Foreign Body Aspiration

Foreign Body Ingestion

KEREN ZHOU
Case Western Reserve University School of Medicine

SANGEETA KRISHNA, MD
Cleveland Clinic Children's

 

A 10-year-old boy presented to the emergency department (ED) with a 6-day history of nausea, nonbilious and nonbloody vomiting, and periumbilical pain. The symptoms had not improved with the administration of omeprazole. On presentation in the ED, physical examination findings were significant only for mild abdominal distension, left upper quadrant tenderness, and hyperactive bowel sounds. The patient appeared comfortable and was hemodynamically stable. Abdominal radiography (A) and ultrasonography results showed a small bowel obstruction with a beaded, metallic object localized to the upper abdomen. Neither the patient nor his parents were able to recall what the boy had ingested.

The patient underwent exploratory laparotomy because of concern for intestinal obstruction. Laparotomy revealed a closed-loop obstruction and fistulization of the middle ileum and proximal jejunum, with resultant volvulus and bowel herniation. Enterectomy with primary anastomosis of the proximal jejunum and enterotomy with primary closure of the proximal mid-ileum subsequently was performed.

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Figure A - Plain radiograph of a 10-year-old boy showing an ingested beaded metallic foreign body in the upper midline abdomen.

Figure B - Plain radiograph showing the complete removal of the foreign body. (The sponge is known not to be in the abdomen.)

Pathology examination results of the bowel specimen confirmed a bowel fistula and a retained metallic object composed of multiple round magnetic beads, rings, and screws extending into the tract. The object was determined to be the boy’s grandmother’s magnetic arthritis bracelet. Postoperative radiographs (B) showed no retention of any objects. Recovery was uncomplicated, and he was discharged home 7 days postoperatively.

Foreign body ingestion is common in children, with coins being the most frequently ingested objects. In the vast majority (80% to 90%) of cases of ingestion, the object passes spontaneously. If an object is retained, most (10% to 20%) can be removed endoscopically, but a minority (1%) will require surgical intervention.1 The typical age of patients with foreign body ingestion is less than 3 years; older patients generally have comorbid developmental conditions such as attention-deficit/hyperactivity disorder.1,2 Our patient’s age, lack of behavioral conditions, and complications related to foreign body ingestion make his situation unusual.

Magnetic object ingestion requires urgent evaluation, since multiple ingested magnets can compress the layers of bowel, possibly leading to necrosis, obstruction, perforation, fistula, and volvulus. Algorithms have been developed for suspected cases of magnet ingestion (Figure).3 The first step is determining whether a single magnet or multiple magnets have been ingested, since ingestion of a single magnet can be managed conservatively. This step can be challenging, because patients may not accurately report the objects ingested; our patient denied any foreign object ingestion. Initially, radiography of the neck and abdomen in two views (anteroposterior and lateral) should be performed to assess for the location and number of magnets present.

There is debate about the initial management of an asymptomatic patient who has ingested multiple magnets. While some sources call for close observation with serial radiographs taken every 4 to 6 hours to assess for movement, most favor removal of the magnets.4-8 Magnets localized to the esophagus or stomach can be removed endoscopically. Magnets retained more distally in the gastrointestinal tract require enteroscopy or colonoscopy. Surgery is the best option for patients who are symptomatic or whose magnets have not advanced when viewed on serial radiographs.4 Case reports have been published of children who had a relatively benign presentation, and/or whose radiographs suggested that the magnets were stuck together in one location, but who later were found to have significant bowel injury on laparoscopy.3,4 Our report further supports aggressive management of children in whom there is any concern for multiple magnet ingestion.

References:

1.
Uyemura MC. Foreign body ingestion in children. Am Fam Physician. 2005;72(2):287-291.

2.
Centers for Disease Control and Prevention (CDC). Gastrointestinal injuries from magnet ingestion in children-—United States, 2003-2006. MMWR Morb Mortal Wkly Rep. 2006;55(48):1296-1300.

3.
Tavarez MM, Saladino RA, Gaines BA, Manole MD. Prevalence, clinical features and management of pediatric magnetic foreign body ingestions. J Emerg Med. 2013;44(1):261-268.

4.
Hussain SZ, Bousvaros A, Gilger M, et al. Management of ingested magnets in children. J Pediatr Gastroenterol Nutr. 2012;55(3):239-242.

5.
Chung JH, Kim JS, Song YT. Small bowel complication caused by magnetic foreign body ingestion of children: two case reports. J Pediatr Surg. 2003;38(10):1548-1550.

6.
Vijaysadan V, Perez M, Kuo D. Revisiting swallowed troubles: intestinal complications caused by two magnets—a case report, review and proposed revision to the algorithm for the management of foreign body ingestion. J Am Board Fam Med. 2006;19(5):511-516.

7.
Butterworth J, Feltis B. Toy magnet ingestion in children: revising the algorithm. J Pediatr Surg. 2007;42(12):e3-e5.

8.
Pryor HI II, Lange PA, Bader A, Gilbert J, Newman K. Multiple magnetic foreign body ingestion: a surgical problem. J Am Coll Surg. 2007;205(1):182-186.