Small bowel obstruction is a common and an important surgical presentation. The initial management is correction of any fluid and electrolyte imbalance with intravenous fluids, combined with small bowel decompression by the passage of a nasogastric tube.1
The presence of peritonitis, or hernia incarceration and strangulation is an indication for early surgical intervention.
Foreign body ingestion is commonly seen in the accident and emergency setting, most frequently in paediatric (80%), older, mentally impaired or alcoholic patients. However, foreign body ingestion is a rare cause of small bowel obstruction as 90% of ingested foreign bodies pass through the gastrointestinal tract without complications.4
Ingestion of a single magnet is expected to behave as any other foreign body, however, ingestion of multiple magnets can result in bowel perforation, bowel obstruction, volvulus, bowel necrosis, peritonitis, sepsis and death.5 6
Conservative management is thus less appropriate in cases of multiple magnet ingestion. At 8 years of age, our patient is older than an average child presenting with foreign body ingestion. The literature concludes that 80% of cases of ingestion will involve children between the ages of 6 months and 3 years.7
Our case presented with right-sided abdominal pain, fever with an elevated WCC, and therefore appendicitis was rightly the main differential diagnosis. It was only on revisiting the history and in further discussion with the patient's mother that the past habit of foreign body ingestion with the possibility of small bowel obstruction became apparent. When looking at the case retrospectively, there are clues that could have highlighted a small bowel obstruction with possible foreign body ingestion earlier. Initially, given the fact that he was a paediatric patient and had learning difficulties, these factors alone were indications of him being in a high-risk group for foreign body ingestion.4
Furthermore, despite the fact that he did not present with foreign body ingestion, given his medical history of pica, this was always a possibility. We feel that there was a good argument to remove his appendix even though histologically it turned out to be normal. In the future with the likelihood of further admissions, and difficult history, this would eliminate appendicitis as a cause and prevent a potentially serious delayed or missed diagnosis. We conclude that you should always have a high index of suspicion of foreign body ingestion in high-risk groups as early surgical intervention may be warranted.
- The classic clinical advice that ‘the sun should not both rise and set’ on a case of non-resolving acute intestinal obstruction is sound and should be followed unless there are positive reasons for delay.2
- Clinicians should have a high index of suspicion of foreign body ingestion in children and those with learning difficulties.
- Multiple magnet ingestion can result in serious intra-abdominal complications and should be carefully monitored with a low threshold for surgical intervention.
- Careful and thorough history taking will always remain one of the most important aspects of a patient's assessment.