A case report of magnetic bead ingestion in a pediatric patient: the diagnostic value of ultrasound imaging and surgical intervention with positive outcome

Introduction

Background

The incidence of foreign body ingestion (FBI) among children has been on the rise in recent years, posing a significant risk of morbidity and mortality. This phenomenon is most prevalent among children aged 6 months to 3 years (1,2). The American Association of Poison Control Centers recorded 94,051 FBI in 2019, with 67,186 in children under 5 years (3). Despite its prevalence, diagnosing FBI can be challenging, particularly when FBI happens without witnesses (4). Moreover, the condition often presents with nonspecific signs and symptoms, complicating timely identification and treatment (5). While many ingested foreign bodies pass through the gastrointestinal tract without causing symptoms, large or pointed objects, as well as button batteries, may become lodged, leading to impaction and perforation, necessitating surgical intervention.

Rationale and knowledge gap

Among the most concerning complications is the formation of an entero-enteric fistula between magnets in adjacent bowel loops, leading to perforation, peritonitis, and bowel wall ischemia (6). Determining which patients require intervention can present a challenge for clinicians, as early signs may be subtle or non-specific, delaying diagnosis and treatment. The rarity of such severe complications, particularly in cases of magnetic foreign body ingestion, make this an important case to report. Existing studies on FBI, describe similar incidents, but few emphasize the role of sonography in the diagnosis of these cases (7). This case highlights a gap in current clinical practice by demonstrating how ultrasound imaging can aid in diagnosing complex foreign body ingestions, particularly in children, where clinical presentations may not immediately suggest such a diagnosis. The addition of imaging studies like sonography can improve the timely identification of potentially life-threatening conditions, thus preventing severe complications.

Objective

In this case report, we present the case of a 2-year-old child who ingested multiple magnetic beads, resulting in multiple bowel perforations. This case highlights the need for timely diagnosis and intervention in pediatric FBI cases to prevent severe complications. Furthermore, it suggests the potential value of sonography as a useful diagnostic tool in promoting the diagnosis process and guiding clinical management in such cases. We present this case in accordance with the CARE reporting checklist (available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-135/rc).

Case presentation

A 2-year-old male with an unremarkable personal or familial medical history was brought to the pediatric emergency department (PED) with complaints of anorexia, abdominal pain, vomiting, and low-grade fever for 5 days.

During the course of his illness, the child exhibited increasing fatigue and pallor, causing concern for his parents. Despite maintaining normal bowel movements, hydration, and reasonable urinary output, he continued to refuse food. On the day of admission, signs of dehydration prompted his community pediatrician to refer him to the PED.

Initial physical examination revealed mild pallor, slightly sunken eyes, a capillary refill time of 2 seconds, warm skin, moist mucosal membranes, mild lip and skin dryness, and no evidence of nuchal rigidity, meningeal irritation, tympanic membrane inflammation, pharyngitis, or peritonitis. The child’s respiratory and heart rates were within normal limits, with clear breath and heart sounds. Symmetric femoral pulses were observed, the abdomen was non-tender and not distended, and there was no skin rash or conjunctival redness. His vital signs were within normal ranges: temperature 36 ℃, heart rate 107 beats per minute, blood pressure 87/65 mmHg, oxygen saturation 97%, and weight 11 kilograms.

In the PED, he remained under supervision for the first hour and was observed by his parents eating a few pieces of snack and a chocolate bar, drinking water appropriately, with no recurrence of vomiting. After the first hour, he was examined again; he still appeared ill and pale, with mild abdominal tenderness. The patient received an intravenous 20 mL/kg 0.9% saline bolus over 30 minutes, with the aim of rehydrating him for the presumed diagnosis of viral gastroenteritis. After the first saline bolus, the child was re-evaluated, but no significant improvement was noted in his symptoms, prompting further diagnostic workup.

An initial venous blood gas analysis revealed no acid-base disturbance but indicated moderate hyponatremia (127 mmol/L), without other electrolyte imbalance. Lactate was measured at 1.6 mmol/L. Despite the saline bolus and rehydration efforts, the child’s condition remained unchanged, leading to a decision to investigate further.

Further investigation included the visualization of the patient’s last vomit through a video captured by the mother in her smartphone, revealing biliary content. A point-of-care-ultrasound (POCUS) raised suspicion of distended bowel loops, leading to formal ultrasound examination. This confirmed an echogenic chain-of-beads shaped finding within the intestinal lumen at the right lower quadrant area, associated with distension of bowel loops. Subsequently, an abdominal X-ray confirmed the presence of a radiopaque chain of beads at the cecum, with signs of retroperitoneal air indicating intestinal perforation (Figure 1).

Figure 1 Abdominal ultrasound and X-ray evaluation. (A,B) Abdominal ultrasound: (A) transverse view of the right upper quadrant displaying dilated bowel loops (arrows); (B) a string of intraluminal echogenic foci with acoustic shadowing observed in the right lower quadrant (arrows), indicative of a foreign body. (C) Abdominal radiograph depicts a chain of small round dense objects in the right lower quadrant, consistent with a foreign body (*). Bowel obstruction is evident from the dilated bowel loops in the center of the abdomen (arrow), with an absence of distal gas in the rectum. Subtle signs of extraluminal gas are present, with gas outlining the right psoas muscle (arrowhead), indicative of retroperitoneal gas (psoas sign).

Based on the findings, the patient underwent prompt surgical intervention. The procedure was performed via an open approach, during which 18 small perforations were observed along the small intestine, starting 30 centimeters from the ligament of Treitz and extending to the cecum. The adjacent bowel segments were found to be adhered to each other. The surgeon noted spillage of bowel content into peritoneal cavity, along with signs of obstruction and strangulation of the terminal ileum. All perforations were sutured, the abdominal cavity was irrigated and suctioned, and a peritoneal drain was placed to manage any possible complications. The magnets and the appendix were removed, and the findings were confirmed through follow-up imaging.

The patient recovered well in the inpatient setting, beginning in the intensive care unit, where he was treated with broad-spectrum antibiotics and total parenteral nutrition. The patient’s previous symptoms alleviated post-surgery, with complete and gradual resolution. On postoperative day 5, the child no longer required mechanical ventilation, and was transferred to the pediatric surgical ward, where he was evaluated by a dietitian and physical therapist. His functional status was closely monitored, and by postoperative day 7, the patient had regained full mobility and resumed oral feeding. The child was discharged home without any long-term complications or functional impairments.

The postoperative course was uneventful, with no adverse or unanticipated events observed. The patient was followed up regularly, with no signs of recurrence of symptoms or complications in the outpatient setting.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent for publication of this case report and accompanying images was not obtained from the patient’s legal guardians after all possible attempts were made.

Discussion

Key findings

FBI poses a significant concern among young children worldwide. This case highlights the potential risks associates with the ingestion of magnetic materials, which can lead to serious complications. In this instance, the child ingested multiple magnetic beads, leading to multiple bowel perforations, which were detected through ultrasound imaging and confirmed with abdominal X-ray. The child underwent prompt surgical intervention and made a complete recovery.

Strengths and limitations

One strength of this case is the use of sonography as both a screening tool and diagnostic tool. This allowed for rapid detection of distended bowel loops, visualization of the magnetic beads, and the eventual identification of bowel perforations. The case also benefited from the integration of modern communication devices, with the mother providing valuable video evidence of the child’s vomiting. However, a limitation of ultrasound is its operator-dependence, which can affect image acquisition and interpretation. Furthermore, while ultrasound is effective in detecting foreign bodies in some cases, its inability to penetrate gas and bone may result in false positives or missed diagnoses, underscoring the need for additional imaging modalities.

Comparison with similar research

Previous studies have highlighted the role of ultrasound in detecting foreign body ingestions, particularly in children (8,9). However, the specific role of ultrasound in detecting magnet ingestion has been less well explored. Several studies have demonstrated its utility in detecting FBI, yet they also emphasize the challenges of interpreting ultrasound images in pediatric patients due to anatomical variations and operator skills (10,11). This case aligns with findings from earlier research that suggest ultrasound can serve as a valuable adjunct to X-ray and other imaging techniques in diagnosing FBI in children, though its accuracy in clinical settings remains under investigation (12).

Explanation of findings

The successful identification of the magnetic beads in this case can be attributed to a combination of detailed clinical observation, prompt use of ultrasound, and confirmatory imaging with an abdominal X-ray. The nonspecific symptoms of anorexia, abdominal pain, and vomiting initially led to a differential diagnosis of viral gastroenteritis. However, the persistence of symptoms despite initial treatment and the observation of biliary content in the vomit triggered further investigation, ultimately leading to the discovery of the foreign body. This case emphasizes the importance of maintaining a broad differential diagnosis in pediatric patients with vague gastrointestinal symptoms that do not resolve with initial treatment.

Implications and actions needed

This case underscores the importance of considering certain pediatric emergencies, such as FBI, which are often diagnosed later than they should be. Such cases are particularly challenging in pediatric patients presenting with nonspecific symptoms, sometimes characterized with symptoms persisting despite initial treatment, and requiring prompt intervention (13). Moreover, this case highlights the growing utility of ultrasound as a screening tool in pediatric emergencies. Ultrasound has proven to be an invaluable tool in rapidly diagnosing critical illnesses in the emergency department, though further research is needed to establish its diagnostic accuracy and potential for detecting specific types of foreign bodies (14,15). Furthermore, the increasing use of smartphones by parents to document their child’s symptoms can provide valuable diagnostic insights and should be considered as part of the diagnostic process.

As a result of these observations, we see potential in future studies focusing on refining ultrasound techniques and assessing their accuracy in detecting various foreign body types. Additionally, future research should explore complementary diagnostic tools to improve the diagnostic accuracy in suspected FBI cases. A flowchart illustrating the decision-making process for the use of abdominal ultrasound and X-ray will be helpful for clinicians in managing pediatric patients suspected of FBI. The flowchart will be based on key clinical indicators such as clinical signs and symptoms, clinical suspicion of foreign body ingestion, initial ultrasound findings, indicators for X-ray. This structured approach will assist in making and accurate diagnoses, enhancing patient care.

Conclusions

In conclusion, FBI emerges as a crucial consideration in specific emergency ward scenarios, while ultrasound demonstrates its effectiveness as a valuable modality for aiding in the diagnosis of FBI.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-135/rc

Peer Review File: Available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-135/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-135/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent for publication of this case report and accompanying images was not obtained from the patient’s legal guardians after all possible attempts were made.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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