Double Jejunoileal Fistula after Ingestion of Magnets.

A double jejunoileal fistula was diagnosed intraoperatively 10 months since a 4-year-old boy had swallowed an object consisted of multiple magnetic items. Magnet ingestion presents characteristics that are misdiagnosing, critical time-consuming, dangerous, and occasionally fatal. The particularities and pitfalls of ingested magnetic items are outlined.

INTRODUCTION

Ingestion of foreign bodies by children is a common problem. The majority pass through the gastrointestinal tract without causing any harm. However, some cases require endoscopic removal, and 1% of patients undergo surgical operation.[1] There are certain types of swallowed objects that require special consideration such as batteries and magnets. When magnets are involved, accidental ingestion of a single one poses no threat for the patient, but ingestion of multiple items or a single magnet and a metallic object may compromise the health of the child.[12] Such a complicated case is presented here.

CASE REPORT

A 4-year-old boy was referred to the emergency department with mild abdominal pain and an incidental radiological finding of a radiopaque object in the abdomen. The patient was stable without vomiting or abdominal distension. Physical examination revealed mild tenderness of the lower abdomen without peritoneal irritation. There were no fever or blood from the rectum, laboratory blood tests were normal, and no nutrition-related issues emerged during this period.

The patient was admitted for observation. During the next 2 days, he was free of pain and could feed and evacuate without difficulty. Follow-up abdominal radiography showed the object still in the lower abdomen. Based on the good clinical status, the child was discharged home, and the parents were instructed to observe the stools and to refer to their pediatrician in case of any new sign noticed.

A month later the boy returned complaining about recurrence of abdominal pain. Abdominal radiography still showed the same object image. The mother who did not follow the medical instructions on a daily basis presumed that the item had been evacuated and that there was nothing to worry about.

The presence of a radiopaque foreign body in the intestine for a long period and the recurrent abdominal pain resulted in the decision of exploratory laparotomy. No contrast radiological study was performed before operation as clinical, plain radiography, and history criteria were considered indicative for laparotomy. During the procedure, two intestinal loops (the 1st of the ileum, 1 m from the ileocecal valve and the 2nd of the jejunum, approximately 40 cm from the Treitz ligament) were found adhered together [Figure 1], with the presence of two fistulas between them [Figure 2]. The implicated item was not single but consisted of 14 small cone-shaped magnets, removed through an enterotomy. Double enterectomy and end-to-end anastomosis followed.

Figure 1

Jejunum and ileum presenting chronic adhesion

Figure 2

Double fistula due to pressure necrosis of the intestinal wall of the loops caused by the magnetic objects. The magnetic components on removal are attracted by the metallic surgical instrument

The patient's postoperative course was uneventful and he was discharged home on the 5th postoperative day. Both parents recognized the removed particles as elements of a refrigerator magnetic ornament in the home of a relative that they had visited 10 months ago. The mechanism of the complication was that of enteric mural ischemia and necrosis. The parts in the jejunum and the parts in the ileum were attracted together, and a permanent pressure was applied to the bowel between them until it gave its place to the two fistulas.

DISCUSSION

Children's curiosity combined with the availability and variability of gadgets with magnetic components may result in accidental ingestion. The attraction between the magnetic elements of these objects causes ischemic necrosis of the intermediate enteric tissue. Bowel necrosis, perforation, fistula formation, and obstruction have been reported.[12345] Thus, intensive promotion of prevention, even formation of algorithms on magnet removal has been attempted.[34]

History is often obscure or misleading. The nature of swallowed magnets is not always clear either from the parental history or the radiographic presentation. Even the time of the ingested item may be obscure, as shown in our case. The number of magnets is important as a single one is not dangerous, but more particles or the combination with another metallic object may produce complications.[125] A cluster of ingested objects that remain together for a long period should raise the suspicion that the foreign bodies are magnetized.

CONCLUSION

There should be major suspicion of magnet presence if a radiopaque metallic object presents prolonged stay in the intestinal lumen. As pressure necrosis of the intestinal wall is quite probable, a more aggressive approach with less time of anticipation should be under consideration if the magnetic components are multiple or combined with other metallic objects. The alarm clock in the cases of swallowed magnets is ticking faster than in other metallic objects.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.