Magnet-associated intestinal perforation results in a new institutional policy of ferromagnetic screening prior to MRI

Pediatr Radiol. 2012 Dec;42(12):1506-9. doi: 10.1007/s00247-012-2441-z. Epub 2012 Jun 23.


Foreign body ingestions are common and the vast majority pass through the gastrointestinal tract without complication. Some ingestions, however, result in serious morbidity and mortality. We present a case in which the patient's chief complaint of severe posterior neck pain was unrelated to his foreign body ingestion (multiple magnets). The ingestion of magnets was not disclosed by the child to either the providing medical team or to the patient's family. In order to evaluate the patient's complaint of severe focal neck pain, MRI of the neck was performed. The authors believe it to be feasible that the MRI scan resulted in intestinal perforations that might not have occurred during the natural course of the ingestion. This complication might have been prevented if the patient had undergone screening with a ferromagnetic detector prior to entering the MRI suite. Because of the serious complications related to this case, all pediatric patients at our institution are now screened with ferromagnetic detectors prior to entering the MRI suite. We encourage nationwide policy revision to prevent further incidents similar to the one described in this case.

Publication types

  • Case Reports

MeSH terms

  • Arizona
  • Child, Preschool
  • Foreign Bodies / complications*
  • Foreign Bodies / diagnosis*
  • Humans
  • Intestinal Perforation / etiology*
  • Intestinal Perforation / prevention & control*
  • Magnetic Resonance Imaging / adverse effects*
  • Magnetic Resonance Imaging / standards
  • Magnets*
  • Male
  • Mass Screening / methods*
  • Mass Screening / standards
  • Organizational Policy
  • Patient Safety
  • Pediatrics / standards
  • Radiology / standards