Advances in Clinical Medicine
Vol. 13  No. 01 ( 2023 ), Article ID: 60313 , 5 pages
10.12677/ACM.2023.131058

保守治疗小儿误食81颗磁力珠1例

赵春阳,张睿泽,刘瑶,邢茂青*

青岛大学附属医院小儿外科,山东 青岛

收稿日期:2022年12月15日;录用日期:2023年1月8日;发布日期:2023年1月16日

摘要

儿童消化道异物是一种常见急诊疾病,其中磁力珠较为特殊,由于多枚磁珠之间的磁力吸引致使其之间软组织受压缺血,最终出现坏死穿孔等严重急腹症。本文报道1例3岁男孩因阵发性腹痛半天就诊。入院时脐周阵发性腹痛,行X线检查结合家属描述考虑磁力珠可能性大,暂无腹胀、腹腔积气及腹膜炎体征,遂行保守观察对症治疗。15天后患儿排出直径约为0.5 cm的磁珠共81枚。由此,在病情稳定及无并发症发生的情况下可进行保守观察。

关键词

小儿,磁珠,保守治疗

Conservative Treatment of 81 Magnetic Beads in Children: A Case Report

Chunyang Zhao, Ruize Zhang, Yao Liu, Maoqing Xing*

Pediatric Surgery Department, Affiliated Hospital of Qingdao University, Qingdao Shandong

Received: Dec. 15th, 2022; accepted: Jan. 8th, 2023; published: Jan. 16th, 2023

ABSTRACT

Children’s digestive tract foreign body is a common emergency disease, in which the magnetic beads are special. Due to the magnetic attraction between multiple magnetic beads, the soft tissue is compressed and ischemic, resulting in severe acute abdomen, such as necrosis and perforation. A 3-year-old boy with paroxysmal abdominal pain for half a day was reported. Periumbilical paroxysmal abdominal pain on admission, X-ray examination combined with family description to consider the possibility of magnetic beads, no abdominal distension, abdominal gas and peritonitis signs, conservative observation and symptomatic treatment were carried out. After 15 days, 81 magnetic beads with a diameter of about 0.5 cm were discharged. Therefore, conservative observation can be carried out when the condition is stable and there are no complications.

Keywords:Child, Magnet Bead, Conservative Treatment

Copyright © 2023 by author(s) and Hans Publishers Inc.

This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).

http://creativecommons.org/licenses/by/4.0/

1. 引言

小儿误食异物是临床上常见腹部急诊之一,患儿出于对事物的好奇心理,将例如玩具、硬币、单颗磁珠、骨头等吞食,通常边缘光滑,形状规则,一般皆可自行排出。然而摄入多个磁铁可能会造成灾难性的后果,尤其是分多次隔段服用,由于磁力相互吸引而导致的胃肠道组织压迫,造成胃肠道管壁缺血坏死,穿孔等严重的并发症产生 [1]。我院收治误食多枚磁力珠患儿1例,现报道如下。

2. 临床资料

患儿,男,3岁。因“阵发性脐周腹痛半天”入院。行X线检查明显可见消化道内团状金属高亮影,并结合家属描述,考虑误服磁力珠。患儿无恶心、呕吐,无发热、寒战,无腹痛、腹胀,无便血、黑便等症状。查体:腹略膨隆,未见胃肠型及蠕动波,肝脾未及,左下腹轻压痛,无反跳痛,无包块,叩鼓,移动性浊音(−),肠鸣音3次/分。复查X线发现左下腹大片串珠状高密度影,未见膈下游离气体(图1(1))。由于患儿未见明显消化道穿孔症状,我们决定暂行保守治疗,同时随时准备急症手术。我们给予密切监测患儿生命体征,腹部症状。给予患儿禁饮食,肠外营养,胃肠减压等对症支持治疗。第二天复查X线(图1(2)),发现有部分磁珠下降至盆腔右侧,准备通过回盲部进入升结肠,但是大部分磁珠还残留在左下腹。第三天复查X线发现下降的部分磁珠已降至盆腔左侧,即将进入乙状结肠,可磁珠的大部分依然存在于左下腹(图1(3))。第4天患儿排出12枚磁珠,复查X线发现下降至盆腔的部分磁珠已经消失,剩余大部分磁珠已下降至右下腹(图1(4))。这期间患儿查体腹平坦,腹肌软,未见胃肠型及蠕动波,肝脾未及,全腹无压痛,无反跳痛,无包块,叩鼓,移动性浊音(−),肠鸣音3次/分,继续给予患儿密切观测患儿生命体征,腹部症状,恢复流质饮食,预备方案准备:一旦发现患儿有腹痛腹胀,发热等,压痛,反跳痛等症穿孔相关症状体征,立即行急诊手术。第6天后再次给予复查X线,发现磁珠位置并未发生大的变化(图1(5))。之后我们分别在第9天(图1(6)),第13天(图1(7))给予复查X线,发现磁珠位置有一定程度下降,考虑到磁珠异物消化道滞留时间过长,怀疑磁珠与肠壁腐蚀粘连可能,与监护人沟通病情,其手术意愿不强,同意继续给予保守治疗。当在第15天(图1(8))约23点的时候患儿排出69枚磁珠。复查X线发现,未见磁珠残留影,所有磁珠都已经排出,表面侵蚀,珠体完整。

3. 讨论

对于儿童误食磁珠是一个全球性的问题,美国的Mazen I. Abbas等 [2] 的研究表示,从2002年到2011年,因磁铁摄入而就诊的儿童数量增加了8.5倍,法国的Talvard等人的研究表示对于误食88%的患儿需要内镜或者手术治疗 [3]。误食异物的孩子多为6个月到5岁 [4] [5],此阶段的儿童处在认知迅速发育的阶段,对于事物充满了好奇,靠触觉和动作来感知周围新鲜事物,这需要其监护人投入大量精力关注这件事。

Figure 1. (1) Re-examination after admission showed that a large number of magnetic beads in the abdominal cavity formed a complete group of magnetic beads, no gas in the downstream of the diaphragm and no effusion in the abdominal cavity; (2) On the second day after admission, the main body of the magnetic beads was divided into one big and one small magnetic beads, and the small magnetic beads were about to enter the colon; (3) On the 3rd day after admission, the small magnetic beads group was about to pass through the descending colon; (4) On the 4th day after admission, the group of small magnetic beads was excreted from the body; (5) On the sixth day after admission, the magnetic bead group was located in the transverse colon; (6) Re-examination on the 9th day after admission; (7) On the 13th day after admission, the magnetic bead group was still in the position of the transverse colon, with little change and no complications; (8) 15 days after admission, the magnetic beads were completely excluded

图1. (1) 入院后复查,可见腹腔内大量磁珠形成的完整磁珠团体,无膈下游离气体,无腹腔积液;(2) 入院后第2天复查,磁力珠团主体分为一大一小两磁珠团体,小磁珠团体即将进入结肠;(3) 入院后第3天复查,小磁珠团体即将通过降结肠;(4) 入院后第4天复查,小磁珠团体已排出体外;(5) 入院后第六天复查,磁珠团体已在横结肠位置;(6) 入院后第9天复查;(7) 入院后第13天复查,磁珠团体仍在横结肠位置,变化不大,无并发症;(8) 入院后15天复查,可见磁珠完全排除

由于儿童沟通的困难性以及监护人的疏忽及危险意识弱,患儿可能不能或不愿意承认他们的行为,往往首诊的时候难以发现是由于误食磁铁引起的临床症状。当误食单颗磁珠时,患儿大多可自行排出,胃肠道的疾病症状往往与误食其他光滑规则无腐蚀性异物的症状相似 [6]。但当患儿分次误食多颗磁珠时,由于磁铁之间的相互吸引作用,两个磁铁之间肠道会受到压迫,缺血坏死,可能会引起消化道穿孔、腹膜炎、肠瘘 [1]、肠扭转 [7]、肠梗阻 [8] 等并发症。此时往往会延误治疗的最佳时机,从而引发更加严重的并发症。

多枚磁珠异物进入消化道病例相对较少,较为特殊。本组病例中无肠梗阻表现,保守治疗后好转,我们分析出现此种情况的原因可能有:1) 进食的多枚磁珠之间存在磁力薄弱点,使两处磁珠团体在通过上消化道时彼此分离,各部分磁珠间吸引成一整体异物,滑落下降的时间间隔长,并未分段压迫肠壁。2) 及时有效的对症治疗,减少消化道液的分泌,控制磁珠对肠管的进一步腐蚀。

对怀疑异物已进入消化道如无腹膜炎表现且位置尚可,尝试内镜探查是个不错的方法,以减少手术探查风险,如患儿一般情况允许,无腹膜炎体征,可酌情尝试胃镜或结肠镜取出,备选急诊手术。幸运的是,这名患儿在首诊的时候家长发现其家中的磁力珠数量减少,确定是由于误食磁珠而引起的腹痛,程度较轻,并且无急性腹膜炎等任何穿孔症状与体征,我们决定暂行保守治疗。此前有报道 [9] 称院前病史1月余,仅凭家长发现家中的磁力珠数量减少判断出患儿将其误食,在此期间无任何症状体征出现。考虑到长期的食入史并无排除迹象,他的医生通过手术将其取出,在探查中发现的肠瘘多达7处,切除修补瘘口达14处,好在无术后并发症。但笔者查阅文献发现,有报道为防止胃肠道危险的发生,对发现无症状的患儿最终进行了手术治疗 [10],取出多枚磁珠,这引起了笔者的思考,是否手术可以避免,是否误食多颗磁珠的患儿都需要手术治疗。

笔者在此发表一些自己的见解:对于确诊短时间内同时服用多枚磁珠的患儿,如果并无临床症状、体征,且行X线检查提示无穿孔症状,可尝试暂时行保守治疗,但同时要做好随时进行急症手术的准备,Julie C. Brown等 [11] 与笔者有类似的观点。但是对于分次服用多枚磁珠的患儿,来就诊时往往已经有明显的临床症状。此时则需要及时进行手术或内镜治疗。对于保守治疗的患儿,笔者建议密切监测患儿的生命体征,腹部症状、体征,必要时禁饮食补液,控制消化道液的分泌,胃肠减压,并进行X线复查,有些学者建议拍摄X线间隔应为6~12小时 [12]。我们考虑到该患儿一直未发现穿孔相关症状和体征,在前期我们每24小时进行一次X线检查,在排出一部分磁珠后,剩余大部分磁珠在短时间内位置变化并不大,结合患儿表现我们大约3天复查一次X线,保守观察用时10天后第二部分排出。在此期间,我们密切观察患儿的症状体征,增加对患儿的查体频率,如发生穿孔相关体征,及时复查X线,做好随时手术的准备。当然,此类病例较为罕见,病例数有待积累有助于最佳治疗方式的确定以保证患儿安全。

此外,我们更加关注对磁力珠的危险性的普及宣传,让家长监护人对磁珠异物提高警惕,一旦患儿误食,建议早发现早诊治,密切观察病情变化。

利益冲突

所有作者均声明不存在利益冲突。

文章引用

赵春阳,张睿泽,刘 瑶,邢茂青. 保守治疗小儿误食81颗磁力珠1例
Conservative Treatment of 81 Magnetic Beads in Children: A Case Report[J]. 临床医学进展, 2023, 13(01): 382-386. https://doi.org/10.12677/ACM.2023.131058

参考文献

  1. 1. Miyamoto, R., Okuda, M., Kaneko, K., Numoto, S. and Okumura, A. (2019) Multiple Magnets Ingestion Followed by Intestinal Fistula With Mild Symptoms. Global Pediatric Health, 6, 1-4. https://doi.org/10.1177/2333794X19855805

  2. 2. Abbas, M.I., Oliva-Hemker, M., et al. (2013) Magnet Ingestions in Children Presenting to US Emergency Departments, 2002-2011. Journal of Pediatric Gastroenterology and Nutrition, 57, 18-22. https://doi.org/10.1097/MPG.0b013e3182952ee5

  3. 3. Talvard, M., Mouttalib, S., et al. (2015) Magnet Ingestions in Children: A French Multicenter Study. Archives de Pédiatrie, 22, 32-38. https://doi.org/10.1016/j.arcped.2014.10.012

  4. 4. Oestreich, A.E. (2009) Worldwide Survey of Damage from Swallowing Multiple Magnets. Pediatric Radiology, 39, 142-147. https://doi.org/10.1007/s00247-008-1059-7

  5. 5. Gummin, D.D., Mowry, J.B., et al. (2017) 2016 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 34th Annual Report. Clinical Toxicology, 55, 1072-1252. https://doi.org/10.1080/15563650.2017.1388087

  6. 6. Hodges, N.L., Denny, S.A. and Smith, G.A. (2015) Ra-re-Earth Magnet Ingestion-Related Injuries in the Pediatric Population: A Review. American Journal of Lifestyle Medicine, 11, 259-263. https://doi.org/10.1177/1559827615594336

  7. 7. Arslan, S., Basuguy, E., et al. (2015) Jejunoileal Perforation and Volvulus Caused by Multiple Magnet Ingestion. Acta Clinica Croatica, 54, 96-98.

  8. 8. Fenton, S.J., Torgenson, M., Holsti, M. and Black, R.E. (2007) Magnetic Attraction Leading to a Small Bowel Obstruction in a Child. Pediatric Surgery International, 23, 1245-1247. https://doi.org/10.1007/s00383-007-1997-4

  9. 9. Taher, H., Azzam, A., Khowailed, O., et al. (2019) A Case Report of an Asymptomatic Male Child with Multiple Entero-Enteric Fistulae Post Multiple Magnet Ingestion. International Journal of Surgery Case Reports, 58, 50-53. https://doi.org/10.1016/j.ijscr.2019.03.043

  10. 10. Bolton, S.M., Saker, M. and Bass, L.M. (2018) Button Battery and Magnet Ingestions in the Pediatric Patient. Current Opinion in Pediatrics, 30, 653-659. https://doi.org/10.1097/MOP.0000000000000665

  11. 11. Brown, J.C., Murray, K.F. and Javid, P.J. (2012) Hidden Attraction: A Menacing Meal of Magnets and Batteries. Journal of Emergency Medicine, 43, 266-269. ttps://doi.org/10.1016/j.jemermed.2011.09.003

  12. 12. Wu, W., Lv, Z., Xu, W., et al. (2017) An Analysis of Foreign Body Ingestion Treatment Below the Pylorus in Children. Medicine, 96, e8095. https://doi.org/10.1097/MD.0000000000008095

  13. NOTES

    *通讯作者Email: maoqingxing1966@163.com

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