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ArticleEinstein (São Paulo) vol.11 no.2 São Paulo Apr./June 2013text in Portuguese

http://dx.doi.org/10.1590/S1679-45082013000200018

CASE REPORT

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Intestinal fistula after magnets ingestion

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Curriculum ScienTI
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Maurício MacedoI; Manoel Carlos Prieto VelhoteII; Rafael Forti
MaschiettoIII; Renata Dejtiar WaksmanIV

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I Hospital Infantil Darcy Vargas, São Paulo, SP, Brazil

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II Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo,BookmarkSão Paulo, SP, Brazil
III Hospital Municipal Infantil Menino Jesus, São Paulo, SP, Brazil
IV Hospital Israelita Albert Einstein, São Paulo, SP, Brazil

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Correspondence

ABSTRACT
Accidental ingestion of magnetic foreign bodies has become more common due to increased availability of objects
and toys with magnetic elements. The majority of them traverse the gastrointestinal system spontaneously
without complication. However, ingestion of multiple magnets may require surgical resolution. The case of an 18month girl who developed an intestinal fistula after ingestion of two magnets is reported.
Keywords: Magnetics/adverse effects; Intestinal fistula/etiology; Foreign bodies; Play and playthings/injuries;
Child; Case reports

INTRODUCTION
Ingestion of foreign bodies is a common complaint in pediatric emergency services. In the United States, theannual incidence is over 100 thousand patients, and more than 80% of the cases are observed in the pediatricpopulation(1). Most cases of foreign body ingestion occur in children aged between six months and three years.
Among the artifacts more frequently ingested, coins, small toy parts, batteries and, less often, magnetic pieces,
stand out. The object usually goes to the stomach, passes by the pyloric sphincter and ileocecal valve, and isnaturally eliminated. In about 80% of cases the object is spontaneously eliminated; 20% require endoscopy, andcomplications occur in less than 1% and demand surgical procedures(2).
Endoscopy is always indicated when the foreign body is in the esophagus or stomach and it is a long and sharp
object, or multiple magnets, batteries, or if it stays in stomach, regardless of its size(3). Surgery is reserved forcomplicated cases or when the object has not been eliminated. The most common complications are obstruction
and perforation of the gastrointestinal tract.
Ingestion of magnetic pieces is still not frequent in Brazil; however it has distinct characteristics from otherforeign bodies that should be known. In this report, we describe a complication related to ingestion of magneticobjects.

CASE REPORTSeven days ago, an 18-month-old girl ingested two magnets, on the same day, which were used to attach
photographs on a metallic surface. The patient was asymptomatic in this period, but the objects were noteliminated in stools. Upon physical examination, the abdomen was flacid, not painful on palpation and percussion,liver and spleen were not palpable, there were no tumors, and bowel sounds were normal. The radiograph takenon the day she ingested the pieces revealed artifacts in the abdominal cavity. Nevertheless, in radiologicalmonitoring, the objects were in the same position in the mesogastrium. It was observed that the two magnetic
pieces were together (Figure 1); thus, surgical treatment was chosen. Videolaparoscopy was initially indicated tolocate the pieces. During the procedure it was noted that two intestinal loops were attached to and blocked byepyplon. When blockage was removed, the two magnets were seen in different bowel segments, and were 20cm
away from each other; they were adhered together and there was a fistula between them (Figure 2). The bowel
was exteriorized through the umbilicus, enterectomy was performed, the magnets removed and enteroenteralanastomosis was made. The patient progressed well and was discharged on the third postoperative day.

DISCUSSION
Accidental ingestion of magnetic foreign bodies by children occur increasingly more often due to availability ofobjects and toys containing magnets(4,5).
Ingestion of magnets and its complications are scarcely discussed in the literature. Most articles published arefrom Korea, Japan and China, where magnets are sold to treat muscle pain and improve circulation(6,7). Magnets
are also utilized as parts of toys and bijoux(8).
The ingestion of a single magnet, small enough to go through the gastrointestinal tract, poses no additional risk.
Likewise, the ingestion of two or more magnets presents no risk if the pieces are ingested simultaneously and ifthey adhere to each other. The complications occur when two or more pieces go through separately, in distinct
segments, and one attracts the other when they are close. In this case, compression may lead to ischemia of theintestinal loop, resulting in complications, such as perforation and peritonitis(8) or formation of fistula(7,9),
intestinal obstruction(2,10) and small bowel volvulus(11).
Once ingestion is diagnosed, if the objects are no longer in the stomach, patients must be submitted to strict
observation, since the radiological differentiation of a single or more magnets can be subtle or even impossible tobe determined.
Monitoring is made by radiographs when there are no signs of intestinal obstruction or perforation. The
radiographic images should be taken after ingestion and repeated 48 to 72 hours later to assess progression of
the object. If during monitoring the pieces are still in the same position, patients should be submitted to surgery.
Parents should be oriented to prevent such accidents. Healthcare professionals must be aware of the potential
risks and possible complications of magnet ingestion, which should be treated differently from ingestion of othertypes of objects due to high associated morbidity.

REFERENCES
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Kay M, Wyllie R. Pediatric foreign bodies and their management. Curr Gastroenterol Rep. 2005;7(3):212-8.
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two case reports. J Pediatr Surg. 2003; 38(10):1548-50.
[ Links ]8. Hernández Anselmi E, Gutiérrez San Román C, Barrios Fontoba JE, Ayuso González L, Valdés Dieguez E, Lluna
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Berg DA, Tynan MG, Grewal H. Magnets in the stomach. J Pediatr Surg. 2006;41(5):1037-9.

[ Links ]10. Wildhaber EB, Le Coulte C, Genin B. Ingestion of magnets: innocent in solitude, harmful in groups. J Pediatr
Surg. 2005;40(10):e33-5.
[ Links ]11. Nui A, Hirama T, Ktsuramaki T, Maeda T, Meguro M, Nagayama M, et al. An intestinal volvulus caused bymultiple magnet ingestion: an unexpected risk in children. J Pediatr Surg.2005;40(9):e9-11.
[ Links ]Corresponding author:
Maurício Macedo
Avenida Albert Einstein, 627/701, building A1, room 223 – Morumbi – Zip code: 05652-040 – São Paulo, SP, Brazil
Phone: (55 11) 2151-5223
E-mail: mmmacedo@uol.com.br
Received on: Sep 3, 2012
Accepted on: Feb 22, 2013

Instituto Israelita de Ensino e Pesquisa Albert Einstein
Avenida Albert Einstein, 627/701
05651-901 São Paulo - SP
Tel.: (55 11) 2151 0904
revista@einstein.br