1. ANNIE PUGEL, MD SEATTLE CHILDREN’S HOSPITAL UNIVERSITY OF WASHINGTON DEPARTMENT OF SURGERY Magnet Ingestion: A Standardized Approach

2. MA 7-year-old boy s/p swallowing magnets Transferred from Bellingham Presented to SCH 8-10 hours post ingestion Afebrile, benign abdomen Abdominal film shows magnet in left side of abdomen

3. MA

4. Magnet(s) on left side of abdomen Reassuring story Reassuring physical exam But….

5. CDC Data Magnet induced injuries from 2003-2006 identified by CPSC  20 cases identified  19 requiring surgery  1 death CDC 2006

6. CDC data Voluntary recalls of certain toys  Magnetix  Polly Pocket

7. Magnet Ingestion What is the best management of patients who have swallowed multiple magnets?

8. Presentation Asymptomatic Mild abdominal pain Obstruction Bowel perforation Sepsis Fistula Death

9. Initial Evaluation Timing of ingestion  Synchronous vs. metachronous Number of magnets ingested Co-ingested objects  Other metal objects  Batteries Other considerations  Difficult historian  Young child

10. Initial Evaluation Imaging  Plain films  CT scan  Avoid MRI Endoscopy Physical exam  unreliable Shah, et al, 2009

11. Treatment Options Watch and wait Endoscopy Laparoscopy Laparotomy Dutta and Barzin, 2008.

12. Treatment Guidelines No formal consensus General guidelines  High index of suspicion  Serial radiographs  Early surgical consultation Standardized regimens

13. Treatment Algorithm Shah, et al, 2009

14. Other Treatment Options Catheter assisted removal Magnetic endoscopy Cathartics/laxatives

15. MA Known to have ingested multiple magnets Magnets moved with subsequent imaging  Postpyloric  Unclear positioning Exam reassuring

16. MA Limited CT to determine location of magnets

17. MA Magnets in cecum Admitted to Surgery Golytely, serial exams Serial abdominal films revealed forward movement of magnet Magnet still had not passed Discharge orders in

18. MA

19. Recommendations Diligent history and exam High index of suspicion Early surgical intervention Close observation Standardized approach to care

20. Sources Butterworth, J, and Feltis, B. Toy magnet ingestion in children: revising the algorithm. J Pediatr Surg. 2007; 42, E3-E5. Centers for Disease Control and Prevention (CDC). Gastrointestinal injuries from magnet ingestion in children: United States 2003-2006. MMWR Morb Mortal Wkly Rep. 2006;55(48) 1296-1300. Dutta, S, and Barzin, A. Multiple magnet ingestion as a source of severe gastrointestinal complications requiring surgical intervention. Arch Pediatr Adolesc Med. 2008; 162(2):123-125. Jamshidi, R, and Harrison, M. Response to: Multiple magnet ingestion as a source of severe gastrointestinal complications requiring surgical intervention. Arch Pediatr Adolesc Med. 2008;162(9):900 Shah, et al. Intestinal complications of magnet ingestion in children from the pediatric surgery perspective. Eur J Pediatr Surg. 2009; 19:328-340. Uchida, et al. Ingestion of multiple magnets: hazardous foreign bodies for children. Pediatr Radiol. 2006; 36:263-264.