P0302 - The Use of Point-Of-Care Ultrasound to Evaluate Acute Abdomen: A Case of Bowel Perforation After Unknown Single Magnet Ingestion

A 3-year-old healthy male presented to the pediatric emergency department with worsening abdominal pain and vomiting. He had been seen earlier in the day for fever, vomiting, and abdominal pain. On exam, he had normal vital signs and soft abdomen with diffuse tenderness to palpation. Workup included labs consistent with dehydration (decreased Cl, elevated BUN/Cr ratio) and negative US for appendicitis and intussusception. He had decreased urine output, despite a NS bolus, which prompted a point-of-care US (POCUS) of the bladder that measured a total volume of 180 cm3. Bladder catheterization was performed, and his UA was unremarkable. Although he had improvement after anti-emetics and pain medication, the clinical team had persistent concerns about the underlying diagnosis. Due to extenuating circumstances, a shared decision was made to discharge with pediatrician follow-up in the morning. Within six hours, he represented with clinical deterioration, tachycardia, tachypnea, and a rigid abdomen.
He was managed as undifferentiated shock with oxygen, fluids, and antibiotics. As part of his immediate workup, an abdomen focused rapid US in shock (RUSH) evaluation was performed. Relevant findings included a small amount of free fluid (FF) by the inferior edge of the tip of the liver, an extraordinary amount of fluid completely encircling the spleen, and a moderate amount of fluid posterior to the bladder. The pediatric surgery service was immediately notified. POCUS was further used to attempt to determine the source of the FF. Findings included dilated loops of bowel with thick walls and a large amount of extramural FF in the right paracolic gutter. Magnification of this FF revealed multiple small echogenic foci which were thought to represent stool that had leaked into the peritoneum. Progression of the case would confirm, that in fact, this was due to ruptured viscous and the presence of air mixed with intraperitoneal fluid. POCUS images were reviewed with the pediatric surgical consultant and a STAT abdominal computed tomography (CT) scan was requested. Imaging revealed signs of small bowel perforation with large pneumoperitoneum and FF. Also, images were degraded due to a metallic foreign body (FB) artifact just above the bladder. On review of the initial POCUS images, a hyperlucency with shadowing and reverberation artifact was noted midline superior to the bladder, correlating with the location on CT.
The child was emergently taken to the OR. He was found to have purulent fluid in the abdomen with three small bowel perforations near the ileocecal junction. A single magnetic FB, which strongly adhered to the surgical instruments, was recovered. Intraoperative fluoroscopy and follow up abdominal radiographs did not find indication of a second magnet.
The patient had a three-week hospital course complicated by wound dehiscence and persistent ileus requiring a central line and TPN.