From Little Things

By Elia Petzierides

When an 8-month-old female presented with signs of bowel obstruction after ingesting what was thought to be a small piece of candy she was eventually taken to the operating theatre for surgery. The cause of the obstruction highlighted a public health concern and a warning for parents and health practitioners alike.

The 8-month-old female presented to the Texas Children’s Hospital, Houston, Texas, 15 hours after ingesting what her mother believed to be a small piece of candy.

The infant had:
– bilious emesis (the vomiting of bile, a greenish-brown fluid which aids digestion and is secreted by the liver)
– abdominal distention (expansion of abdomen beyond its normal girth due to accumulation of fluid and/or gas)
– obstipation (severe or complete constipation)

An abdominal examination revealed:
– hypoactive (less than usual) bowel sounds
– diffuse discomfort with palpation
– no focal tenderness
– no masses, and
– minimal distention

A plain abdominal radiograph (X-ray) showed:
– multiple dilated loops of the small bowel
– no radio-opaque foreign body (no foreign body visible on X-ray)

Given the cluster of signs pointing to bowel obstruction a decision was made to admit the infant for observation and repeat abdominal examinations. Over the next 48 hours the infant did not display any signs of improvement and her abdominal distention worsened. At this juncture the decision was made to take her to the operating theatre for laparoscopic surgery to inspect the digestive tract. This confirmed what was seen on X-ray – markedly dilated small bowel loops and also a decompressed colon.

Much like a blocked road, an obstructed bowel has a backlog (dilated loops of bowel containing air and fluid) behind the point of obstruction and empty bowel beyond the point of obstruction. The point of obstruction or transition point was identified and an object was found to be obstructing the third portion of the small intestine (distal ileum). An incision was made in the lower abdomen where the affected bowel segment was exteriorised and a 3.5cm spherical gel ball was removed intact.

Some obvious questions to ask at this point are:
1. How did an 8-month-old infant swallow such a large object?
2. How did it travel so far down the bowel before causing an obstruction?

The answer? She didn’t swallow such a large ball. What she swallowed was an expanding gel polymer ball. The ball was the size of a pea (1cm in diameter when dry) which can expand to about the size of a tennis ball (5.5cm after absorbing liquid). In this case the gel polymer ball was from the infant’s older sibling’s toy made from expanding polymer balls. The bright colour making it an attractive and potentially fatal object for an infant to swallow. With advertised growth of up to 400 times their original size the use of these expanding gel polymer balls is not limited to children’s toys, gardening and other household products are also utilising their expanding and water-retaining properties.

Once the gel polymer ball was removed and noted to be intact the bowel was closely inspected. No bowel damage was noted and as such no resection of bowel was required. The infant survived the bowel obstruction and went on to make a full recovery. Information for this article was sourced from a case study published in the Journal of Paediatrics (2012). We highly recommend you view the article, for the surgical pictures at the very least.

While it is pleasing to see that this case was diligently documented and published in a medical journal, some three years after publication the lessons learned from this case were not learned in other countries such as Australia. In 2015 the Australian Competition and Consumer Corporation released a recall of expanding gel polymer balls urging consumers not to use them as children’s toys and urged businesses supplying these balls as toys to cease doing so immediately after several children required hospital treatment to have the balls removed from their digestive tract.

Traditional thinking has always held the belief that if an ingested foreign body is small enough to pass through the pylorus (opening from the stomach into the small intestine) the swallowed object will pass through without causing a bowel obstruction. However the expanding gel polymer ball in this case study was small enough to pass through the pylorus then grow in size while moving through the small intestine until it completely obstructed the distal end of the small intestine.

Hourly measurements of expanding gel polymer balls submerged in water found that the balls can exceed the diameter of the small intestine (2.5cm) within 6 hours and double it within 48 to 72 hours. As such, timely diagnosis and treatment are essential to prevent adverse outcomes. Additionally, no degradation of the balls was noted in the balls submerged in water or the ball retrieved from the patient indicating that it would not be advisable to wait for ingested balls to degrade and pass as this is unlikely.

This case study highlights the need to update traditional thinking associated with ingested foreign bodies. The possibility of an expanding gel polymer ball should always be considered while bearing in mind their radiolucence (inability to be seen on xray) and rate of expansion.

Children will continue to ingest foreign objects. The onus is not only on parents and caregivers to provide a safe environment for children to play in, but also on healthcare professionals to be aware of the possibility of expanding gel polymer balls in the setting of ingested foreign bodies and/or potential bowel obstruction. Adhering to the long held and now outdated belief that ‘if a swallowed object is small enough to enter the small intestine then it is small enough to pass through’ is a disaster waiting to happen if an expanding gel polymer ball has been ingested. We must now be vigilant with the knowledge that from little things big things grow.

The author Elia Petzierides is a Victorian based Advanced Life Support Paramedic and Registered Nurse with a Graduate Diploma in Advanced Clinical Nursing.

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