Presentation
Two days abdominal pain and fever
Patient Data
Free fluid within the pouch of Douglas, right adnexa, right iliac fossa and minimally left flank. Several isolated free gas locules, therefore perforation suspected. No drainable collections or abscesses.
There is partial proximal small bowel obstruction with a small bowel feces sign.
The ingested foreign bodies cause significant streak artifacts and are poorly identified and hence poorly characterized on all windows including 3D reconstructions.
Abdominal x-rays were performed after CT to clarify the nature of the ingested foreign bodies, as streak artifact on CT precluded confident assessment of their nature.
Specifically ~9 small magnetic balls aligned in a row and projecting obliquely anteroposteriorly at L4/L5 vertebral level.
There is upper abdominal small bowel distension and features suggest partial small obstruction and/or developing ileus.
There is no free intraperitoneal gas to suggest perforation.
Radiopaque bladder due to IV contrast excretion from recent CT.
Case Discussion
The patient presented with an acute abdomen without trauma history and no initial history of foreign body ingestion was conveyed.
Due to the emergent acute out of hours presentation, CT was requested versus x-rays +/- ultrasound.
CT confirmed metallic foreign body ingestion and associated sequela of bowel perforation.
The patient was questioned and confirmed "Buckyball" ingestion approximately two days prior. Abdominal x-rays were performed and demonstrated a line of nine metallic circular foreign bodies.
At emergency operation, multiple sealed small bowel perforations and two fistulous tracts with early segmental small bowel necrosis were seen.
Magnetic foreign bodies
Buckyballs are just one brand of small (~5 mm) diameter, round strongly magnetic balls which are very popular children's toys. They are banned in some countries, e.g. the United States, due to ongoing safety issues, as demonstrated by this case.
Due to their strong magnetic force (these are rare earth metal magnets, not transition metals, and therefore stronger), they may perforate the bowel and form fistulous tracts especially when multiple spheres are ingested at varying times. Peristalsis also results in a scattered intraluminal distribution of the spheres further exacerbating bowel perforation, fistulous tracts, and pressure necrosis, and ischemia due to close apposition of the magnetic spheres in adjacent loops and bowel wall compression consequently.
This is a classic example of all three complications at laparotomy, specifically small bowel perforation/ fistulae and small bowel wall necrosis.
CT was difficult to assess accurately due to the significant streak artifacts however alluded to the foreign body ingestion and likely complications and also reaffirmed the need for x-rays (in two planes) to assist in delineating the nature and position of the foreign bodies. When ingested, they may mistakenly appear to be aligned in a single loop of the bowel on plain radiography.
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