What is the management for a 2-year-old boy with accidental ingestion of high-power, rare-earth magnets (45 minutes prior), presenting with normal vital signs (normothermia, normal pulse rate, and normal respiratory rate), no symptoms, and a chest x-ray showing two small, radiopaque objects in the distal esophagus?

From the Guidelines

The patient requires immediate endoscopic removal of the magnets from the distal esophagus, as multiple magnets can attract each other across tissue layers, potentially causing pressure necrosis, perforation, fistula formation, or bowel obstruction 1. This is an emergency situation, and the lack of symptoms does not rule out serious complications developing.

Key Considerations

• Endoscopic removal should be performed under general anesthesia by a pediatric gastroenterologist or surgeon experienced in foreign body removal.
• While awaiting the procedure, the child should remain NPO (nothing by mouth) to prevent any further complications.
• Following removal, a repeat imaging study should be performed to confirm complete extraction of all magnetic foreign bodies.
• The parents should be educated about keeping small magnets and other potential foreign bodies away from young children, as ingestion of multiple magnets carries significant morbidity and mortality risks.

Diagnostic Approach

• Initial evaluation should be based on the patient’s history and physical examination, with recommended biochemical investigations including complete blood count (CBC), C-reactive protein (CRP), blood gas analysis for base excess, and lactate 1.
• Neck, chest, and abdominal radiographs are useful to assess the presence, location, shape, and size of radiopaque or unknown shape objects, but may have a false-negative rate of up to 47% 1.
• Computed tomography (CT) scan should be performed in patients with suspected perforation or other complications that may require interventional endoscopy or surgery, as it has a higher sensitivity and specificity compared to plain X-rays 1.

Importance of Prompt Intervention

• Delayed diagnosis or management can lead to severe complications requiring surgical intervention.
• The attraction force between rare-earth magnets is particularly strong, which increases the risk of tissue injury compared to traditional magnets.
• Prompt endoscopic removal is crucial to prevent serious complications and improve outcomes in patients with magnet ingestion.

From the Research

Patient Assessment and Management

• The patient, a 2-year-old boy, has ingested high-power, rare-earth magnets and is currently asymptomatic, with no chest or abdominal pain, nausea, or difficulty breathing 2.
• The patient's temperature, pulse, and respirations are within normal limits, and the physical examination is unremarkable.
• A chest x-ray reveals 2 small, radiopaque objects in the distal esophagus, with no mediastinal widening or subdiaphragmatic air.

Diagnostic Evaluation

• According to the European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline, plain radiography is recommended to assess the presence, location, size, configuration, and number of ingested foreign bodies if ingestion of radiopaque objects is suspected or the type of object is unknown 2.
• The ESGE guideline also recommends computed tomography (CT) scan in all patients with suspected perforation or other complication that may require surgery 2.

Treatment Options

• The ESGE guideline recommends emergent (preferably within 2 hours, but at the latest within 6 hours) therapeutic esophagogastroduodenoscopy for foreign bodies inducing complete esophageal obstruction, and for sharp-pointed objects or batteries in the esophagus 2.
• For asymptomatic patients with ingestion of blunt and small objects (except batteries and magnets), the ESGE guideline recommends clinical observation without the need for endoscopic removal 2.
• However, since the patient has ingested magnets, which are considered a high-risk object, urgent (within 24 hours) therapeutic esophagogastroduodenoscopy may be recommended 2.

Complications and Management

• Perforation of the GI tract is a potential complication of foreign body ingestion, and early recognition and immediate management are essential to optimize outcome 3, 4.
• Endoscopic closure of acute perforations of the GI tract has become an attractive alternative treatment to surgical repair, with a success rate of 89.9% in a systematic review of 24 cohort studies 5.