Double jejunoileal fistula after ingestion of magnets: case
The present case has been reported in the Journal of Pediatric Surgery. A double jejunoileal fistula was diagnosed intraoperatively 10 months since a 4-year-old boy had swallowed an object consisted of multiple magnetic items.

A 4-year-old boy was referred to the emergency department with mild abdominal pain and an incidental radiological finding of a radiopaque object in the abdomen. The patient was stable without vomiting or abdominal distension. During the next 2 days, he was free of pain and could feed and evacuate without difficulty. Follow-up abdominal radiography showed the object still in the lower abdomen. Based on the good clinical status, the child was discharged home, and the parents were instructed to observe the stools and to refer to their pediatrician in case of any new sign noticed.

A month later the boy returned complaining about recurrence of abdominal pain. Abdominal radiography still showed the same object image. The mother who did not follow the medical instructions on a daily basis presumed that the item had been evacuated and that there was nothing to worry about.

The presence of a radiopaque foreign body in the intestine for a long period and the recurrent abdominal pain resulted in the decision of exploratory laparotomy. No contrast radiological study was performed before operation as clinical, plain radiography, and history criteria were considered indicative for laparotomy.

During the procedure, two intestinal loops (the 1st of the ileum, 1 m from the ileocecal valve and the 2nd of the jejunum, approximately 40 cm from the Treitz ligament) were found adhered together, with the presence of two fistulas between them. The implicated item was not single but consisted of 14 small cone-shaped magnets, removed through an enterotomy. Double enterectomy and end-to-end anastomosis followed.

The patient's postoperative course was uneventful and he was discharged home on the 5th postoperative day. Both parents recognized the removed particles as elements of a refrigerator magnetic ornament in the home of a relative that they had visited 10 months ago.

Key takeaways:-

- Magnet ingestion presents characteristics that are misdiagnosing, critical time-consuming, dangerous, and occasionally fatal.

- The mechanism of the complication in this patient was that of enteric mural ischemia and necrosis. The parts in the jejunum and the parts in the ileum were attracted together, and a permanent pressure was applied to the bowel between them until it gave its place to the two fistulas.

-There should be major suspicion of magnet presence if a radiopaque metallic object presents prolonged stay in the intestinal lumen. As pressure necrosis of the intestinal wall is quite probable, a more aggressive approach with less time of anticipation should be under consideration if the magnetic components are multiple or combined with other metallic objects.

- The alarm clock in the cases of swallowed magnets is ticking faster than in other metallic objects.

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