An indigestion or a viral gastritis, or not?

Case report: An 18 mth old boy was sent to the Emergency Room of the Jessa Hospital (Hasselt, Belgium) because of persistent vomiting. The clinical examination was without particularities, except for a runny nose. The diagnosis of indigestion or (viral) gastritis was made. Patient was sent home. He was represented at the ER five days later. He stopped vomiting for 3 consecutive days after his first hospital visit, but started to vomit again the last 2 days, the last night even two times with bilious vomiting. His appetite was decreased since one week. The infant was not comfortable during abdominal palpation. This finding led to the decision for further investigations. An abdominal ultrasound showed air superposition in the epi- and mesogastrium. There were no signs of intussusception. An abdominal X-ray was performed (fig 1).

Answer and discussion: The abdominal X-ray showed a corpus alienum, presumably magnets, in the mesogastrium and free air under the right diaphragm (fig. 1). An abdominal CT-scan could not visualise whether the magnets were situated in- or outside the intestinal lumen. At laparoscopy, clitted small intestinal loops with multiple perforation sites were detected as well as a purulent peritonitis in the left fossa iliaca (fig. 2). Magnets were removed. Perforations were sutured. Postoperatively augmentin was given. Patient recovered completly.