A 2-year-old boy is brought to the emergency department after swallowing magnets 45 minutes ago. The patient was playing with his older brother's toys when he ingested a few high-power, rare-earth magnets. He has no chest or abdominal pain, nausea, or difficulty breathing. When the patient drank water, he had no pain with swallowing. He has no medical conditions and has had no surgeries. Temperature is 36.9 C (98.4 F), pulse is 88/min, and respirations are 25/min. On examination, the patient is playful and not in distress. Cardiopulmonary examination is normal. The abdomen is soft and nontender. The remainder of the physical examination is unremarkable. Chest x-ray reveals 2 small, radiopaque objects in the distal esophagus; there is no mediastinal widening or subdiaphragmatic air. Which of the following is the best next step in management of this patient?

Question

A 2-year-old boy is brought to the emergency department after swallowing magnets 45 minutes ago.  The patient was playing with his older brother's toys when he ingested a few high-power, rare-earth magnets.  He has no chest or abdominal pain, nausea, or difficulty breathing.  When the patient drank water, he had no pain with swallowing.  He has no medical conditions and has had no surgeries.  Temperature is 36.9 C (98.4 F), pulse is 88/min, and respirations are 25/min.  On examination, the patient is playful and not in distress.  Cardiopulmonary examination is normal.  The abdomen is soft and nontender.  The remainder of the physical examination is unremarkable.  Chest x-ray reveals 2 small, radiopaque objects in the distal esophagus; there is no mediastinal widening or subdiaphragmatic air.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d67c_4d0c_bc81_dd8399e9a2f0_MD0003_00 Foreign body ingestions are common in children age 6 months to 3 years due to increased oral exploratory behavior. The incidence of magnet ingestion is increasing because more toys and household appliances contain multiple small, rare-earth magnets. In general, recently swallowed foreign bodies may be managed expectantly with serial x-rays if patients are asymptomatic and the object is small and blunt (eg, coin) with no high-risk features. However, in cases of high-risk esophageal foreign bodies, such as magnets, button batteries, and sharp objects, immediate endoscopic removal is required to prevent complications. magnets Ingestion of ≥2 magnets, especially if swallowed separately, can entrap bowel via attraction across varying intestinal segments and lead to necrosis, fistulae, or perforation. Therefore, magnets visualized in the esophagus or stomach on x-ray require immediate endoscopic removal even if patients are asymptomatic, like this boy. Magnets identified beyond the stomach can be removed via colonoscopy or followed with serial x-rays (every 4-6 hr). If symptoms (eg, abdominal pain, gastrointestinal bleeding) develop or if the magnets do not progress in the gastrointestinal tract, surgical removal is indicated. (Choice A) Induction of emesis is not indicated in the treatment of foreign body ingestion because of the risk of aspiration and delay of definitive care (ie, object removal). (Choice B) An asymptomatic patient who ingested a small, blunt object (eg, coin) may be observed with repeat x-rays after 24 hours to confirm progression of the object beyond the stomach. Likewise, although ingestion of a single magnet may cause bowel entrapment (via attraction to external metal such as belts or buttons), observation and serial imaging can be considered because of a relatively lower risk of complications. Observation is contraindicated in a patient with ≥2 esophageal magnets due to the risk of necrosis and perforation. (Choice C) Barium contrast is typically avoided in patients with an esophageal foreign body because the contrast may be aspirated and/or impair visualization, hindering object removal during endoscopy. (Choice E) Polyethylene glycol, which has laxative properties, can hasten gastrointestinal transit of an object in the intestines, not the esophagus. Educational objective: When ≥2 magnets are ingested and identified in the esophagus or stomach, immediate endoscopic removal is required, even in asymptomatic patients, to prevent bowel entrapment, necrosis, and perforation. References: Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee. (http://www.ncbi.nlm.nih.gov/pubmed/25611037) A systematic review of paediatric foreign body ingestion: presentation, complications, and management. (http://www.ncbi.nlm.nih.gov/pubmed/23261258)

A 2-Year-Old Boy Is Brought to the Emergency Department After