Following resection of the necrosed borders, single-plan extra-mucosal enterorrhaphy of the lesion was performed. No intestinal resection or anastomosis were deemed necessary. No intraoperative complications were reported. The patient passed a small volume of stools on postoperative day 4. On postoperative day 8 there was superficial wound dehiscence of 3 skin sutures and scant purulent drainage (Clavien-Dindo Classification I). The abdomen of the patient was mildly distended, with no peritoneal signs, and normal bowel sounds, and discharge occurred on the same day. The patient was followed up weekly, for two weeks, and bi-weekly for a month by Pediatrics at our institution. Recovery was uneventful. The patient was then discharged and instructed to follow up with her family doctor for regular clinical assessment.

Fig. 6.

Ischemia and perforation of the ileal wall.

Fig. 7.

Removal of the 7 magnets attached to each other in a linear pattern.

Fig. 8.

Seven spherical magnets still connected after removal from the ileum of the patient.

4. Discussion

Ingestion of magnets has increased in the US recently, most frequently in patients younger than 5 years old [1]. The Public Health Agency of Canada reported magnet related injuries in 328 children from emergency department visits between 1993 and 2007. Half of those cases involved oral ingestion of magnets [5].

A cohort study of 12 countries in Latin America reported a 1.05 % incidence of magnet ingestion in 2363 children subjected to endoscopic procedures due to foreign body ingestion [2]. This rate is fairly similar to that of 1.97 % found at Children's Hospital of Pittsburg [3].

Foreign body ingestion is common among children, and it usually resolves spontaneously, including cases in which a single magnet has been ingested. Contrastingly, the risk of complications is much higher when multiple magnets are ingested simultaneously [6].

The attraction between two or more magnets, or between a magnet and a metallic object, can lead to pressure necrosis of two intestinal loops causing fistulas, volvulus or perforation [3,[5], [6], [7]]. We hypothesize that one or more ball magnets attracted other non-adjacent magnets, pinching a small area of the intestinal wall between them, which led to ischemia, necrosis, and subsequent perforation in the present case. This, however, was not demonstrated in the abdominal radiological studies performed, and the exact mechanism remains unclear. The literature shows that neodymium magnets can lead to corrosion of the intestinal wall, consequently leading to its perforation [8]. Despite not having been able to determine the chemical composition of the magnets reported in this article, chemical corrosion could be an alternative hypothesis to explain the intestinal perforation in this case.

Whenever possible, foreign bodies should be removed from the gastrointestinal tract through endoscopy [3,7,9]. This is usually achievable when the foreign body is still located proximal to the pylorus [9].

When multiple magnets are connected and shown in different locations through serial imaging, a watchful waiting approach can be adopted successfully. In contrast, if the magnets are not progressing through the gastrointestinal tract, it is reasonable to presume that they are anchoring each other through the intestinal wall, making perforation more likely [10].

5. Conclusion

The ingestion of magnets is an unusual event. However, it can lead to increased risks of intestinal mechanical obstruction, volvulus, fistulas, and perforation. These complications can cause peritonitis and lead to death if not timely treated.

That notion is important when more than one magnet is ingested, particularly by children, as demonstrated in the case presented in this report. Therefore, patients should be followed closely with sequential image studies to document the location and progression of the foreign bodies, to allow timely surgical management where appropriate.

Consent

Written informed consent was obtained from the patient's parents/legal guardian for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Ethical approval was provided by the regional ethics committee (FUTO – Faculdades Unificadas de Teófilo Otoni, MG, Brazil).

Funding

None.

Guarantor

Daniel Capdeville Tanure; Jansen Cherfani Tanure

Research registration number

71599123.1.0000.8747.

CRediT authorship contribution statement

• Data collection: Daniel Capdeville Tanure; Laura Cheib Silva Moreira; Jansen Cherfani Tanure.

• Study concept or design: Daniel Capdeville Tanure, Jansen Cherfani Tanure, Laura Cheib Silva Moreira.

• Data interpretation: Daniel Capdeville Tanure; Laura Cheib Silva Moreira; Jansen Cherfani Tanure; Joao Rezende-Neto, Renato Leandro Alves Rebouças.

• Writing the paper: Daniel Capdeville Tanure; Laura Cheib Silva Moreira; Jansen Cherfani Tanure; Joao Rezende-Neto; Renato Leandro Alves Rebouças.

Declaration of competing interest

None declared.