Multiple singing magnet ingestion leading to pressure necrosis of the small bowel.

Multiple Magnet ingestion may cause a number of sinister complications. We report a case of multiple singing magnets ingestion by a 2-year-old girl resulting in intestinal obstruction and pressure necrosis of the small bowel. A bunch of seven magnets present in the small bowel was removed operatively.

INTRODUCTION

Magnets are unusual gastrointestinal (GIT) foreign bodies (FBs). The bullets like singing magnets are popular in children owing to the sound produced while a pair of these is tossed in air, thus called as singing magnets. Multiple magnet ingestion may produce sinister complication as intestinal obstruction and intestinal necrosis leading to perforation peritonitis.[12] We managed such a child with an ingestion of multiple singing magnets leading to intestinal obstruction and pressure necrosis of the small bowel.

CASE REPORT

A 2-year-old girl referred to our hospital with abdominal distension, abdominal pain, and constipation for two weeks. On admission, the patient was vitally stable but slightly dehydrated. The abdominal examination revealed abdominal distension and mild tenderness especially in the lower quadrants. A digital rectal examination (DRE) performed yielded finger stained with feces. All laboratory investigations were within normal limits. A x-ray of the abdomen erect performed divulged metallic FB in the pelvis with no air fluid levels. Ultrasound of the abdomen showed gaseous distension of the bowel loops. The parents identified metallic FB as magnets. As the FB appeared to be located in the pelvis, we planned sigmoidoscopy. However, during the course of admission, the patient developed complete mechanical intestinal obstruction with increased tenderness in the lower abdomen. Repeat x-ray of the abdomen erect showed multiple air fluid levels [Figure 1] along with the FB at the previous location. A repeat DRE revealed empty rectum. Patient was explored and a bunch of seven magnets was noted in a loop of ileum [Figure 2] compressing a loop of jejunum against bony pelvis resulting in pressure necrosis of the jejunum. The magnets were milked to the necrotic part of the jejunum and were retrieved [Figure 2]. A jejuno-jejunal end-to-end anastomosis was performed after resection of the necrotic jejunum. The immediate postoperative course was uneventful till the 5th postoperative day, when the patient was re-operated for burst abdomen. Afterwards, the patient started passing stool but could not tolerate feeds. Contrasts follow through GIT study performed on 15th postoperative day revealed slow transit. Keeping the prolonged starvation and presence of FB in GIT for a prolonged time in view, a motility disturbance was also thought of; and so the syrup erythromycin (10 mg/kg/dose twice a day) and syrup domeperidone were started. The patient responded well and discharged on 3rd day of starting prokinetics. At the 3-month follow-up visit, she is responding well.

Figure 1

Radiograph showing air fluid levels and metallic FB in the pelvis

Figure 2

Magnets in the ileum. Insets showing perforated jejunum and retrieved magnets

DISCUSSION

Singing magnets are hematite magnets (ferrous oxide based).[1] Magnet ingestion is a rising problem in children and a number of new cases are being reported with a myriad of complications like chocking in case of inhalation; piercing of soft tissues requiring surgical removal; and intestinal obstruction and perforation in case of multiple magnets ingestion. In case of multiple magnets ingestion, the gut may entrap between the magnets resulting in intestinal obstruction, pressure necrosis, and perforation peritonitis.[23] In our case, all the magnets were present as a bunch in the mid ileum and did not entrap any loop of bowel. Rather, the heavy weight of these magnets dragged the containing loop of ileum to the pelvis and compressed another loop of jejunum against the bony pelvis. The little girl might have ingested the magnets in bits over few days and on jumbling up in the mid ileum could not progress due to the significant weight. In case if she has ingested all the magnets in a single setting, these could have jumbled up in the stomach, not passable through the pylorus.

In 2012, European and North American Societies of Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN and NASPGHAN) developed an algorithm for the management of single or multiple magnets ingestion. They recommend early surgical intervention when multiple magnets get beyond the stomach to preempt serious complications especially in symptomatic cases; however, in asymptomatic cases, enteroscopic or colonoscopic retrieval of the magnets is advised.[2] In the index case, we too planned a sigmoidoscopy as the location of the magnets seemed in the sigmoid colon; but complete intestinal obstruction led us to surgery.

To conclude, multiple magnet ingestion is a serious problem. It may damage the bowel in various ways. We described another mechanism whereby the weight of multiple magnets compressed the bowel against the bone leading to its pressure necrosis.