Abdominal Pain Caused by a Potentially Fatal Attraction Danielle Claire Mercurio, DO,* Candace Scace, MD,† Bhairav Shah, MD,‡ Evan Weiner, MD,* and Rajeev Prasad, MD‡ Abstract: Abdominal pain is a challenging presentation in children. Examination findings and etiology vary greatly, spanning a vast spectrum from flatulence to frank peritonitis with septic shock. Here, we discuss a 10-year-old boy with 24 hours of progressively worsening lower abdomi- nal pain, nausea, and subjective fevers. History and physical examination findings were consistent with appendicitis. However, physicians were sur- prised when the single-view abdominal radiograph showed an unantici- pated, somewhat perplexing discovery. Key Words: abdominal pain, foreign body, ingestion, magnets, peritonitis (Pediatr Emer Care 2016;00: 00–00) CASE A 10-year-old boy with attention-deficit/hyperactivity disor- der presented to the pediatric emergency department complaining of abdominal pain. His symptoms began 1 day prior and were progressing intensely, with a pain scale report of 2/10 at the start of symptoms and 10/10 at 24 hours later in the emergency depart- ment. Pain was described as achy, diffuse, and worst in the lower abdomen. Associated symptoms included nausea and constipa- tion. Family denies previous abdominal surgeries, treatment for constipation, and recent travel. His skin was warm, but there was no measured fever by history. Patient and family denied vomiting, diarrhea, diet changes, bloody stools, rash, hematuria, radiation of pain, relief of symptoms with flatus, or recent viral illness. On physical examination, he appeared uncomfortable, but nontoxic. Initial vital signs were a temperature of 98.2°F, heart rate of 120 beats/min, blood pressure of 155/103 mm Hg, respirations of 20 breaths/min, and pulse oximetry of 100%. His skin was warm and dry without rash. His HEENT (head, ears, eyes, nose and throat), lymphatic, pulmonary, musculoskeletal, and neuro- logic examinations were within normal limits. His cardiac exami- nation was normal with intermittent tachycardia and adequate perfusion. His abdomen was nondistended, but moderately tender in the periumbilical right and left lower quadrants. There were no scars, palpable masses, or organomegaly. The patient politely re- fused to stand when asked secondary to pain. DISCUSSION The differential for the combination of progressively worsen- ing lower abdominal tenderness, nausea, constipation, and subjec- tive fever in a previously healthy boy includes both surgical and nonsurgical causes. It is most important to first determine if the patient is in need of emergent surgical intervention. Indications for this include appendicitis, testicular torsion, malrotation, volvu- lus, obstruction, incarcerated hernia, and traumatic injury causing clinical deterioration. Some clinical scenarios such as ileus, for- eign body ingestion, severe constipation with impaction, and pan- creatitis with pseudocyst or abscess may require close monitoring by the surgical team. Only after these conditions are ruled out can the more benign etiologies such as constipation, gastroenteritis, and mesenteric adenitis be considered. Once the tenderness was confirmed on examination, the patient was made NPO. STATabdominal radiographs and ultra- sonography orders were placed simultaneously. Because of a high clinical suspicion for appendicitis, the ultrasound was per- formed first. The appendix was not visualized. There was “moder- ate to large free fluid within the right lower quadrant” along with “several dilated and inflamed bowel loops with superimposed in- flammation of the adjacent mesentery” (Fig. 1). This was concern- ing for appendicitis, with potential perforation. However, subsequent views localized several intraluminal echogenic structures with poste- rior acoustic shadowing suggestive of foreign bodies (Fig. 2). During the ultrasound, the patient denied ingestion of any foreign bodies. The abdominal radiographs then showed what appeared to be an intact strand of beaded items (Fig. 3). This was quickly recog- nized by the radiologist, “parts of a magnetic construction toy in the lower abdomen including plastic tubes with magnets seem- ingly fixed to a central ball bearing…. ” The arrangement was so peculiar that the attending radiologist requested a repeat frontal view, in the event that the child had elaborately embroidered cloth- ing, toys, or jewelry lying on his abdomen. After confirmation, a lateral view was obtained for localiza- tion purposes. Given the anterior positioning and fluid levels, it was thought that the toys were located within the small bowel, causing obstruction. Although there was no free air noted on these images, the ultrasound revealed corresponding free fluid, making perforation a concern. There was also consideration of a left lateral decubitus view to identify the presence of free air. However, the surgical team was consulted, and the patient developed fever and From the Departments of *Emergency Medicine, †Radiology, and ‡General Surgery, St Christopher’s Hospital for Children, Philadelphia, PA. Disclosure: The authors declare no conflict of interest. Reprints: Danielle Claire Mercurio, DO, St Christopher's Hospital for Children, Philadelphia, PA. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0749-5161 FIGURE 1. Grayscale US image of the right lower quadrant demonstrates free fluid surrounding a mildly thick-walled loop of bowel. The appendix was not visualized. ILLUSTRATIVE CASE Pediatric Emergency Care • Volume 00, Number 00, Month 2016 www.pec-online.com 1 Copyright © 2016 Wolters Kluwer Health, Inc. 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