593910
research-article2015
CPJXXX10.1177/0009922815593910Clinical PediatricsDeFilippis et al
Resident Rounds
Bilious Emesis and Small Bowel Obstruction in a Young Male
Clinical Pediatrics 1–3 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922815593910 cpj.sagepub.com
Ersilia M. DeFilippis, MD1, Elaine Barfield, MD1, Robbyn Sockolow, MD1, Edmund Kessler, MD1
Case Report
Final Diagnosis
An 18-month-old male presented to an outside hospital following multiple episodes of bilious emesis. Three days prior, the patient reportedly ingested 2 Buckyball magnets. At the outside hospital, an abdominal radiograph showed 2 magnets in the mid-to-lower abdomen with evidence of a small bowel obstruction. The patient was transferred to our institution for management. On arrival in our emergency department, the patient’s vitals were temperature 37.1°C, heart rate 135 beats/ min, blood pressure 103/68 mm Hg. Physical examination was unremarkable. Laboratory analysis was significant for white blood cell count of 8.1 × 103/µL, blood urea nitrogen 30 mg/dL, hemoglobin 11.7 g/dL, and anion gap of 20. Repeat abdominal radiograph showed 2 round radiopaque objects in the mid-lower abdomen as well as a small bowel obstruction with a transition point at the site of the radiopaque foreign bodies but no evidence of free air (Figure 1). The patient was taken emergently to the operating room for exploratory laparotomy and removal of foreign bodies. A perforated terminal ileum was found where the magnets were located as well as a near-perforated jejunum and intra-abdominal abscess (Figure 2). Abdominal fluid cultures grew Gram-negative rods and he was subsequently treated with piperacillin/tazobactam.
Small bowel obstruction and bowel perforation secondary to multiple magnet ingestion.
Hospital Course Intraoperatively, the patient became hypotensive with systolic blood pressure in the 50 mm Hg range but was responsive to fluid resuscitation. Postoperatively, the patient remained intubated and was transferred to the pediatric intensive care unit. His course was complicated by a deep venous thrombosis treated with enoxaparin. The thrombosis was thought to be due to sepsis and abscess formation secondary to the attraction of the 2 magnets through the bowel wall, leading to perforation. He was subsequently discharged on amoxicillin/ clavulanic acid and metronidazole.
Discussion Foreign body ingestions are very common in the pediatric population. In 2011, more than 93 500 ingestions were reported in the United States in the pediatric age group.1 The most common objects ingested are coins; however, toys, batteries, magnets, pins, and screws have also been reported.2 In most cases, these objects can be retrieved via upper endoscopy by pediatric gastrointestinal teams. Here we present an unusual case requiring surgical removal at our institution. With the rise of neodymium magnets in toys and other small objects, increased morbidity and mortality from magnet ingestions is increasingly reported.3-5 As many as 28% of patients require surgical intervention following ingestion.2 These magnets, often referred to as Buckyballs, have 5 times the attractive force of conventional magnets. Consequently, they have a greater tendency to cause injury via enteroenteric fistula formation between magnets in adjacent loops of bowel, leading to perforation, abscess formation, and obstruction as in this case.4 These products were recalled by the Consumer Product Safety Commission in 2012; however, this recall has been contested by some manufacturers.2 Therefore, urgent removal of multiple magnet ingestions is indicated even in an asymptomatic patient.2 Endoscopic removal of single magnets is not necessary unless radiologic images cannot exclude multiple magnet ingestion. In certain instances, 1
New York Presbyterian Hospital–Weill Cornell Medical Center, New York, NY, USA Corresponding Author: Elaine Barfield, Department of Pediatrics, New York Presbyterian Hospital–Weill Cornell Medical Center, 525 East 70th Street, Floor 3, New York, NY 10021, USA. Email: [email protected]
Downloaded from cpj.sagepub.com at U.A.E University on November 14, 2015
2
Clinical Pediatrics The ingestion of multiple magnets that are separated should be considered a surgical emergency. In patients who present with a history of multiple magnet ingestions, radiographs including anterior-posterior and lateral views should be obtained immediately. Multiple magnets in the small or large bowel require prompt surgical removal because of the risk of complications.6,7 Most management algorithms for foreign body ingestions in children in the upper gastrointestinal tract involve endoscopic removal. However, endoscopy is not always successful8 and as our case demonstrates, some ingestions may present initially with perforations or small bowel obstruction. Yalçin et al9 reviewed 112 cases of foreign body ingestions. Endoscopic removal was attempted in 84 patients and successful in 57 patients. In the 27 remaining patients, the foreign body was not found by endoscopy. Ultimately, 20 patients required surgery.
Conclusion
Figure 1. Two magnets seen on abdominal plain films in the mid-abdomen.
Our case report describes a child requiring surgical intervention secondary to a complicated foreign body ingestion. The need for surgical or nonsurgical management should be dictated by the patient’s condition, the location of the foreign body, the size of the patient, the size of the foreign body as well as available equipment.9 In the case of dangerous ingestions such as Buckyballs, consideration of all of the above is crucial for setting up the safest protocol for removal. Pediatric gastroenterologists and pediatric surgeons should have a multidisciplinary approach to managing patients with the potential for complicated removal. Author Contributions EMD drafted the initial manuscript. EB, RS and EK reviewed and revised the manuscript and approved the final manuscript as submitted.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding Figure 2. Magnet visualized in the small intestine intraoperatively at the site of perforation of the terminal ileum.
multiple magnets may adhere tightly together and appear as a single object on a single view radiograph, so multiple views should be obtained. This conglomerate mass of magnets may pass as a single entity.2
The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Wright CC, Closson FT. Updates in pediatric gastrointestinal foreign bodies. Pediatr Clin North Am. 2013;60:1221-1239. 2. Kramer RE, Lerner DG, Lin T, et al. Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee. J Pediatr Gastroenterol Nutr. 2015;60:562-574.
Downloaded from cpj.sagepub.com at U.A.E University on November 14, 2015
3
DeFilippis et al 3. Brown JC, Otjen JP, Drugas GT. Too attractive: the growing problem of magnet ingestions in children. Pediatr Emerg Care. 2013;29:1170-1174. 4. Hussain SZ, Bousvaros A, Gilger M, et al. Management of ingested magnets in children. J Pediatr Gastroenterol Nutr. 2012;55:239-242. 5. Strickland M, Rosenfield D, Fecteau A. Magnetic foreign body injuries: a large pediatric hospital experience. J Pediatr. 2014;165:332-335. 6. Romine M, Ham PB 3rd, Yon JR, Pipkin WL, Howell CG, Hatley RM. Multiple magnet ingestion in children. Am Surg. 2014;80:e189-e191.
7. Soomro S, Mughal SA. Singing magnets ingestion: a rare cause of intestinal obstruction in children. J Coll Physicians Surg Pak. 2014;24:688-689. 8. Schramm JC, Sewell RK, Azarow KS, Raynor SC, Abdessalam SF. Chronic cervical esophageal foreign bodies in children: surgical approach after unsuccessful endoscopic management. Ann Otol Rhinol Laryngol. 2014;123:19-24. 9. Yalçin S, Karnak I, Ciftci AO, Senocak ME, Tanyel FC, Büyükpamukçu N. Foreign body ingestion in children: an analysis of pediatric surgical practice. Pediatr Surg Int. 2007;23:755-761.
Downloaded from cpj.sagepub.com at U.A.E University on November 14, 2015
research-article2015
CPJXXX10.1177/0009922815593910Clinical PediatricsDeFilippis et al
Resident Rounds
Bilious Emesis and Small Bowel Obstruction in a Young Male
Clinical Pediatrics 1–3 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922815593910 cpj.sagepub.com
Ersilia M. DeFilippis, MD1, Elaine Barfield, MD1, Robbyn Sockolow, MD1, Edmund Kessler, MD1
Case Report
Final Diagnosis
An 18-month-old male presented to an outside hospital following multiple episodes of bilious emesis. Three days prior, the patient reportedly ingested 2 Buckyball magnets. At the outside hospital, an abdominal radiograph showed 2 magnets in the mid-to-lower abdomen with evidence of a small bowel obstruction. The patient was transferred to our institution for management. On arrival in our emergency department, the patient’s vitals were temperature 37.1°C, heart rate 135 beats/ min, blood pressure 103/68 mm Hg. Physical examination was unremarkable. Laboratory analysis was significant for white blood cell count of 8.1 × 103/µL, blood urea nitrogen 30 mg/dL, hemoglobin 11.7 g/dL, and anion gap of 20. Repeat abdominal radiograph showed 2 round radiopaque objects in the mid-lower abdomen as well as a small bowel obstruction with a transition point at the site of the radiopaque foreign bodies but no evidence of free air (Figure 1). The patient was taken emergently to the operating room for exploratory laparotomy and removal of foreign bodies. A perforated terminal ileum was found where the magnets were located as well as a near-perforated jejunum and intra-abdominal abscess (Figure 2). Abdominal fluid cultures grew Gram-negative rods and he was subsequently treated with piperacillin/tazobactam.
Small bowel obstruction and bowel perforation secondary to multiple magnet ingestion.
Hospital Course Intraoperatively, the patient became hypotensive with systolic blood pressure in the 50 mm Hg range but was responsive to fluid resuscitation. Postoperatively, the patient remained intubated and was transferred to the pediatric intensive care unit. His course was complicated by a deep venous thrombosis treated with enoxaparin. The thrombosis was thought to be due to sepsis and abscess formation secondary to the attraction of the 2 magnets through the bowel wall, leading to perforation. He was subsequently discharged on amoxicillin/ clavulanic acid and metronidazole.
Discussion Foreign body ingestions are very common in the pediatric population. In 2011, more than 93 500 ingestions were reported in the United States in the pediatric age group.1 The most common objects ingested are coins; however, toys, batteries, magnets, pins, and screws have also been reported.2 In most cases, these objects can be retrieved via upper endoscopy by pediatric gastrointestinal teams. Here we present an unusual case requiring surgical removal at our institution. With the rise of neodymium magnets in toys and other small objects, increased morbidity and mortality from magnet ingestions is increasingly reported.3-5 As many as 28% of patients require surgical intervention following ingestion.2 These magnets, often referred to as Buckyballs, have 5 times the attractive force of conventional magnets. Consequently, they have a greater tendency to cause injury via enteroenteric fistula formation between magnets in adjacent loops of bowel, leading to perforation, abscess formation, and obstruction as in this case.4 These products were recalled by the Consumer Product Safety Commission in 2012; however, this recall has been contested by some manufacturers.2 Therefore, urgent removal of multiple magnet ingestions is indicated even in an asymptomatic patient.2 Endoscopic removal of single magnets is not necessary unless radiologic images cannot exclude multiple magnet ingestion. In certain instances, 1
New York Presbyterian Hospital–Weill Cornell Medical Center, New York, NY, USA Corresponding Author: Elaine Barfield, Department of Pediatrics, New York Presbyterian Hospital–Weill Cornell Medical Center, 525 East 70th Street, Floor 3, New York, NY 10021, USA. Email: [email protected]
Downloaded from cpj.sagepub.com at U.A.E University on November 14, 2015
2
Clinical Pediatrics The ingestion of multiple magnets that are separated should be considered a surgical emergency. In patients who present with a history of multiple magnet ingestions, radiographs including anterior-posterior and lateral views should be obtained immediately. Multiple magnets in the small or large bowel require prompt surgical removal because of the risk of complications.6,7 Most management algorithms for foreign body ingestions in children in the upper gastrointestinal tract involve endoscopic removal. However, endoscopy is not always successful8 and as our case demonstrates, some ingestions may present initially with perforations or small bowel obstruction. Yalçin et al9 reviewed 112 cases of foreign body ingestions. Endoscopic removal was attempted in 84 patients and successful in 57 patients. In the 27 remaining patients, the foreign body was not found by endoscopy. Ultimately, 20 patients required surgery.
Conclusion
Figure 1. Two magnets seen on abdominal plain films in the mid-abdomen.
Our case report describes a child requiring surgical intervention secondary to a complicated foreign body ingestion. The need for surgical or nonsurgical management should be dictated by the patient’s condition, the location of the foreign body, the size of the patient, the size of the foreign body as well as available equipment.9 In the case of dangerous ingestions such as Buckyballs, consideration of all of the above is crucial for setting up the safest protocol for removal. Pediatric gastroenterologists and pediatric surgeons should have a multidisciplinary approach to managing patients with the potential for complicated removal. Author Contributions EMD drafted the initial manuscript. EB, RS and EK reviewed and revised the manuscript and approved the final manuscript as submitted.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding Figure 2. Magnet visualized in the small intestine intraoperatively at the site of perforation of the terminal ileum.
multiple magnets may adhere tightly together and appear as a single object on a single view radiograph, so multiple views should be obtained. This conglomerate mass of magnets may pass as a single entity.2
The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Wright CC, Closson FT. Updates in pediatric gastrointestinal foreign bodies. Pediatr Clin North Am. 2013;60:1221-1239. 2. Kramer RE, Lerner DG, Lin T, et al. Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee. J Pediatr Gastroenterol Nutr. 2015;60:562-574.
Downloaded from cpj.sagepub.com at U.A.E University on November 14, 2015
3
DeFilippis et al 3. Brown JC, Otjen JP, Drugas GT. Too attractive: the growing problem of magnet ingestions in children. Pediatr Emerg Care. 2013;29:1170-1174. 4. Hussain SZ, Bousvaros A, Gilger M, et al. Management of ingested magnets in children. J Pediatr Gastroenterol Nutr. 2012;55:239-242. 5. Strickland M, Rosenfield D, Fecteau A. Magnetic foreign body injuries: a large pediatric hospital experience. J Pediatr. 2014;165:332-335. 6. Romine M, Ham PB 3rd, Yon JR, Pipkin WL, Howell CG, Hatley RM. Multiple magnet ingestion in children. Am Surg. 2014;80:e189-e191.
7. Soomro S, Mughal SA. Singing magnets ingestion: a rare cause of intestinal obstruction in children. J Coll Physicians Surg Pak. 2014;24:688-689. 8. Schramm JC, Sewell RK, Azarow KS, Raynor SC, Abdessalam SF. Chronic cervical esophageal foreign bodies in children: surgical approach after unsuccessful endoscopic management. Ann Otol Rhinol Laryngol. 2014;123:19-24. 9. Yalçin S, Karnak I, Ciftci AO, Senocak ME, Tanyel FC, Büyükpamukçu N. Foreign body ingestion in children: an analysis of pediatric surgical practice. Pediatr Surg Int. 2007;23:755-761.
Downloaded from cpj.sagepub.com at U.A.E University on November 14, 2015
