Multiple magnet ingestion: An uncommon cause of peritonitis.

Foreign body ingestion is common in infants and young children and they pass spontaneously in most of the cases. Magnetic foreign bodies, though not very common, require early intervention to avoid severe gastrointestinal complications. We report a case of multiple magnet ingestion who presented with peritonitis.

INTRODUCTION

Infants and small children instinctively put anything in the mouth. Nearly, 80% of the ingested foreign bodies pass from the gastrointestinal tract without any complication.[12] Rounded foreign bodies with no sharp edges, if found beyond esophagus, are usually the left for spontaneous passage. However, multiple magnetic foreign bodies if managed conservatively may lead to severe gastrointestinal morbidity and extensive surgery. We report an infant who came with peritonitis after ingestion of multiple magnets.

CASE REPORT

A 1-year-old child presented with the complaints of pain in the abdomen and constipation for 4 days, progressively increasing abdominal distension for 3 days and several episodes of bilious vomiting for 2 days. There was no history of fever or preceding diarrhea. She was hemodynamically stable. Abdomen was distended, tense and tender and guarding was present. Bowel sounds were absent. Abdominal radiograph showed distended bowel loops with multiple air fluid levels, absence of distal bowel gas and a foreign body with no free air in the peritoneal cavity [Figure 1a]. Parents could not recall any foreign body of that nature even after seeing the radiograph. After initial resuscitation, exploratory laparotomy was performed. There was no gross peritoneal contamination. One tiny perforation was found 25 cm distal to duodeno-jejunal flexure and 3-4 sealed perforations were found spread in 3 cm length of proximal ileum. The segment of ileum having multiple perforations was resected and five metallic beads could be palpated and removed from small bowel separately in the set of 2, 2 and 1. Jejunal perforation was primarily repaired. These beads were magnetic and took similar shape when put together as was seen on radiograph [Figure 1b]. The beads when shown to mother were recognized as beads from the magnetic bracelet, which got broken a week earlier. The child did well in the post-operative period and was discharged on full oral feeds on the post-operative day 6.

Figure 1

(a) Abdominal radiograph showing distended bowel loops with multiple air fluid levels, absence of distal bowel gas and a foreign body with no free air. (b) Magnetic beads after removal from small bowel

DISCUSSION

Less than 55 cases of multiple magnet ingestion have been reported in the English literature till date.[3] Similar to our case, history of foreign body ingestion is either not found or a week old. Patients are either young children (6 months to 3 years) or older children with autism.-[4] The magnets are usually part of toys or household electronic items, beads from jewelry used for magnetic therapy or broken pieces from a large magnet. These are usually ingested on separate occasions or they get separated when they pass through the pylorus.[5]

Small bowel is the site of morbidity in most of the cases. The cause of preferential small bowel injury in these cases is mobility and thin walls of the small intestine. Magnets in the small bowel lumen attract each other through thin walls and attach to each other if they are in adjacent loops. This causes ischemia and necrosis of adjacent bowel and leads to perforation or bowel fistulization and other complications.[4]

Most of the patients reported in the literature, presented with complications such as perforation peritonitis, entero-enteric fistulae, obstruction, volvulus and internal herniation. Magnets were retrieved after laparotomy. In few cases, magnets have also been removed even in asymptomatic patients to avoid complications.[6]

In day-to-day practice, if we see a metallic foreign body without sharp edges, we usually wait for spontaneous passage through gastrointestinal tract and monitor it with plain abdominal radiograph. The ingestion of multiple magnets poses a significantly different clinical problem compared with the other foreign bodies or the ingestion of a single magnet. They can lead to severe gastrointestinal morbidity if left untreated. If in stomach, they should be removed with endoscopy[78] or a catheter with magnetic tip.[9] If passed distal to pylorus, prompt surgical intervention is required before a complication develops [Figure 2].

Figure 2

Algorithm for management of magnetic foreign body ingestion

To conclude, the clinicians should be aware of the hazards of multiple magnet ingestion and should opt for an early intervention even in the asymptomatic patient. Conservative approach in these patients can lead to severe gastrointestinal complications, extensive surgery and its consequent morbidity and mortality.