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    Figure 1—

    Lateral (A) and ventrodorsal (B) radiographic views of portions of the thorax and abdomen of a 3-year-old Yorkshire Terrier with a 3-day history of vomiting, hyporexia, and lethargy after suspected ingestion of magnetic desk toys. Notice the multiple well-defined metal opacities in the region of the caudal portion of the esophagus and gastric cardia with extension into the gastric fundus. In both views, increased soft tissue opacity within the thoracic cavity (arrows) is evident. In panel B, multiple pleural fissure lines (arrowheads) are indicative of bilateral pleural effusion.

  • 1. Hickey MC, Magee A. Gastrointestinal tract perforations caused by ingestion of multiple magnets in a dog. J Vet Emerg Crit Care 2011; 21: 369374.

    • Search Google Scholar
    • Export Citation
  • 2. Kiefer K, Hottinger H, Kahn T, et al. Magnet ingestion in dogs: two cases. J Am Anim Hosp Assoc 2010; 46: 181185.

  • 3. Rossmeisl EM, Palmer KG, Holzier MG, et al. Multiple magnet ingestion as a cause of septic peritonitis in a dog. J Am Anim Hosp Assoc 2011; 47: 5659.

    • Search Google Scholar
    • Export Citation
  • 4. CDC. Gastrointestinal injuries from magnet ingestion in children—United States, 2003–2006. MMWR Morb Mortal Wkly Rep 2006; 55: 12961300.

    • Search Google Scholar
    • Export Citation
  • 5. Tavarez MM, Saladino RA, Gaines BA, et al. Prevalence, clinical features, and management of pediatric magnetic foreign body ingestions. J Emerg Med 2013; 44: 261268.

    • Search Google Scholar
    • Export Citation
  • 6. Butterworth J, Feltis B. Toy magnet ingestion in children: revising the algorithm. J Pediatr Surg 2007; 42: e3e5.

  • 7. Honzumi M, Shigemori C, Ito H, et al. An intestinal fistula in a 3-year-old child caused by the ingestion of magnets: report of a case. Surg Today 1995; 25: 552553.

    • Search Google Scholar
    • Export Citation
  • 8. Nui A, Hirama T, Katsuramaki T, et al. An intestinal volvulus caused by multiple magnet ingestion: an unexpected risk in children. J Pediatr Surg 2005; 40: e9e11.

    • Search Google Scholar
    • Export Citation
  • 9. Alzahem AM, Soundappan SS, Jefferies H, et al. Ingested magnets and gastrointestinal complications. J Paediatr Child Health 2007; 43: 497498.

    • Search Google Scholar
    • Export Citation
  • 10. Robinson AJ, Bingham J, Thompson RL. Magnet induced perforated appendicitis and ileo-caecal fistula formation. Ulster Med J 2009; 78: 46.

    • Search Google Scholar
    • Export Citation
  • 11. Ilçe Z, Samsum H, Mammadov E, et al. Intestinal volvulus and perforation caused by multiple magnet ingestion: report of a case. Surg Today 2007; 37: 5052.

    • Search Google Scholar
    • Export Citation
  • 12. Kircher MF, Milla S, Callahan MJ. Ingestion of magnetic foreign bodies causing multiple bowel perforations. Pediatr Radiol 2007; 37: 933936.

    • Search Google Scholar
    • Export Citation
  • 13. Shah SK, Tieu KK, Tsao K. Intestinal complications of magnet ingestion in children from the pediatric surgery perspective. Eur J Pediatr Surg 2009; 19: 334337.

    • Search Google Scholar
    • Export Citation
  • 14. Dutta S, Barzin A. Multiple magnet ingestion as a source of severe gastrointestinal complications requiring surgical intervention. Arch Pediatr Adolesc Med 2008; 162: 123125.

    • Search Google Scholar
    • Export Citation
  • 15. Kabre R, Chin A, Rowell E, et al. Hazardous complications of multiple ingested magnets: report of four cases. Eur J Pediatr Surg 2009; 19: 187189.

    • Search Google Scholar
    • Export Citation
  • 16. Shastri N, Leys C, Fowler M, et al. Pediatric button battery and small magnet coingestion: two cases with different outcomes. Pediatr Emerg Care 2011; 27: 642644.

    • Search Google Scholar
    • Export Citation
  • 17. Sahin C, Alver D, Gulcin N, et al. A rare cause of intestinal perforation: ingestion of magnet. World J Pediatr 2010; 6: 369371.

  • 18. Wong HH, Phillips BA. Opposites attract: a case of magnet ingestion. CJEM 2009; 11: 493495.

  • 19. Saeed A, Johal NS, Aslam A, et al. Attraction problems following magnet ingestion. Ann R Coll Surg Engl 2009; 91: W10W12.

  • 20. Hussain SZ, Bousvaros A, Gilger M, et al. Management of ingested magnets in children. J Pediatr Gastroenterol Nutr 2012; 55: 239242.

    • Search Google Scholar
    • Export Citation

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Multiple magnetic gastrointestinal foreign bodies in a dog

Mark S. GarneauDepartment of Veterinary Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA 01536.

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Robert J. McCarthyDepartment of Veterinary Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA 01536.

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Abstract

Case Description—A 3-year-old castrated male Yorkshire Terrier was referred because of a 3-day history of vomiting, hyporexia, and lethargy after suspected ingestion of magnetic desk toys. Multiple metallic gastric foreign bodies were visible on radiographic views obtained 24 hours previously by the referring veterinarian.

Clinical Findings—On physical examination of the dog, findings included moderate dyspnea, signs of pain in the cranial portion of the abdomen, hypothermia, and tachycardia. Repeated radiography revealed moderate pleural effusion and the presence of several round metallic foreign bodies in a linear ring formation in the distal aspect of the esophagus and gastric cardia.

Treatment and Outcome—Endoscopy was performed, at which time the dog became increasingly dyspneic, tachycardic, and hypotensive. Thoracocentesis was performed, and a large volume of septic exudate was removed from the left hemithorax. Exploratory surgery of the thoracic and abdominal cavities was performed, during which the magnetic foreign bodies were removed and esophageal and gastric perforations were debrided and closed. The dog died following acute cardiac arrest 48 hours after surgery.

Clinical Relevance—Ingestion of multiple magnetic foreign bodies carries a high risk of gastrointestinal tract perforation, volvulus, and obstruction. Immediate surgical intervention is recommended in such cases and would have likely improved the outcome for the dog of this report.

Abstract

Case Description—A 3-year-old castrated male Yorkshire Terrier was referred because of a 3-day history of vomiting, hyporexia, and lethargy after suspected ingestion of magnetic desk toys. Multiple metallic gastric foreign bodies were visible on radiographic views obtained 24 hours previously by the referring veterinarian.

Clinical Findings—On physical examination of the dog, findings included moderate dyspnea, signs of pain in the cranial portion of the abdomen, hypothermia, and tachycardia. Repeated radiography revealed moderate pleural effusion and the presence of several round metallic foreign bodies in a linear ring formation in the distal aspect of the esophagus and gastric cardia.

Treatment and Outcome—Endoscopy was performed, at which time the dog became increasingly dyspneic, tachycardic, and hypotensive. Thoracocentesis was performed, and a large volume of septic exudate was removed from the left hemithorax. Exploratory surgery of the thoracic and abdominal cavities was performed, during which the magnetic foreign bodies were removed and esophageal and gastric perforations were debrided and closed. The dog died following acute cardiac arrest 48 hours after surgery.

Clinical Relevance—Ingestion of multiple magnetic foreign bodies carries a high risk of gastrointestinal tract perforation, volvulus, and obstruction. Immediate surgical intervention is recommended in such cases and would have likely improved the outcome for the dog of this report.

A 3-year-old 3.1-kg (6.8-lb) castrated male Yorkshire Terrier was referred to the emergency service of the Foster Hospital for Small Animals at Cummings School of Veterinary Medicine because of a 3-day history of vomiting, hyporexia, and lethargy. The dog had been seen playing with a set of neodymium desk toy magnetsa before the onset of clinical signs and was suspected to have ingested them.

Radiography performed at the local veterinarian's office approximately 24 hours before the referral examination revealed the presence of several round metallic objects in the dog's stomach. A laxative was administered orally and an enema performed to facilitate passage of the magnets through the gastrointestinal tract. The dog continued to vomit and developed signs of severe abdominal pain, and it was referred to the authors’ facility the following day.

Physical examination revealed signs of pain associated with the cranial portion of the abdomen and moderate tachypnea with abdominal effort. Initial clinicopathologic evaluation revealed mild metabolic acidosis (blood pH, 7.26; reference range, 7.337 to 7.467), hyperlactatemia (7.9 mmol/L; reference range, 0.0 to 2.0 mmol/L), mildly high BUN concentration (38.0 mmol/L; reference range, 12.0 to 28.0 mmol/L), hypoglycemia (41 mL/dL; reference range, 80 to 120 mL/dL), hyponatremia (135.9 mmol/L; reference range, 140.0 to 154.0 mmol/L), and hypochloremia (107 mmol/L; reference range, 109 to 120 mmol/L).

Initial stabilization including an IV bolus administration of lactated Ringer's solution and IV dextrose supplementation was initiated, and whole body radiography was performed. Radiographic views of the abdomen revealed 13 well-defined metal opacities arranged in a ring pattern in the abdominal portion of the esophagus and gastric cardia with extension into the gastric fundus (Figure 1). An increase in soft tissue opacity within the pleural space was also noted, with multiple pleural fissure lines and rounding of the left caudal lung lobe margins (radiographic signs consistent with pleural effusion).

Figure 1—
Figure 1—

Lateral (A) and ventrodorsal (B) radiographic views of portions of the thorax and abdomen of a 3-year-old Yorkshire Terrier with a 3-day history of vomiting, hyporexia, and lethargy after suspected ingestion of magnetic desk toys. Notice the multiple well-defined metal opacities in the region of the caudal portion of the esophagus and gastric cardia with extension into the gastric fundus. In both views, increased soft tissue opacity within the thoracic cavity (arrows) is evident. In panel B, multiple pleural fissure lines (arrowheads) are indicative of bilateral pleural effusion.

Citation: Journal of the American Veterinary Medical Association 246, 5; 10.2460/javma.246.5.537

The dog was anesthetized, and upper gastrointestinal endoscopy was performed to evaluate the integrity of the esophagus and stomach and to potentially retrieve the magnets. The magnets were embedded in the gastric and caudal esophageal mucosa. After passage of the endoscope through the lower esophageal sphincter, the dog became increasingly dyspneic, hypotensive, and bradycardic. Thoracocentesis was performed, and approximately 100 mL of septic exudate with a mixed population of cocci and rods was removed from the thoracic cavity. Because of the strong suspicion of esophageal perforation, the dog was administered broad-spectrum antimicrobial treatment with ampicillin (22 mg/kg [10 mg/lb], IV) and enrofloxacin (10 mg/kg [4.5 mg/lb], IV) and was prepared for exploratory surgery of the thorax and abdomen.

Routine ventral midline celiotomy was performed in conjunction with a median sternotomy. The diaphragm was incised at the esophageal hiatus to gain access to the abdominal portion of the esophagus. A gastrotomy was performed at the gastric cardia, and the magnets were removed from the gastric cardia and abdominal portion of the esophagus. Perforations of the stomach and esophagus were evident where adjacent magnets had attracted and become conjoined, subsequently causing pressure necrosis of the tissue. A focal region of tissue surrounding the esophageal perforation was severely inflamed and contained a thick discharge (consistent with the exudate). The authors believed that this region contained a localized abscess, which was ruptured by the manipulation of the esophagus during the endoscopic examination. The perforations were debrided and closed with 4–0 polydioxanone suture in a simple continuous pattern, and the thoracic and abdominal cavities were thoroughly lavaged with 1.5 L of sterile saline (0.9% NaCl) solution. A thoracostomy tubeb was placed as well as a low-profile gastrostomy tubec for nutrient and medication delivery.

The dog was treated with intensive supportive care over the next 48 hours. Although some clinical improvement was seen following surgery, the dog ultimately had acute cardiovascular arrest approximately 48 hours after surgery and was unable to be resuscitated. A necropsy was not performed, so the cause of death was unknown.

Discussion

To the authors’ knowledge, this is the first case report in the small animal veterinary medical literature regarding rare earth magnetic foreign bodies causing esophageal perforation and subsequent pyothorax in a dog. Ingestion of magnetic foreign bodies causing gastrointestinal perforations and subsequent septic peritonitis has been reported in dogs and has been managed successfully with surgical intervention.1–3 The CDC4 issued a report in 2006 summarizing the results of 20 cases of rare earth magnet ingestion by children over a 3-year period. Those children ranged in age from 10 months to 11 years, and most cases involved ingestion of multiple magnets. Each child required surgical treatment, and several children had prolonged hospitalization. In 15 cases, intestinal perforations were detected; 4 children had intestinal obstruction and peritonitis, and 3 children developed intestinal volvulus. One death secondary to intestinal volvulus, bowel necrosis, and sepsis was documented.

In another report,5 emergency room management of magnet ingestion in 38 humans was described. Thirty of the 38 cases involved single magnet ingestion; 4 of these patients had clinical signs, and the magnets were removed endoscopically. The remaining 8 of the 38 cases involved multiple magnet ingestion. Two of those patients had only 1 remaining magnet (as detected via radiography) and required no intervention. The magnets were removed endoscopically in 2 other patients, and exploratory surgery was performed in 4 patients because of clinical signs of peritonitis. Of those latter 4 patients, 3 had small intestinal perforations and 1 had a small intestinal fistula; all 4 individuals underwent intestinal resection and anastomosis and made a full recovery. One person who underwent surgery subsequently developed intra-abdominal abscesses, which were treated with drainage via interventional radiology procedures. There are reports6–20 of several other cases involving magnet ingestion in children that resulted in severe morbidity and required surgical intervention.

When untreated, ingestion of multiple magnetic foreign bodies often leads to intestinal obstruction, perforation, or volvulus and to sepsis in humans.4–20 Rare earth magnets, which are composed of a mixture of neodymium, iron, and boron, have attractive forces that are 5 to 10 times as powerful as those of traditional magnets.20 When ingested, the powerful attractive forces of the rare earth magnets bring them together, even when they are in different portions of the intestinal tract. Once together, the magnets do not easily separate; tissue can become trapped between magnets, which results in intestinal wall ischemia, pressure necrosis, and eventually perforation or fistulation.5,20 Ulceration of the gastric mucosa secondary to magnet-related compression has been observed within 8 hours after magnet ingestion.20 Compared with ingestion of multiple magnets, there is considerably less risk associated with ingestion of a single magnetic foreign body in humans; in determining prognosis, however, it has to be considered that multiple magnets may appear as a single structure on radiographic views.5 When apparently a single magnet is detected radiographically, close attention to client history and clinical signs is required; serial diagnostic imaging may also be warranted.

In the dog described in this report, the authors believe that the magnets were ingested as a long chain, which became lodged at the lower esophageal sphincter. A few of the magnets then passed through to the gastric cardia but became attracted to the end of the chain in the abdominal portion of the esophagus. This resulted in focal gastric and esophageal pressure necrosis leading to perforation and subsequent pyothorax.

Because of the potential for severe consequences of ingestion of multiple magnetic foreign bodies documented for humans,4–20 the authors recommend immediate surgical intervention in dogs that have ingested multiple magnets. It is possible that early surgical intervention at the time of initial diagnosis of the magnetic foreign bodies would have offered a better chance for survival of the dog described in this report.

a.

Bucky Balls, Maxfield & Oberton Holdings LLC, New York, NY.

b.

Mila International Inc, Erlanger, Ky.

c.

Low-profile gastrostomy tube, Cook Medical Inc, Winston-Salem, NC.

References

  • 1. Hickey MC, Magee A. Gastrointestinal tract perforations caused by ingestion of multiple magnets in a dog. J Vet Emerg Crit Care 2011; 21: 369374.

    • Search Google Scholar
    • Export Citation
  • 2. Kiefer K, Hottinger H, Kahn T, et al. Magnet ingestion in dogs: two cases. J Am Anim Hosp Assoc 2010; 46: 181185.

  • 3. Rossmeisl EM, Palmer KG, Holzier MG, et al. Multiple magnet ingestion as a cause of septic peritonitis in a dog. J Am Anim Hosp Assoc 2011; 47: 5659.

    • Search Google Scholar
    • Export Citation
  • 4. CDC. Gastrointestinal injuries from magnet ingestion in children—United States, 2003–2006. MMWR Morb Mortal Wkly Rep 2006; 55: 12961300.

    • Search Google Scholar
    • Export Citation
  • 5. Tavarez MM, Saladino RA, Gaines BA, et al. Prevalence, clinical features, and management of pediatric magnetic foreign body ingestions. J Emerg Med 2013; 44: 261268.

    • Search Google Scholar
    • Export Citation
  • 6. Butterworth J, Feltis B. Toy magnet ingestion in children: revising the algorithm. J Pediatr Surg 2007; 42: e3e5.

  • 7. Honzumi M, Shigemori C, Ito H, et al. An intestinal fistula in a 3-year-old child caused by the ingestion of magnets: report of a case. Surg Today 1995; 25: 552553.

    • Search Google Scholar
    • Export Citation
  • 8. Nui A, Hirama T, Katsuramaki T, et al. An intestinal volvulus caused by multiple magnet ingestion: an unexpected risk in children. J Pediatr Surg 2005; 40: e9e11.

    • Search Google Scholar
    • Export Citation
  • 9. Alzahem AM, Soundappan SS, Jefferies H, et al. Ingested magnets and gastrointestinal complications. J Paediatr Child Health 2007; 43: 497498.

    • Search Google Scholar
    • Export Citation
  • 10. Robinson AJ, Bingham J, Thompson RL. Magnet induced perforated appendicitis and ileo-caecal fistula formation. Ulster Med J 2009; 78: 46.

    • Search Google Scholar
    • Export Citation
  • 11. Ilçe Z, Samsum H, Mammadov E, et al. Intestinal volvulus and perforation caused by multiple magnet ingestion: report of a case. Surg Today 2007; 37: 5052.

    • Search Google Scholar
    • Export Citation
  • 12. Kircher MF, Milla S, Callahan MJ. Ingestion of magnetic foreign bodies causing multiple bowel perforations. Pediatr Radiol 2007; 37: 933936.

    • Search Google Scholar
    • Export Citation
  • 13. Shah SK, Tieu KK, Tsao K. Intestinal complications of magnet ingestion in children from the pediatric surgery perspective. Eur J Pediatr Surg 2009; 19: 334337.

    • Search Google Scholar
    • Export Citation
  • 14. Dutta S, Barzin A. Multiple magnet ingestion as a source of severe gastrointestinal complications requiring surgical intervention. Arch Pediatr Adolesc Med 2008; 162: 123125.

    • Search Google Scholar
    • Export Citation
  • 15. Kabre R, Chin A, Rowell E, et al. Hazardous complications of multiple ingested magnets: report of four cases. Eur J Pediatr Surg 2009; 19: 187189.

    • Search Google Scholar
    • Export Citation
  • 16. Shastri N, Leys C, Fowler M, et al. Pediatric button battery and small magnet coingestion: two cases with different outcomes. Pediatr Emerg Care 2011; 27: 642644.

    • Search Google Scholar
    • Export Citation
  • 17. Sahin C, Alver D, Gulcin N, et al. A rare cause of intestinal perforation: ingestion of magnet. World J Pediatr 2010; 6: 369371.

  • 18. Wong HH, Phillips BA. Opposites attract: a case of magnet ingestion. CJEM 2009; 11: 493495.

  • 19. Saeed A, Johal NS, Aslam A, et al. Attraction problems following magnet ingestion. Ann R Coll Surg Engl 2009; 91: W10W12.

  • 20. Hussain SZ, Bousvaros A, Gilger M, et al. Management of ingested magnets in children. J Pediatr Gastroenterol Nutr 2012; 55: 239242.

    • Search Google Scholar
    • Export Citation

Contributor Notes

Dr. Garneau's present address is Red Bank Veterinary Hospital, 210 Rte 206 S, Hillsborough, NJ 08844.

Address correspondence to Dr. Garneau (mark.garneau@gmail.com).