“Necklace of magnets” in the abdomen: an unusual case with “multiple” bowel perforations

Abstract

Magnetic foreign body ingestion poses a threat especially if more than one is ingested.

If consumed alone, small magnetic foreign bodies are likely to pass without significant event; however, when multiple magnets are ingested, they can be attracted to each other through the intestinal wall, which may lead to serious consequences and complications, including bowel perforation, obstruction, peritonitis, and death. We report a case of a 2-years male child patient presented with multiple small round magnetic beads ingestion from a magnetic pendant that appeared like a necklace pearl after conglomeration on abdominal radiograph. On exploration, we found multiple perforations involving ileum, cecum, and transverse colon, with multiple conglomerated beads extruding from the perforation sites.

Introduction

Foreign body ingestion occurs frequently in young children. In the majority of cases, treatment is conservative.¹ Among the varieties of foreign bodies, magnetic foreign body ingestion poses a significant problem, especially when more than one is ingested due to their ability of attraction toward each other across the intestinal layers, resulting in necrosis of bowel wall and perforation.² Management of such cases depends on the duration of history, clinical presentation, number and location of ingested magnets, and complications.³ Here, we report a case of ingestion of 17 small magnetic beads from an ornament pendant that later led to perforation peritonitis. Abdominal radiograph showed a chain of 17 beads in the form of a pearl necklace. On exploration, multiple perforations were found involving ileum, cecum, and transverse colon, with multiple conglomerated beads found to be extruding from the perforation sites.

Case report

A 2-years male child patient presented to the emergency department with 2-day history of multiple magnetic beads ingestion witnessed by the mother. Following the day of ingestion, child developed abdominal pain and nonbilious vomiting. The vomitus initially consisted of gastric secretions and milk, but later, the child vomited coffee-ground-like material. The child was admitted for observation. At the time of admission, he was conscious and alert, heart rate of 119 beats/min, respiratory rate of 21 breaths/min, blood pressure of 78/40 mm Hg, oxygen saturation was 97% on room air, and temperature was 99°F. Abdomen was soft with mild fullness and no signs of peritoneal irritation. Abdominal radiograph showed a chain of 17 beads extending from the epigastric region to the central abdomen. However, no signs of small bowel obstruction or free gas were identified (Fig. 1A). Preliminary blood investigations, including complete blood count, coagulation profile, renal function test, and routine electrolytes, were unremarkable. He was kept on intravenous fluids and close monitoring with serial abdominal radiographs, which showed no change in the location of the foreign bodies. Initial regimen of laxatives and rectal enemas was prescribed to encourage foreign body expulsion on the day of admission, although their role is not proven in multiple magnetic foreign body ingestion. On the third day, he became lethargic with decreased oral intake and activity. He was passing stools but no evidence of passing foreign bodies. On the fourth day, the child started showing signs of abdominal distension and tenderness with decrease in the amount of stools. Abdominal radiograph revealed multiple air-fluid levels with dilated loops and unchanged foreign body locations (Fig. 1B). He was taken for exploratory laparotomy, and multiple perforations were found, viz. ∼3cm perforation involving ileum (70cm distal to DJ flexure) along with ∼1cm wall hematoma adjacent to perforation, ∼1.5cm perforation involving caecum, and ∼2cm perforation along the antimesenteric border of transverse colon. Multiple adhesions were present between the segment of ileum and transverse colon. Omentum was found to be adhered to ileal and colonic segments near perforation sites. Patches of discoloration involving proximal bowel wall were also found at some places but returned to pink color with normal peristalsis on applying hot mops and 100% oxygen. Four magnetic beads were found to be extruding at the site of transverse colon perforation and adhesions with the ileal segment, whereas 13 magnetic beads were found to be extruding from the site of caecal perforation (Fig. 2). All magnetic beads (total 17) were taken out, inter bowel loop adhesions were released, and lavage was done. Resection of the ileal segment with perforation and end-to-end anastomosis was done. Cecal and transverse colon perforation were repaired primarily after refreshing the margins. Loop ileostomy was done ∼20cm proximal to ileocecal junction. Abdominal drain was put, and abdomen was closed in layers. Postoperative period was uneventful. Fresh frozen plasma was given for 5 days in view of poor nutritional status and low serum albumin (2.9 g/dL) in postoperative period. Stoma started functioning on postoperative day 3, but he was kept nil per oral for extended period up to postoperative day 7, as we came across patches of discoloration involving proximal bowel wall at some places during exploration. Child was allowed orally on postoperative day 7, and the drain was removed on postoperative day 8. Child was discharged on postoperative day 10 on oral antibiotics. He was followed up after 2 weeks and showed appropriate recovery. On further follow-up visits, the child was doing good and showing signs of nutritional improvement and weight gain. After about 3 months, distal cologram was done that showed normal bowel continuity, and the child was then planned for stoma closure. Patient consent was obtained for images and inclusion in the study.

Fig. 1.

(A) Abdominal radiograph showing foreign body in mid abdomen, (B) serial abdominal radiograph showing air-fluid levels and unchanged location of foreign body.

Fig. 2.

(A) Foreign body extruding from the site of cecal perforation, (B) foreign body extruding from the site of transverse colon perforation, (C) removed magnetic beads in toto in the shape of necklace/bracelet, (D-F) successive images showing perforation in the segment of ileum, cecum, and transverse colon, respectively, (G) area of adhesions between segment of ileum, transverse colon, and omentum, (H–I) perforations at the respective sites and extruding magnetic beads from the perforation site.

Discussion

Foreign body ingestion is commonly seen in the pediatric population. Less than 1% of ingested foreign bodies require any type of surgical intervention. When the foreign body is of magnetic material, it poses a substantial challenge to a surgeon especially when other metal objects are present or multiple magnetic components are present because of the likelihood that the magnet will attract metal or another magnet, causing pressure necrosis of the intervening intestine. Potential complications include intestinal wall necrosis and fistula formation, intestinal obstruction and perforation, volvulus, or intraperitoneal hemorrhage if mesenteric vessels are found between the magnets.² Wildhaber et al⁴ proposed that when a single magnet is ingested, the patient can be observed, but when there is a history of ingestion of multiple magnets, the patient should be further evaluated with endoscopy or laparotomy if signs of intestinal distress develop. Anselmi et al⁵ suggested that surgical intervention is necessary if the locations of the magnets are unchanged on serial radiographs. In our case, we got a history of ingestion of multiple magnetic beads that appeared like a necklace on abdominal radiograph. On serial abdominal radiographs, the position as well as the shape of foreign bodies remained unchanged. This possible scenario could be due to (a) magnetic beads ingested separately and went across the pylorus in installments, (2) few beads remained in proximal ileum, and some went across the ileocecal junction, (3) major portion of the beads remained in cecum and rest proceeded to transverse colon, and (4) the necklace/bracelet formed after the bowel wall necrosis and internal fistulization between the segment of ileum and transverse colon as well contacted the rest of the segments extraluminally across the root of mesentery (Fig. 2 [A-I]).

There are no current guidelines for serial abdominal radiographs in cases of multiple magnetic beads ingestion, as early removal is recommended. If successive radiographs show unchanged position after ingestion of multiple magnetic foreign bodies, which is indirect evidence of interposed bowel wall between two magnetic foreign body objects or deterioration of abdominal condition, then exploration is recommended.

In our case, the magnetic attraction between the components of the necklace resulted in this appearance of ingested foreign bodies on plain radiograph. Therefore, we can say there is a possible relationship between multiple magnetic foreign body ingestion and intestinal fistula formation along with other possible complications.

Conclusion

A treating physician or a surgeon should be highly vigilant and cautious while treating a child where history of magnetic foreign body ingestion is suspected. Potential bowel complications may occur, especially when the history of multiple magnetic foreign body ingestion is present. High index of suspicion and early removal is warranted in cases of multiple magnetic foreign body ingestion to reduce potential morbidity and mortality. Initial endoscopy can be tried if the child is presented early or if magnetic foreign bodies cannot be removed by endoscopy; an operation is suggested as soon as possible to avoid serious complications.

Disclosure of competing interest

The authors have none to declare.