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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

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Author(s): Bailey James R | Eisner Eric A | Edmonds Eric W

Journal: Patient Safety in Surgery
ISSN 1754-9493

Volume: 6;
Issue: 1;
Start page: 16;
Date: 2012;
Original page

ABSTRACT
Abstract 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.

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