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Bowel obstruction by ingestion of superabsorbent polymer balls

DOI:10.1016/j.epsc.2018.11.005
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Adil Merghni M. Mohamed
Adil Merghni M. Mohamed
Adil Merghni M. Mohamed
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Hamid Qoura
Hamid Qoura
Hamid Qoura
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Ibtisam Alshuili
Ibtisam Alshuili
Ibtisam Alshuili
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Ahmed M. Abushosha
Ahmed M. Abushosha
Ahmed M. Abushosha
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Abstract and Figures

Ingestion of foreign bodies is a common complaint among children. However, few cases require surgical intervention [1] of non-food foreign bodies in young children [2]. This study reports 2 cases of intestinal obstruction by superabsorbent gel balls in children ages 15 months and 18 months. Both presented with symptoms and signs of small bowel obstruction. The first patient underwent two operations during the same admission for other missing balls. Both patients did well postoperatively and were discharged home. Superabsorbent balls or polymer balls are new and emerging unexpected causes of intestinal obstruction. Their ingestion causes catastrophic sequelae; these items should always be kept out of the reach of children [3].
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Journal of Pediatric Surgery Case Reports
journal homepage: www.elsevier.com/locate/epsc
Bowel obstruction by ingestion of superabsorbent polymer balls
Adil Mohamed
a,∗
, Hamid Qoura
a
, Ibtisam Alshuili
b
, Moanes Karim
a
, Ahmed Abushosha
a
,
Niam Abdulsattar
a
, Mohamed Hassan
a
a
Nizwa Hospital, Paediatric Surgery Department, Oman
b
Nizwa Hospital, Radiology Department, Oman
ARTICLE INFO
Keywords:
Polymer balls
Water beads
Intestinal obstruction in children
Ingestion of foreign body
ABSTRACT
Ingestion of foreign bodies is a common complaint among children. However, few cases require surgical in-
tervention [1] of non-food foreign bodies in young children [2].
This study reports 2 cases of intestinal obstruction by superabsorbent gel balls in children ages 15 months and
18 months. Both presented with symptoms and signs of small bowel obstruction. The first patient underwent two
operations during the same admission for other missing balls. Both patients did well postoperatively and were
discharged home.
Superabsorbent balls or polymer balls are new and emerging unexpected causes of intestinal obstruction.
Their ingestion causes catastrophic sequelae; these items should always be kept out of the reach of children [3].
1. First case
A 15-month-old boy was admitted with persistent non-bilious vo-
miting more than 20 times in 2 days. Upon examination, he appeared
sick and dehydrated. He was treated for gastroenteritis at health centre
and private clinic. An abdominal USG revealed a well-defined anechoic
cystic lesion within the dilated proximal jejunum. It was 2.8*2.4 cm
and resembled an enteric duplication cyst.
After resuscitation, NGT was fixed, and the patient underwent an
exploratory laparotomy. No cystic or non-cystic lesion was found at the
jejunum although proximal 40 cm of the jejunum was dilated more than
its distal part. This difference in diameter gave a suspicion of mobile
foreign body. On looking for it, a large swelling was found impacted at
the second part of the duodenum. On manipulation of the duodenum it
found to be mobile. It pushed down to the jejunum. An enterotomy was
performed, a large jelly ball measuring ∼3*3 cm in diameter was found
and removed (Fig. 1). Also ultrasound was reporting only one shadow.
The patient was kept NPO postoperatively, but his NGT output was
quite significant, reaching 450 ml of greenish fluid. Postoperative day
4, abdominal USG was repeated and revealed at least 2 round anechoic
structures measuring ∼3*3 cm within the jejunum. A second lapar-
otomy was performed and 2 expandable jelly balls in the jejunum re-
moved through the previous enterotomy incision site (Fig. 2a and b).
Three days following the second surgery, the patient tolerated
breastfeeding. He was discharged in good condition five days after the
second laparotomy.
Fig. 1. One jelly ball in the jejunum.
https://doi.org/10.1016/j.epsc.2018.11.005
Received 5 November 2018; Received in revised form 12 November 2018; Accepted 24 November 2018
∗
Corresponding author.
E-mail address: adilmerghni87@hotmail.com (A. Mohamed).
Journal of Pediatric Surgery Case Reports 41 (2019) 27–29
Available online 29 November 2018
2213-5766/ © 2018 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
T
2. Second case
An 18-month-old boy presented with repeated vomiting for 2 days.
His parents thought he might have ingested two small decorative gel
balls 3 days prior. He was mildly dehydrated but otherwise appeared
healthy, and his abdomen was soft. Abdominal USG revealed two well-
defined cystic structures measuring 3*3.7 cm in the terminal ileum
(Fig. 3). The boy underwent an exploratory laparotomy that found 3 gel
balls in the jejunum 30 cm from the duodenojejunal flexure. Their
surfaces were eroded (Fig. 4).
He was allowed oral intake on postoperative day 2 and was dis-
charged on day 4 in good condition.
3. Discussion
Ingestion of foreign bodies is a common complaint among children.
However, few cases require surgical intervention [1] of non-food
foreign bodies in young children [2].
Water absorbable polymer balls (known as water beads or jelly
balls) when they come into contact with liquid, can expand to the size
of a golf ball, up to 400 times their original size. They are commonly
used as decorative items in vases and centrepieces [4].
Upon ingestion, these balls will enlarge and cause obstructions in
either the jejunum or distal ileum [5]. They initially cause partial ob-
structions, which often become complete [3].
In the first case, re-exploration was performed based on high NGT
output and abdominal sonographic findings of another 2 balls in the
bowel. In such incidents, it is recommended to always assume that the
child might have ingested multiple jelly balls. In the second case, a clear
history of jelly ball ingestion was provided. The condition was quickly
diagnosed, and the patient was treated promptly and efficiently. Both
patients underwent laparotomy, enterotomy, and the extraction of the
foreign bodies.
As water beads are emerging as potential causes of morbidity and
mortality, community awareness is necessary. These items should al-
ways be kept out of the reach of children.
Fig. 2. a: Two balls in the jejunum proximal to the previous enterotomy site. b:
The 2 extracted jelly balls.
Fig. 3. Abdominal USG of the well-defined anechoic cystic lesion.
Fig. 4. The 3 eroded balls extracted from the second case.
A. Mohamed et al. Journal of Pediatric Surgery Case Reports 41 (2019) 27–29
28
Patient consent
Consent to publish the case report was not obtained. This report
does not contain any personal information that could lead to the
identification of the patient.
Funding
No funding or grant support.
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Authorship
All authors attest that they meet the current ICMJE criteria for
Authorship.
Conflict of interest
The following authors have no financial disclosures (Adil, Hamid,
Ibtisam, Ahmed, Moanes, Niam, Mohamed.)
References
[1] Lyons MF, Tsuchida AM. Foreign bodies of the gastrointestinal tract. Med Clin North
Am 1993;77:1101–14. [PubMed].
[2] Kim SY, Park B, Kong IG, Choi HG. Clin Otolaryngol 2016;41(6):p640–5. Dec, 6pp.
[3] Mirza B, Sheikh A. Mortality in a case of crystal gel ball ingestion: an alert for par-
ents. APSP J Case Rep 2012;3(1):6.
[4] Australian Competition and Consumer Commission. ACCC warns of dangers of water
expanding balls to kids. 6 Mar 2015. [media release]. https://www.accc.gov.au/
media-release/accc-warns-of-dangers-of-water-expanding-balls-to-kids.
[5] Moon JS, Bliss D, Hunter CJ. An unusual case of small bowel obstruction in a child
caused by ingestion of water-storing gel beads. J Pediatr Surg 2012;47:e19–22.
A. Mohamed et al. Journal of Pediatric Surgery Case Reports 41 (2019) 27–29
29
... After reading the full texts or abstracts, we removed reports reporting ear canal obstructions (N ¼ 2), ingestions without bowel obstruction (N ¼ 14), and bowel obstructions not related to the ingestion of superabsorbent polymer-made products (N ¼ 67). Overall, 25 reports reporting 43 cases were considered for analysis: 20 articles with English full-text [3,10,[14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31], three articles with English abstracts but not English full-texts (two in Russian and one in Korean) [32][33][34], and two conference abstracts (one in English and one in French) [5,35]. The first report was published in 2011 [22]. ...
... The first report was published in 2011 [22]. All the included reports were retrospective, including 20 case reports [3,10,[17][18][19][20][21][22][23][24][25][26][27][28][29][30][32][33][34][35] and 4 case series [5,[14][15][16]31]. ...
... Age was available in all reports, except for one case series of 15 patients which provided only the mean age and age range [31] (Table 1). In the reports providing age individually, the median age was 15 months (interquartile range: [10;18]) [3,5,10,[14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][32][33][34][35]. In the case series, the mean age was 2 years [31]. ...
Bowel obstruction following ingestion of superabsorbent polymers beads: literature review
Article
  • Oct 2021
Rationale Superabsorbent polymers are marketed as toys, and cases of ingestion in children are increasingly reported. Even if these cases are usually considered benign, bowel obstruction has been reported. Objective To investigate the exposure characteristics, clinical presentation, management, and outcome of patients who developed bowel obstruction following ingestion of superabsorbent polymer-made products. Methods Databases were searched (no start date − 2020/01/31) using the following keywords: (“superabsorbent” OR "polymer” OR “hydrogel” OR “crystal” OR "jelly" OR “Orbeez” OR "beads") AND (“ingestion” OR “obstruction” OR "perforation") AND (“intestinal” OR “bowel”). All cases of bowel obstruction following superabsorbent polymer-made product ingestion were included. Results Report selection: We found 25 reports reporting 43 cases of bowel obstruction following superabsorbent polymer-made product ingestion. All the reports were retrospective, including 20 case reports and 4 case series. Patient characteristics and clinical presentation: Age ranged from 6 to 36 months, and the female/male sex ratio was 1.3. The median delay between the ingestion of the product and the onset of the first symptoms (available in only four reports) was 1.0 [0.7;1.8] day (from 15 h to 2 days). The median delay between the onset of gastrointestinal symptoms and hospital admission, available for all but 15 patients, was 3 [2;4] days (from 15 h to 30 days). The reported symptoms were persistent vomiting in all cases, associated with constipation (11/43), diarrhea (1/43), abdominal pain (1/43), and clinically assessed dehydration (14/43). Abdominal palpation found abdominal tenderness or distension in 11/43 and 28/43 patients, respectively. An abdominal mass was palpated in 3/43 patients. Two patients presented with fever, and three patients developed seizures. Characteristics of exposure: Ingestion of superabsorbent polymer-made products was reported by relatives on hospital admission in only 10/43 cases. Based on imaging and/or surgically/endoscopically removed products, all were bead-shaped objects. The median number of beads removed (available in 27/43) was 1 [1–2] (range from 1 to 6). Their median diameter (available in 21/43 patients) at the time of the diagnosis of bowel obstruction – i.e., at hydrated state – was 30 [30;36] mm (range from 25 to 65 mm). Imaging findings: Abdominal radiography, performed in 31/43 patients, never showed evidence of foreign body ingestion Abdominal computed tomography scanning, performed in 10/43 patients, visualized an intraluminal mass in 5/10 cases. Abdominal ultrasound performed in 34/43 patients allowed visualization of a rounded intraluminal image that corresponded to a bead in 28/34 patients but led to a correct diagnosis of foreign body-induced bowel obstruction in only 15/34 cases. One case reported the contributory use of abdominal MRI. Beads were always located in the small bowel (from the duodenum to the terminal ileum). Removal of beads: Bead removal required endoscopy in 2/43 cases and surgery in 41/43 cases (enterotomy or resection in 36/43 and 5/43 cases, respectively). In 3/36 cases, additional enterotomy was performed to remove beads that had not been found during the first surgery. The delay between the onset of gastrointestinal symptoms and removal procedures ranged from 1 to 7 days. Outcome: Except for two fatal cases, the outcome was favorable. Conclusions Ingestion of superabsorbent polymer-made beads can be responsible for fatal bowel obstruction in children related to the increase in bead size within the intestinal tract. Diagnosis is made difficult by the radiolucent properties of the beads. The management of bowel obstruction probably most often requires endoscopic or surgical procedures. Children under 4 years of age are probably the most at risk of developing bowel obstruction.
... The gel beads become slippery and fragile when wet in water and usually reaches maximum size after 12 hours of submersion in water. 2 When swallowed, the slippery beads pass through gastrointestinal tract (GIT) until it absorbs water and gets enlarged rapidly causing acute intestinal obstruction, morbidity and occasionally mortality, especially in younger children below 2 years of age. [2][3][4][5][6][7] The laparoscopic minimally invasive surgery (lap-MIS) surgery is challenging to locate and retrieve the fragile slippery gel beads. Here we summarize our innovative technique of successful lap-MIS as a feasible and safe alternative to open surgery in children for GIT obstruction due to SAPGBs. ...
... There is report of intestinal obstruction by SAPGBs in a 15 months child required re-laparotomy during the same admission for other missing gel beads. 7 Similar to our findings, plain abdomen X-ray helps show presence of intestinal obstruction but do not give information on SAPGBs because these FB are radiolucent. 8 In contrast, USG is helpful to identify these FB showing cystic lesion with double wall sign, a crucial sign to avoid unnecessary additional imaging and harmful radiation in children. ...
Laparoscopic surgery for intestinal obstruction in children due to water absorbing gel beads
Article
Full-text available
  • Dec 2019
Introductions: Super absorbent polymer gel bead (SAPGB) is increasingly available as toys for children. When ingested it swells by absorbs water and leads to acute intestinal obstruction. Diagnosis and surgery is challenging as its radiolucent, fragile and slippery. We present outcome of our innovative technique of stabilization and removal SAPGBs by laparoscopy minimal invasive surgery (lap-MIS). Methods: This retrospective analyse of outcome of lap-MIS in intestinal obstruction caused by ingestion of foreign body, the SAPGBs, in children who were managed at Children's Hospital Affiliated to Zhengzhou University, China. The outcome variables included removal of SAPGBs, length of hospital stay and postoperative occurrence of anastomotic leak, wound infection, wound dehiscence, re-surgery, or mortality. Results: There were 15 children, male 9 (60%), average age 2 years, and duration of ingestion of SAPGBSs 1.5 days (range 2-4 days), parents gave history of accidental ingestion in 6 (40%). All children had uneventful postoperative recovery after lap-MIS removal of foreign body with no wound infection, anastomotic leak, re-surgery or mortality. Average hospital stay was 4 days (range 3 to 5 days). Conclusions: We had successful outcome lap-MIS with our innovative technique to stabilize and extract foreign bodies, the super water absorbent gel beads, ingested by children.
... İnce bağırsakta yutulan yabancı cisimlere bağlı komplikasyon gelişmesi mıknatıslar, keskin cisimler ve piller dışında nadirdir (10) . Ancak, son yıllarda ince bağırsakta tıkanıklığa neden olan yabancı cisimlere SEB de eklenmiştir (4,8,(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28) . Yutulan SEB'ler gastrointestinal sistemde farinks, özofagus, mide ve piloru kısa sürede büyümeden geçerken ince bağırsakta gastrointestinal sistem salgıları ve alınan sıvılar ile büyümeye devam edip ince bağırsak tıkanıklığına neden olmuşlardır. ...
... Bütün olgular referans hastanelerde çocuk cerrahları tarafından ameliyat edilmesine rağmen, anastomoz kaçağı veya ilk ameliyatta belirlenemeyen diğer SEB'ler nedeni ile 24 olgunun 4'ü 2 kez ameliyat edilmiştir (Tablo 1). SEB yutulma kuşkusu varsa gastrointestinal sistemin ameliyat sırasında dikkatli bir şekilde kontrol edilmesi önemlidir, çünkü diğer yabancı cisimlerden farklı olarak aynı anda çok sayıda SEB yutulabilmektedir (26) . SEB yutulmasının infantlarda nadir görülen ince bağırsak tıkanıklığı nedenleri arasına alınması, erken tanı ve tedavi planları için yararlı olacaktır. ...
Comparison of the Water Absorbing Bead Ingestion Results in Turkey and World Literature
Article
Full-text available
  • Dec 2019
Objective: Water absorbing beads (WAB), also known as water monkey in Turkey, are popular foreign bodies and swell when they come in contact with water or water containing solutions. If ingested, they have potential for causing intestinal obstruction. The aim of the present study is to compare the results and the differences of WAB ingestion in Turkey and world literature. Method: Patients who had undergone surgery due to ingestion of WAB were screened, and analyzed using the most used medical databases according to author, year, country, age, sex, time elapsed from onset of symptoms to admission to hospital, diagnosis and treatment applied. Results: Twenty-four cases have been reported so far starting from the year 2011 when the first case operated due to WAB ingestion in the world was published. All of the cases aged ≤ 2 years and they were operated due to small bowel obstruction. In Turkey, very small number of studies have been performed related to WAB ingestion and none of the cases have been operated so far. Conclusion: In Turkey none of the patients underwent surgery due to WAB ingestion, because nationwide sales of WAB are limited, precautions have been taken. The number of cases are very scarce because WAB are being used mostly outside the household thus the risk group can not reach WAB or presumably the cases are not being reported.
... Patients can develop symptoms within 24 h of ingestion as these balls enlarge progressively, causing obstruction in either distal jejunum or ileum. [3] Patients may be asymptomatic or suffer from vomiting, refusal to eat, abdominal pain, constipation, and symptoms of dehydration. Although WABs are radiolucent, X-rays play an important role in evaluation as features of acute intestinal obstruction will become apparent as the presence of air-fluid levels and dilated bowel loops. ...
Multidisciplinary Management for Intestinal Obstruction by Gel Ball Ingestion
Article
Foreign body ingestion is common in young children. Very few cases require surgical exploration for removal. We report a case of superabsorbent gel ball ingestion causing intestinal obstruction, managed by a combination of endoscopic and open surgical removal under intraoperative ultrasound guidance.
Superabsorbent polymers beads ingestion: Retrospective study in France
Article
  • Jul 2021
Introduction Cases of ingestion of superabsorbent polymers (SAPs) marketed as ornamental products and toys are increasingly reported. Objective The objectives of this study were to describe the trend and outcome of SAPs beads ingestion in France. Methods We conducted a retrospective descriptive study over a 10-year period of all cases of SAPs beads ingestion collected by the French Poison Control Centers. Results In total, 193 cases of SAPs bead ingestion were collected, 90% of whom among children (median 30 months). More than 75% of cases were asymptomatic while the remaining cases exhibited minor/mild gastrointestinal symptoms. The outcome was spontaneously favorable in all cases except for one fatality in a 18-month-old girl who developed bowel obstruction. Conclusions SAPs beads ingestions were mostly asymptomatic but could be responsible for fatal bowel obstruction in children, related to the increase in SAPs beads size within the intestinal tract. The diagnosis was made difficult by SAPs radiolucent properties. SAPs bead ingestion should be considered by practitioners as a possible cause of obstruction with no foreign body found.
Mortality in a Case of Crystal Gel Ball Ingestion: An Alert for Parents
Article
Full-text available
  • Feb 2012
Decorative crystal gel balls are used for decoration purpose. Due to their attractive appearance they may be ingested by children. This may result in grave complications. A case of decorative crystal ball ingestion is being reported in a 6 months old infant who presented with sub acute intestinal obstruction and was operated. Crystal gel balls were causing obstruction of jejunum. Enterotomy and removal of the mass of jelly balls was done with primary closure. The patient was re-operated for anastomotic disruption on 6th postoperative day. Baby developed septicemia, and succumbed after 2 days of second operation.
An unusual case of small bowel obstruction in a child caused by ingestion of water-storing gel beads
Article
Foreign body ingestion occurs most commonly in the pediatric population. Small bowel obstruction is a rare complication that can occur, and surgical intervention is required. We present the first report of a case of an 18-month-old child with a jejunal obstruction caused by ingestion of water-storing gel beads used for botanical arrangements. The child presented with obstipation and nonbloody, nonbilious emesis. Symptoms resolved after a large bead 3 cm in diameter was retrieved via laparoscopic-assisted excision. This case suggests that water-storing gel beads are particularly dangerous foreign bodies and should be kept out of the reach of children.
Foreign bodies of the gastrointestinal tract
Article
The majority of foreign bodies in the gastrointestinal tract require no medical or surgical intervention for removal. Prior to the era of modern gastrointestinal endoscopy, the management of ingested objects or nontherapeutic objects placed in the rectum required general anesthesia and was relegated to the general surgeon or otolaryngologist. With the advancement of therapeutic endoscopy, fewer affected individuals require surgical intervention. The physician involved with the initial evaluation of these patients must have a working knowledge of foreign bodies of the gastrointestinal tract to facilitate appropriate and timely management and referral.
  • Dec 2016
  • Clin Otolaryngol
  • 6
  • S Y Kim
  • B Park
  • I G Kong
  • H G Choi
Kim SY, Park B, Kong IG, Choi HG. Clin Otolaryngol 2016;41(6):p640-5. Dec, 6pp.