Case report
Unwitnessed magnet ingestion in a 5 year-old boy leading to bowel perforation after magnetic resonance imaging: case report of a rare but potentially detrimental complication
1 Department of Orthopaedic Surgery, Naval Medical Center, 34800 Bob Wilson Drive, San Diego, CA, 92134, USA
2 Department of Orthopedics/Scoliosis/Sports Medicine, Rady Children’s Hospital, 3030 Children’s Way, Ste 410, San Diego, CA 92123, USA
3 Department of Orthopaedic Surgery, University of California, San Diego, UCSD Medical Center, Hillcrest, 200 West Arbor Drive, San Diego, CA 92103, USA
Patient Safety in Surgery 2012, 6:16 doi:10.1186/1754-9493-6-16
Published: 19 July 2012Abstract
Background
The ingestion of non-food items in children is a relatively common event, often unwitnessed, unknown, and unreported. For those children brought in for medical evaluation, less than 10% require intervention, and only 1% require surgery. This, however, is not the case for magnet ingestion. Magnets, in plurality, can become attracted to one another through intestinal walls, causing a variety of surgical emergencies.
Case presentation
We present a case of unwitnessed multiple magnet ingestion in a 5 year-old boy who presented to the emergency department with the atypical chief complaint of neck pain. The diagnostic work-up including a neck magnetic resonance imaging (MRI) potentially led to bowel perforations managed definitely by a subsequent exploratory laparotomy. The child had an uneventful postoperative recovery and was discharged to home upon surgical recovery.
Conclusions
Institutions should make all possible efforts to attempt to prevent such potential life-threatening circumstances. We propose a screening tool that can further enhance the care of children who cannot or do not report unwitnessed magnetic ingestion prior to MRI evaluation.
