How Strong Construction Toy Magnets Are! A Gastro‐Gastro‐Duodenal Fistula Formation

Abstract

Children like to play with many kinds of magnetic construction toys, and their size and shape make them easy to swallow. They can cause serious complications such as intestinal obstruction, perforation, and fistula formation when multiple magnets are ingested (1–3). Ingestion accidents can occur frequently in young children, especially those with developmental disabilities (1,3). We introduce an extremely unusual case involving the ingestion of multiple construction toy magnets that formed a gastro-gastro-duodenal fistula formation without bowel perforation. A 12-y-old boy with autism presented to the emergency department after vomiting for 4 d. On clinical examination he was afebrile and had no abdominal distension or peritoneal irritation. An abdominal x-ray demonstrated that the multiple radiopaque bar objects arranged in multiple tandem structures were found in the stomach (Fig. 1A). The exact time of the ingestion could not be ascertained because the ingestion was not witnessed and the patient was nonverbal. On showing the x-ray to his parents, they recognized the foreign bodies as parts of a magnetic educational construction toy, and they recalled that 22 rods had disappeared from the toy box. An esophagogastroduodenoscopy (EGD) was performed under general anesthesia. After repeated EGD with a polypectomy snare, 17 of 22 rods were removed from the stomach. Then it was noticed that 1 rod was deeply embedded in the fundic wall of the gastric angle (Fig. 1B), and its distal end was found in the antral side across the gastric angle. In the antrum this embedded rod was being attracted by another magnetic rod, which had passed through the prepyloric antral wall into the duodenum (Fig. 1C). Hence, these 2 connected magnets had caused the formation of a gastro-gastro-duodenal penetration. This tandem complex of 2 magnets was connected with another tandem complex of 3 pieces, forming a “T” shape, in the duodenal bulb (Fig. 1C). A surgery consult was obtained for suspected bowel perforation despite the lack of free air on the x-ray. An operation or EGD removal was scheduled after a further evaluation of the risk of perforation or bleeding. However, an abdominal x-ray taken the next day revealed that the remaining 5 rods were located in the descending colon (Fig. 1D); there was no sign of peritoneal irritation on physical examination and no sign of perforation by radiographic and ultrasonographic evaluations. The patient was treated with a proton pump inhibitor for 14 d, and a follow-up EGD showed that the fistulas in the stomach and duodenum had completely healed.FIG. 1: A, An assemblage of multiple radiopaque bar objects in the stomach. B, A magnetic rod is deeply embedded in the fundic wall, and (C) this protrudes across the gastric angle and attracts another rod in the antrum. This antral rod also penetrates the prepyloric antral wall into the duodenum. D, Five magnetic rods in the descending colon. F indicates fundic wall; A, antral wall; P, pyloric ring.In the present case, the pressure exerted on the respective walls of the bowel because of magnetic attraction and the pressure of gastroduodenal peristalsis probably led to local pressure necrosis and perforation with attracted rods, which dramatically demonstrates the strength of construction toy magnets. After 17 pieces had been endoscopically removed, the remaining magnets appeared to lose the ability to resist gastroduodenal peristalsis, and were probably dislodged from their embedded positions in gastric and duodenal walls. Fortunately, the lesions that had developed in the stomach and duodenum healed without perforation or bleeding. We suggest that warning labels concerning the unique dangers of ingesting magnetic toys be implemented on all packaging.