Erik
K. Paulson,
MD
#{149} Richard
B. Jaffe,
MD
Metallic Foreign Bodies In the Stomach: Fluoroscopic Removal with a Magnetic Orogastric Tube’ Thirty-six patients with 37 cases of metallic foreign bodies in the stomach were referred for fluoroscopic removal with a magnet coupled to an orogastnic tube. Removal was successful in 34 of the cases. No complications occurred. No patient required hospital admission, endoscopic or surgical intervention, or general anesthesia. Fluoroscopic removal of metallic foreign bodies in the stomach with an orogastric magnet is an alternative to endoscopic or surgical removal. Index
terms: Children, gastrointestinal Foreign bodies, in air and food passages, 72.46 #{149} Gastrointestinal tract, interventional procedure, 72.1299 Radiology
tract.
1990; 174:191-194
I
of foreign bodies is a common problem in the pediatric population (1). Once past the esophagus, most foreign bodies readily traverse the gastrointestinal tract, and patients require only observation (2). However, the ingestion of alkali-contaming disk batteries or other large metallic foreign bodies warrants a more aggressive approach, since dinical symptoms may develop in these patients. In the acidic stomach, the seal of the battery casing may leak and result in mucosal inflammation and perforation (3-5). Larger blunt foreign bodies such as metallic toys, nuts and bolts, hairpins, or paper clips may lead to perforation (6,7). Although many reports describe the surgical or endoscopic experience with removal of gastric foreign bodies
NGESTION
(6,8),
little
has
been
written
about
the fluoroscopic removal of gastric foreign bodies (9,10). Consequently, we expand our previously reported experience with the use of the orogastric
tube
roscopic
and
magnet
removal
bodies
for
the
of gastric
fluo-
foreign
AND
January
METHODS
1981 to January
patients were referred department for removal
1989, 36
tothe radiology of metallic for-
eign bodies from the stomach. Six of these patients who ingested a battery were described previously (11). Thirtyseven removal formed, as one
procedures were patient ingested
pera disk
battery on two separate occasions. Twenty-eight patients ingested a single disk battery, two patients ingested a metallic nail, and two patients ingested a metallic screw. Three patients ingested one of the following: an unopened pen knife, a nut From the Department of Radiology, Univerof Utah Medical Center, Salt Lake City (E.K.P.) and the Department of Medical Imaging, Primary Children’s Medical Center, 320 12th Ave. Salt Lake City, UT 84103 (R.B.J.). Received May 1, 1989; revision requested June 29; revision received August 14; accepted August
and bolt, tient age 1 1 months
28.
department after radiographic tation of the metallic foreign
1
Address C
RSNA,
reprint
1990
requests
to
R.B.J.
18)
and
a whistle.
promptly
The
was 4 years,
with
to 13 years.
of patients
The
earth
magnet.
66-cm-long,
with
majority referred
were
Fifty
average
the range percent
stomach. A pediatric surgeon referred two patients with a nail in the stomach who were referred to him for endoscopic removal. One patient with a metallic in the stomach
was
referred 5 the parents
from
the
to
pass
through removal.
the gastrointestinal tract without After 5 days of observation,
however, showed
an abdominal that the whistle
radiograph had separated
two portions, with one metallic piece remaining in the stomach. Removal with the orogastric magnet was then performed. The criteria for selection of patients ininto
cluded (a) the presence of a metallic foreign body in the stomach, (b) no evidence of perforation or peritonitis, and (c) parental sion
approval with
the
following radiologist
a joint and
discus-
the was
refer-
the
gastroin-
pa-
Each parent specifithat the majority of in the stomach would
from
spontaneously
pass
(n
testinal ents
children
Si-
rare-
ring physician. cally informed foreign bodies
boys.
of the
20-F
attached
days after ingestion. Initially elected to allow the whistle
PATIENTS
sity
1. Radiopaque nasogastmic tube
whistle
(11).
From
Figure lastic
were emergency
documenbody in the
were
tract without presented
through
complication. with
the
option
Parof ei-
ther fluoroscopic removal of the ingested foreign body or observation of the patient and following movement of the ingested foreign body without removal. Parents of
191
a.
b.
C.
Removal of a screw with the rare-earth orogastnic magnet. ach adjacent to the foreign body. (b) Orogastric magnet-foreign body retrieved through the esophagus into the mouth, where it is expelled Figure
children who ingested disk batteries were encouraged to elect fluoroscopic removal because of the rare complications that can result from battery ingestion. In those cases in which a child ingested a relative-
ly large
metallic foreign body, pen knife or screw,
such
as an
parents of the unlikely, but seripossibility of bowel perforation. All parents were specifically informed that although the risk of complication was low from either the disk battery or other metallic foreign body ingestion, fluoroscopic removal was safe, effective, and quickly performed. Those children for whom spontaneous passage of the foreign body though the gastrointestinal tract was elected are not included in this unopened
were ous,
informed
report.
On initial phone inquiry, the referring physician was advised to place the patients in the left lateral decubitus position to prevent passage of the foreign body into the duodenum. After informed consent was obtained from parents selecting fluoroscopic removal, the young patients were immobilized on a plastic restraining board with elastic wrap. We used a cylindrical magnet, 5 mm in diameter, that was permanently attached with glue to a 66cm-long 20-F Silastic (Dow Corning, Midland, Mich) nasogastric tube (Mag-100; Cook,
md) (Fig of a small amount
Bloomington,
ministration 192
(a) Under fluoroscopic unit is pulled above or manually retrieved.
2.
#{149} Radiology
1). After
of viscous
ad-
guidance, the the gastroesophageal
magnet
is passed junction.
into
the
stom-
Foreign
(C)
body
is
lidocaine into the oropharynx, the lubricated tube was passed through the mouth and into the stomach. A sterile bite block was used when necessary to prevent the patient from biting the tube. The supine patient was then rotated into the left antenor oblique position so that the foreign
bodies from the esophagus, we have not encountered a single instance of laryngeal aspiration. Two types of magnets were used in this
body
points
would
move
toward
the
the stomach. Under fluoroscopic ance, the magnet was coupled eign body. Changes in patient
were foreign roscopic
used
to facilitate
body
to the
guidance,
cardia
guidto the forposition
attachment
magnet. the
of
of the
Under
orogastric
fluomagnet
with the attached foreign body was withdrawn above the gastroesophageal junction, through the esophagus, and into the mouth, where the foreign body was expelled or manually retrieved (Fig 2). If the foreign body disengaged from the magnet while in the esophagus, removal was achieved by passing a Foley catheter beyond the foreign body. Under fluoroscopic guidance, the Foley balloon was inflated and the magnet, coupled to the foreign body and Foley catheter, was then withdrawn as previously described (1 1-13)
were
(Fig
3). No
special
study.
With
to 1986, body
the
the
from
magnet
the
newer,
magnet
narrowing.
stronger
magnets,
disengagement
the the
cobalt
was
foreign use
prior
With
rare-earth
allowing without
used
of the foreign was common at
of physiologic
body
uncommon,
to be removed
of a Foley
catheter
(Figs
4, 5). Prior surgeon
to planned referred
ingested the nail
magnet in
wire
endoscopy, two patients
a metallic
who
had cases,
to immobilize
the
gastric cardia. An 18-gauge was then passed through a rubber nasogastric tube and
snare
small, red, was looped
around magnet,
The snare, carefully
used
a pediatric
In these
nail.
was
the
pulled
troesophageal esophagus
the immobilized and nail were as a unit
junction into
the
across
and mouth
nail. then the
through (Fig
gas-
the
6).
RESULTS
precautions
employed to prevent laryngeal aspiration of the foreign body in the event of detachment from the magnet other than prone oblique positioning of the patient. In our experience with the removal of over 400 nonopaque and opaque foreign
alnico
disengagement
Removal procedures, rate (Table). suit
was successful in 34 of 37 yielding a 92% success Two failures were the reof inadvertent passage of disk
batteries
into
the
duodenum
during January
1990
Figure 3. Foley catheter passed beyond disk battery in the esophagus. Foley balloon (F) is inflated with diluted barium. The magnet (M), disk battery (B), and Foley catheter then are withdrawn as a unit. (Reprinted, with permission, from reference 11.)
Figure 6. Removal of a metallic nail. The magnet was used to immobilize the nail in the gastric cardia. A snare was passed through a red rubber catheter and then looped around the nail. The snare, magnet, and nail esophagus
tract
were then into the
without
pulled mouth.
through
consequence,
the
serious
complications may occur with disk batteries and other metallic foreign bodies. Once a disk battery is in the stomach, bowel injury may result from leakage of corrosive contents, direct pressure necrosis, or low voltage burns (4,5,14). One report de5. Removal of an unopened pen knife from the stomach with a rare-earth orogastric magnet. The knife was removed Figure
in less only.
than
30 seconds
with
the
magnet
the attempted removal. One metallic disk battery could not be removed because it lacked magnetic attraction. In the three cases in which removal was unsuccessful, the foreign bodies were allowed to spontaneously pass through the gastrointestinal tract. No complications occurred in
this
group;
scopic
Volume
no patient
or surgical
174
required
intervention.
#{149} Number
1
Time needed to perform fluoroscopy ranged from 15 seconds to 5 mmutes. The total procedure was completed in less than 5 minutes in the majority of the cases. All removal procedures were performed on outpatients. No patient required general anesthesia or surgical or endoscopic intervention. All patients tolerated the procedure well, and there were no complications.
DISCUSSION
endoies
While
most
pass
through
ingested the
foreign gastrointestinal
bod-
scribes
a patient
forated
Meckel
who
survived
a per-
diverticulum
by a disk battery (15). perience with battery
Early
caused
in our ex-
removal, we noted that many batteries were heavily corroded after only several hours in the stomach and that a few were surrounded by a moderate-size coagulum of blood and mucus. These
findings,
plus
the
complications
re-
ported
in the literature, prompted an aggressive policy regarding battery removal from the stomach, despite the fact that most batteries pass uneventfully. Larger blunt metallic foreign bodies such as toys, nuts and bolts, hairpins, or paper clips may infrequently
Radiology
#{149} 193
lead
to bowel
recent cases
perforations
retrospective
(6,7).
review
In a
of 101
of ingested
foreign bodies, five gastric or small bowel perforations were reported among the 57 cases in which the foreign body reached the stomach (6). Three of the five perforations were due to paper clips or nuts and bolts, items amenable to magnetic fluoroscopic removal. Unfortunately it is not possible to predict which patients will develop complications following foreign body ingestion. This uncertainty may lead to parental and physician anxiety, frequent clinic visits, and the acquisition of multiple radiographs. Despite the possible risks, it is currently recommended that endoscopic or surgical removal be avoided in uncomplicated cases (6,16,17). We agree with this recommendation because
(a) most
foreign
bodies
will
pass
un-
eventfully, (b) endoscopic removal frequently requires general anesthesia, and (c) surgical removal is expensive and is associated with patient morbidity. In our experience, removal of magnetic foreign bodies from the stomach with the orogastric magnet is safe, quick, and considerably less expensive than endoscopy or surgery. Similar results have been found by other investigators (9,10). The method requires neither hospital admission nor general anesthesia and is effective in the majority of cases. Although the procedure is undoubtedly uncomfortable, it obviates multiple radiographs and alleviates parental and physician anxiety. In our experience, the radiation exposure to the patient can be kept to a minimum with the use of intermit-
194
.
Radiology
tent fluoroscopic technique and close collimation. Other investigators have reported that fluoroscopy took as long as 20 minutes to complete (9). In contrast, in our series the time required for fluoroscopy was no longer than 5 minutes and was occasionally as short as 15 seconds. One of our three failures was unavoidable because the disk battery lacked magnetic attraction and, therefore, could not be coupled to the magnet. However, two of the three failures were the result of madvertent passage of the foreign body into the duodenum prior to attachment of the magnet. This can be avoided if careful attention is paid to patient positioning. When a referring call is received by the radiology department regarding a patient who has ingested a metallic foreign body, the caller should be advised to place the patient in the left lateral decubitus position to prevent the foreign body from passing into the duodenum. During fluoroscopy, placing the patient in the supine and the right anterior oblique positions will keep the foreign body in the dependent gastric fundus, but rotation of the patient may be necessary to coupie the foreign body to the magnet. We think cases of uncomplicated
ingestion
of blunt
magnetic
foreign
bodies, including disk batteries, should be managed by means of removal with an orogastric magnet. If symptoms indicative of perforation are present, cases should be managed with endoscopy or surgery. #{149}
2.
Schwartz eign
Am 3.
CF.
bodies
Surg
1976;
Shabino
CL,
5.
Votteler hazards
Ingested
fortract.
42:236-238. AN.
secondary
ingestion.
Temple battery
HS. gastrointestinal
Feinberg
perforation 4.
Polsley of the
JACEP
Esophageal
to alkaline 1979;
battery
8:360-362.
DM, McNeese MC. ingestion. Pediatrics
Hazards of 1983; 71:100-
103. TP, Nash of ingested
in children.
6.
7.
8.
10.
1 1.
12.
JAMA
1983;
JC, disc
The batteries
249:2504-2506.
Selivanov V. Sheldon CF. Cello JP, Crass RA. Management of foreign body ingestion. Ann Surg 1984; 199:187-191. Maleki M, Evans WE. Foreign body perforation of the intestinal tract. Arch Surg 1970; Webb ies
9.
JC, Rutledge alkaline
101:475-477. WA. Management of the
upper
of foreign
gastrointestinal
bod-
tract.
Gas-
troenterology 1988; 94:204-216. Ito Y, Ihara N, Sohma S. Magnet removal of alkaline batteries from the stomach. Pediatr Surg 1985; 20:250-251. Volle E, Hanel D, Beyer P. Kaufman HJ. Ingested foreign bodies: removal by magnet. Radiology 1986; 160:407-409. Jaffe RB, Corneli HM. Fluoroscopic removal of ingested alkaline batteries. Radiology
1984;
Nixon
GW.
150:585-586.
esophageal sion
Foley
catheter
foreign
body
of applications.
method
of
removal:
AJR
1979;
exten132:441-
442. 13.
Campbell
Foley
JB, Quattromani
catheter
al foreign consecutive
14.
15.
16.
17.
removal
FL,
Foley
of blunt
bodies: experience children. Pediatr
LC.
esophagewith 100 Radiol 1983;
13:116-119. Litovitz TL. Button battery ingestions: review of 56 cases. JAMA 1983; 249:24952500. Willis
GA,
Ho
WC.
Perforation
a
of Meck-
el’s diverticulum by an alkaline hearing aid battery. Can Med Assoc J 1982; 126:497-498. Litovitz TL. Battery ingestions: product accessibility and clinical course. Pediatrics 1985; 75:469-476. Rumack
ingestion
BH,
Rumack
(editorial).
CM.
JAMA
Disk
battery
1983;
249:2509-2511.
References 1.
1987 annual report of the ciation of Poison Control al Data Collection System. Med 1988; 6:479-515.
American AssoCenters NationAm J Emerg
January
1990
K. Paulson,
MD
#{149} Richard
B. Jaffe,
MD
Metallic Foreign Bodies In the Stomach: Fluoroscopic Removal with a Magnetic Orogastric Tube’ Thirty-six patients with 37 cases of metallic foreign bodies in the stomach were referred for fluoroscopic removal with a magnet coupled to an orogastnic tube. Removal was successful in 34 of the cases. No complications occurred. No patient required hospital admission, endoscopic or surgical intervention, or general anesthesia. Fluoroscopic removal of metallic foreign bodies in the stomach with an orogastric magnet is an alternative to endoscopic or surgical removal. Index
terms: Children, gastrointestinal Foreign bodies, in air and food passages, 72.46 #{149} Gastrointestinal tract, interventional procedure, 72.1299 Radiology
tract.
1990; 174:191-194
I
of foreign bodies is a common problem in the pediatric population (1). Once past the esophagus, most foreign bodies readily traverse the gastrointestinal tract, and patients require only observation (2). However, the ingestion of alkali-contaming disk batteries or other large metallic foreign bodies warrants a more aggressive approach, since dinical symptoms may develop in these patients. In the acidic stomach, the seal of the battery casing may leak and result in mucosal inflammation and perforation (3-5). Larger blunt foreign bodies such as metallic toys, nuts and bolts, hairpins, or paper clips may lead to perforation (6,7). Although many reports describe the surgical or endoscopic experience with removal of gastric foreign bodies
NGESTION
(6,8),
little
has
been
written
about
the fluoroscopic removal of gastric foreign bodies (9,10). Consequently, we expand our previously reported experience with the use of the orogastric
tube
roscopic
and
magnet
removal
bodies
for
the
of gastric
fluo-
foreign
AND
January
METHODS
1981 to January
patients were referred department for removal
1989, 36
tothe radiology of metallic for-
eign bodies from the stomach. Six of these patients who ingested a battery were described previously (11). Thirtyseven removal formed, as one
procedures were patient ingested
pera disk
battery on two separate occasions. Twenty-eight patients ingested a single disk battery, two patients ingested a metallic nail, and two patients ingested a metallic screw. Three patients ingested one of the following: an unopened pen knife, a nut From the Department of Radiology, Univerof Utah Medical Center, Salt Lake City (E.K.P.) and the Department of Medical Imaging, Primary Children’s Medical Center, 320 12th Ave. Salt Lake City, UT 84103 (R.B.J.). Received May 1, 1989; revision requested June 29; revision received August 14; accepted August
and bolt, tient age 1 1 months
28.
department after radiographic tation of the metallic foreign
1
Address C
RSNA,
reprint
1990
requests
to
R.B.J.
18)
and
a whistle.
promptly
The
was 4 years,
with
to 13 years.
of patients
The
earth
magnet.
66-cm-long,
with
majority referred
were
Fifty
average
the range percent
stomach. A pediatric surgeon referred two patients with a nail in the stomach who were referred to him for endoscopic removal. One patient with a metallic in the stomach
was
referred 5 the parents
from
the
to
pass
through removal.
the gastrointestinal tract without After 5 days of observation,
however, showed
an abdominal that the whistle
radiograph had separated
two portions, with one metallic piece remaining in the stomach. Removal with the orogastric magnet was then performed. The criteria for selection of patients ininto
cluded (a) the presence of a metallic foreign body in the stomach, (b) no evidence of perforation or peritonitis, and (c) parental sion
approval with
the
following radiologist
a joint and
discus-
the was
refer-
the
gastroin-
pa-
Each parent specifithat the majority of in the stomach would
from
spontaneously
pass
(n
testinal ents
children
Si-
rare-
ring physician. cally informed foreign bodies
boys.
of the
20-F
attached
days after ingestion. Initially elected to allow the whistle
PATIENTS
sity
1. Radiopaque nasogastmic tube
whistle
(11).
From
Figure lastic
were emergency
documenbody in the
were
tract without presented
through
complication. with
the
option
Parof ei-
ther fluoroscopic removal of the ingested foreign body or observation of the patient and following movement of the ingested foreign body without removal. Parents of
191
a.
b.
C.
Removal of a screw with the rare-earth orogastnic magnet. ach adjacent to the foreign body. (b) Orogastric magnet-foreign body retrieved through the esophagus into the mouth, where it is expelled Figure
children who ingested disk batteries were encouraged to elect fluoroscopic removal because of the rare complications that can result from battery ingestion. In those cases in which a child ingested a relative-
ly large
metallic foreign body, pen knife or screw,
such
as an
parents of the unlikely, but seripossibility of bowel perforation. All parents were specifically informed that although the risk of complication was low from either the disk battery or other metallic foreign body ingestion, fluoroscopic removal was safe, effective, and quickly performed. Those children for whom spontaneous passage of the foreign body though the gastrointestinal tract was elected are not included in this unopened
were ous,
informed
report.
On initial phone inquiry, the referring physician was advised to place the patients in the left lateral decubitus position to prevent passage of the foreign body into the duodenum. After informed consent was obtained from parents selecting fluoroscopic removal, the young patients were immobilized on a plastic restraining board with elastic wrap. We used a cylindrical magnet, 5 mm in diameter, that was permanently attached with glue to a 66cm-long 20-F Silastic (Dow Corning, Midland, Mich) nasogastric tube (Mag-100; Cook,
md) (Fig of a small amount
Bloomington,
ministration 192
(a) Under fluoroscopic unit is pulled above or manually retrieved.
2.
#{149} Radiology
1). After
of viscous
ad-
guidance, the the gastroesophageal
magnet
is passed junction.
into
the
stom-
Foreign
(C)
body
is
lidocaine into the oropharynx, the lubricated tube was passed through the mouth and into the stomach. A sterile bite block was used when necessary to prevent the patient from biting the tube. The supine patient was then rotated into the left antenor oblique position so that the foreign
bodies from the esophagus, we have not encountered a single instance of laryngeal aspiration. Two types of magnets were used in this
body
points
would
move
toward
the
the stomach. Under fluoroscopic ance, the magnet was coupled eign body. Changes in patient
were foreign roscopic
used
to facilitate
body
to the
guidance,
cardia
guidto the forposition
attachment
magnet. the
of
of the
Under
orogastric
fluomagnet
with the attached foreign body was withdrawn above the gastroesophageal junction, through the esophagus, and into the mouth, where the foreign body was expelled or manually retrieved (Fig 2). If the foreign body disengaged from the magnet while in the esophagus, removal was achieved by passing a Foley catheter beyond the foreign body. Under fluoroscopic guidance, the Foley balloon was inflated and the magnet, coupled to the foreign body and Foley catheter, was then withdrawn as previously described (1 1-13)
were
(Fig
3). No
special
study.
With
to 1986, body
the
the
from
magnet
the
newer,
magnet
narrowing.
stronger
magnets,
disengagement
the the
cobalt
was
foreign use
prior
With
rare-earth
allowing without
used
of the foreign was common at
of physiologic
body
uncommon,
to be removed
of a Foley
catheter
(Figs
4, 5). Prior surgeon
to planned referred
ingested the nail
magnet in
wire
endoscopy, two patients
a metallic
who
had cases,
to immobilize
the
gastric cardia. An 18-gauge was then passed through a rubber nasogastric tube and
snare
small, red, was looped
around magnet,
The snare, carefully
used
a pediatric
In these
nail.
was
the
pulled
troesophageal esophagus
the immobilized and nail were as a unit
junction into
the
across
and mouth
nail. then the
through (Fig
gas-
the
6).
RESULTS
precautions
employed to prevent laryngeal aspiration of the foreign body in the event of detachment from the magnet other than prone oblique positioning of the patient. In our experience with the removal of over 400 nonopaque and opaque foreign
alnico
disengagement
Removal procedures, rate (Table). suit
was successful in 34 of 37 yielding a 92% success Two failures were the reof inadvertent passage of disk
batteries
into
the
duodenum
during January
1990
Figure 3. Foley catheter passed beyond disk battery in the esophagus. Foley balloon (F) is inflated with diluted barium. The magnet (M), disk battery (B), and Foley catheter then are withdrawn as a unit. (Reprinted, with permission, from reference 11.)
Figure 6. Removal of a metallic nail. The magnet was used to immobilize the nail in the gastric cardia. A snare was passed through a red rubber catheter and then looped around the nail. The snare, magnet, and nail esophagus
tract
were then into the
without
pulled mouth.
through
consequence,
the
serious
complications may occur with disk batteries and other metallic foreign bodies. Once a disk battery is in the stomach, bowel injury may result from leakage of corrosive contents, direct pressure necrosis, or low voltage burns (4,5,14). One report de5. Removal of an unopened pen knife from the stomach with a rare-earth orogastric magnet. The knife was removed Figure
in less only.
than
30 seconds
with
the
magnet
the attempted removal. One metallic disk battery could not be removed because it lacked magnetic attraction. In the three cases in which removal was unsuccessful, the foreign bodies were allowed to spontaneously pass through the gastrointestinal tract. No complications occurred in
this
group;
scopic
Volume
no patient
or surgical
174
required
intervention.
#{149} Number
1
Time needed to perform fluoroscopy ranged from 15 seconds to 5 mmutes. The total procedure was completed in less than 5 minutes in the majority of the cases. All removal procedures were performed on outpatients. No patient required general anesthesia or surgical or endoscopic intervention. All patients tolerated the procedure well, and there were no complications.
DISCUSSION
endoies
While
most
pass
through
ingested the
foreign gastrointestinal
bod-
scribes
a patient
forated
Meckel
who
survived
a per-
diverticulum
by a disk battery (15). perience with battery
Early
caused
in our ex-
removal, we noted that many batteries were heavily corroded after only several hours in the stomach and that a few were surrounded by a moderate-size coagulum of blood and mucus. These
findings,
plus
the
complications
re-
ported
in the literature, prompted an aggressive policy regarding battery removal from the stomach, despite the fact that most batteries pass uneventfully. Larger blunt metallic foreign bodies such as toys, nuts and bolts, hairpins, or paper clips may infrequently
Radiology
#{149} 193
lead
to bowel
recent cases
perforations
retrospective
(6,7).
review
In a
of 101
of ingested
foreign bodies, five gastric or small bowel perforations were reported among the 57 cases in which the foreign body reached the stomach (6). Three of the five perforations were due to paper clips or nuts and bolts, items amenable to magnetic fluoroscopic removal. Unfortunately it is not possible to predict which patients will develop complications following foreign body ingestion. This uncertainty may lead to parental and physician anxiety, frequent clinic visits, and the acquisition of multiple radiographs. Despite the possible risks, it is currently recommended that endoscopic or surgical removal be avoided in uncomplicated cases (6,16,17). We agree with this recommendation because
(a) most
foreign
bodies
will
pass
un-
eventfully, (b) endoscopic removal frequently requires general anesthesia, and (c) surgical removal is expensive and is associated with patient morbidity. In our experience, removal of magnetic foreign bodies from the stomach with the orogastric magnet is safe, quick, and considerably less expensive than endoscopy or surgery. Similar results have been found by other investigators (9,10). The method requires neither hospital admission nor general anesthesia and is effective in the majority of cases. Although the procedure is undoubtedly uncomfortable, it obviates multiple radiographs and alleviates parental and physician anxiety. In our experience, the radiation exposure to the patient can be kept to a minimum with the use of intermit-
194
.
Radiology
tent fluoroscopic technique and close collimation. Other investigators have reported that fluoroscopy took as long as 20 minutes to complete (9). In contrast, in our series the time required for fluoroscopy was no longer than 5 minutes and was occasionally as short as 15 seconds. One of our three failures was unavoidable because the disk battery lacked magnetic attraction and, therefore, could not be coupled to the magnet. However, two of the three failures were the result of madvertent passage of the foreign body into the duodenum prior to attachment of the magnet. This can be avoided if careful attention is paid to patient positioning. When a referring call is received by the radiology department regarding a patient who has ingested a metallic foreign body, the caller should be advised to place the patient in the left lateral decubitus position to prevent the foreign body from passing into the duodenum. During fluoroscopy, placing the patient in the supine and the right anterior oblique positions will keep the foreign body in the dependent gastric fundus, but rotation of the patient may be necessary to coupie the foreign body to the magnet. We think cases of uncomplicated
ingestion
of blunt
magnetic
foreign
bodies, including disk batteries, should be managed by means of removal with an orogastric magnet. If symptoms indicative of perforation are present, cases should be managed with endoscopy or surgery. #{149}
2.
Schwartz eign
Am 3.
CF.
bodies
Surg
1976;
Shabino
CL,
5.
Votteler hazards
Ingested
fortract.
42:236-238. AN.
secondary
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