What is the management for a patient with a 14.2 mm magnet that has passed the pylorus (the region of the stomach that connects to the small intestine) and only one magnet is visualized?

Management of a Single Magnet Past the Pylorus

Emergent flexible endoscopy (within 2-6 hours) is recommended for a 14.2 mm magnet that has passed the pylorus, even when only one magnet is visualized, due to the risk of pressure necrosis and potential complications. 1

Assessment and Initial Management

• Obtain immediate abdominal radiographs to confirm the location of the magnet and to carefully search for additional magnets that may not be initially apparent 1, 2
• Consider additional imaging with CT scan if there is any suspicion of complications such as perforation, abscess, or if the exact location needs better definition 1
• Assess for signs of peritonitis, abdominal pain, vomiting, or other symptoms that might indicate complications 3
• Do not delay intervention while waiting for spontaneous passage, especially with magnets of this size (14.2 mm) 1, 4

Intervention Approach

• For a single magnet that has passed the pylorus but appears to be moving through the gastrointestinal tract without obstruction:

  • Close observation with serial abdominal radiographs every 6-12 hours to track movement 5
  • If the magnet remains in the same location on repeated imaging, this suggests impaction or possible attraction to an undetected second magnet or metallic object 4

• For a magnet showing signs of impaction or if there is clinical deterioration:

  • Proceed with surgical intervention (laparoscopy or laparotomy) without delay 4, 5
  • During surgery, carefully examine the entire bowel for evidence of pressure necrosis, perforation, or fistula formation 3

Special Considerations

• Even when only one magnet is visualized, there is a possibility that multiple magnets are present but appear as a single object on radiographs when they are stuck together 2, 3
• The risk of complications increases significantly if multiple magnets are present, with up to 50% of patients with multiple magnet ingestions presenting with signs of peritonitis and requiring surgical intervention 2
• Magnets pose unique risks compared to other foreign bodies because they can attract each other across bowel loops, causing pressure necrosis and perforation even when they appear to be moving normally on imaging 4

Follow-up

• After successful removal, patients should be monitored for signs of delayed complications 5
• Patient and family education about the dangers of magnet ingestion is essential to prevent recurrence 2

Pitfalls to Avoid

• Do not assume that a single magnet will pass spontaneously like other foreign bodies - magnets require more aggressive management due to their unique risks 1, 2
• Do not delay intervention if the magnet appears stationary on serial imaging, as this may indicate attraction to an undetected second magnet or metallic object 4
• Do not rely solely on plain radiographs if there is clinical suspicion of complications; additional imaging with CT may be necessary 1, 3