What's the Diagnosis?
Co-author: Laura Kantor, MD | Pediatric Resident, PGY-1
Co-author: Laura Plencner, MD | Pediatric Hospital Medicine | Associate Professor of Pediatrics, UMKC School of Medicine
Column Editor: Joe Julian, MD, MPHTM, FAAP | Hospitalist, Internal Medicine - Pediatrics | Assistant Professor, Internal Medicine and Pediatrics, UMKC School of Medicine
A 3 1/2-year-old previously healthy female was admitted for ingestion of magnets one day prior to presentation. The patient’s last bowel movement was prior to the ingestion. She is happy and playful without abdominal pain or vomiting. Vital signs are stable and physical exam is unremarkable. An abdominal radiograph is obtained.
Of the following, which is NOT an appropriate next course of action?
A. Consult pediatric surgery
B. Discharge home
C. Endoscopy and/or colonoscopy
D. Serial abdominal radiographs
Answer: B. Discharge home
The radiographs reveal three magnets in the large intestine without signs of perforation on radiograph. In an additional radiograph of the neck (not pictured), two additional magnets appear to be in the vallecula. Since this patient ingested multiple magnets, it is unsafe to send her home immediately due to high risk of colonic perforation. Consulting pediatric surgery, performing endoscopy and/or colonoscopy, or monitoring with serial radiographs are all potential next steps in this child’s management.
Over 75% of annual foreign body ingestions in the United States are in children, usually occurring between 6 months to 5 years old. Commonly ingested items include coins, button batteries, toys or toy parts, magnets, safety pins, screws, marbles, and bones, with coins being the most common. Newer rare earth magnets are a dangerous potential ingestion for pediatric patients due to the attraction of two magnets across mucosal surfaces potentially leading to ulceration, necrosis and perforation. These high-powered magnets are composed of neodymium and are common parts of household appliances.
In determining the appropriate management for an ingested magnet, it is important to differentiate between the ingestion of a single magnet and multiple magnets. Magnets can be seen on X-ray, but it is not always easy to tell how many are present on plain films alone. Multiple radiographic views are necessary because it is possible for magnets to stick together, and in a single view radiograph, multiple magnets may be misdiagnosed as a single magnet. Ultrasound is another option for detection but is operator dependent.
For ingestion of a single magnet that is in the stomach or esophagus, current recommendations include offering endoscopic removal or following with serial outpatient radiographs. If the magnet is distal to the stomach, serial monitoring is the best option. These patients should avoid clothes with metallic buttons and belts with buckles as these may attract the ingested magnets which could increase risk of bowel necrosis or rupture. In cases of delayed passage, clinicians often use PEG 3350 solution or other laxative prep to aid in passage, although there is limited published data suggesting this decreases the time to magnet passage.
Multiple magnets may attract across layers of bowel leading to pressure necrosis, fistula, perforation, infection or obstruction. Endoscopic retrieval may be considered for patients with multiple magnets ingested via upper endoscopy if the magnets are proximal to the stomach or colonoscopy if magnets are distal to the ileum. However, in the asymptomatic patient, watchful waiting can also be considered with hospitalization and serial radiographs. If the magnets continue progressing through the GI tract in an asymptomatic patient, it is appropriate to continue monitoring with serial radiographs as an outpatient. However, the patient must be readmitted if at any time the magnets do not progress, or the patient develops symptoms of abdominal pain, distension, hematochezia or emesis. At this time, they must be immediately referred to surgery for removal due to concern for bowel obstruction, fistula or perforation.
- Bolton SM, Saker M, Bass LM. Button battery and magnet ingestions in the pediatric patient. Curr Opin Pediatr. 2018 Oct; 30(5):653-659.
- Hussain SZ, Bousvaros A, Gilger M, Mamula P, Gupta S, Kramer R, Noel A. Management of ingested magnets in children. Journal for Pediatric Gastroenterology and Nutrition. 2012; 55(3): 239-242.