Duodenal ileus caused by a cage magnet in a Fleckvieh cow.

The present report aims to describe the case of a duodenal obstruction ileus in a dairy cow that was caused by a cage magnet. The 4.7-year-old German Fleckvieh cow was hospitalized because of symptoms of intestinal obstruction such as anorexia, noticeable drop in milk yield, reduced defecation, dehydration and positive percussion and swinging auscultation in a circumscribed area cranial of the right flank over the last 2 ribs. Six months as well as 3 days prior to hospitalization the cow had already been treated for signs of hardware disease, which included administration of a cage magnet.After the initial clinical diagnostic procedure on hospital admission, a diagnostic laparotomy in the right paralumbar fossa was performed to identify the cause of the ileus. The cranial part of the duodenum was markedly dilated, and a solid foreign body was found obstructing the intestine immediately aboral to the duodenal sigmoid flexure. This was identified as a cage magnet, which was massaged in retrograde direction into the pyloric antrum and removed via abomasotomy. The cow recovered from surgical intervention and was discharged from the hospital 6 days later.The present report describes an unusual complication of cage magnet administration, which is a standard veterinary procedure and generally considered a safe treatment option in cows with clinical signs of acute traumatic reticuloperitonitis.

Chronic jejuno-colonic fistula and intestinal malabsorption due to multiple magnet ingestions: A case report and systematic review.

Magnet ingestion in children can lead to serious complications, both acutely and chronically. This case report discusses the treatment approach for a case involving multiple magnet ingestions, which resulted in a jejuno-colonic fistula, segmental intestinal volvulus, hepa-tosteatosis, and renal calculus detected at a late stage. Additionally, we conducted a literature review to explore the characteristics of intestinal fistulas caused by magnet ingestion. A six-year-old girl was admitted to the Pediatric Gastroenterology Department pre-senting with intermittent abdominal pain, vomiting, and diarrhea persisting for two years. Initial differential diagnoses included celiac disease, cystic fibrosis, inflammatory bowel disease, and tuberculosis, yet the etiology remained elusive. The Pediatric Surgery team was consulted after a jejuno-colonic fistula was suspected based on magnetic resonance imaging findings. The physical examination revealed no signs of acute abdomen but showed mild abdominal distension. Subsequent upper gastrointestinal series and contrast enema graphy confirmed a jejuno-colonic fistula and segmental volvulus. The family later reported that the child had swallowed a magnet two years prior, and medical follow-up had stopped after the spontaneous expulsion of the magnets within one to two weeks. Surgical intervention was necessary to correct the volvulus and repair the large jejuno-colonic fistula. To identify relevant studies, we conducted a detailed literature search on magnet ingestion and gastrointestinal fistulas according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We identified 44 articles encompassing 55 cases where symptoms did not manifest in the acute phase and acute abdomen was not observed. In 29 cases, the time of magnet ingestion was unknown. Among the 26 cases with a known ingestion time, the average duration until fistula detection was 22.8 days (range: 1-90 days). Fistula repairs were performed via laparotomy in 47 cases.

Management patterns of multiple magnet ingestion reported to New Jersey Poison Information and Education System.

BACKGROUND: Ingestion of multiple high-powered neodymium rare-earth magnets poses a significant risk for gastrointestinal (GI) injury such as bowel perforation or ischemia. Given the rising incidence of rare earth magnetic ingestions and the corresponding increase in serious injuries in children, published guidelines recommend urgent endoscopic removal of all magnets within endoscopic reach in cases involving ingestions of two or more magnets. RESEARCH QUESTION: Do management patterns for multiple magnet ingestion align with current practice guidelines, and does hospital length of stay (LOS) differ based on the initial emergency department (ED) approach? METHODS: This is a retrospective chart review of consecutive patient encounters reported to the New Jersey Poison Information and Education System (NJPIES) between January 2021 and April 2022 involving multiple magnet ingestion. Potential cases were retrieved from the NJPIES TOXICALL® database, using substance codes relating to magnet or foreign body ingestion. Two-sample T tests were used to determine the statistical difference in the hospital LOS between the group of patients receiving early emergent esophagogastroduodenoscopy (EGD) versus those receiving expectant management on initial presentation. RESULTS: There was a difference in the average LOS of 2.7 days (p = 0.023) longer in the expectant management group with no medical complications in either group. Twenty-five percent or 2 out of 8 cases deviated from guidelines. CONCLUSION: The initial ED decision to pursue expectant management instead of attempting emergent EGD removal of magnets may result in prolonged hospitalization, increased risk for readmission, and delayed definitive removal of magnets due to nonprogression along the GI tract.

Magnet ingestion in growing children: a multi-center observational study on single and multiple magnet incidents.

Over the past 15 years, there has been a noticeable uptick in incidents involving children ingesting multiple magnetic foreign bodies which can cause injuries and gastrointestinal complications including death. The current study aimed to identify the prevalence, clinical presentation, and management of single or multiple magnet ingestions. A retrospective multi-central cross-sectional study was conducted to include all pediatric patients < 18 years presented to the emergency department with ingestion of single or multiple magnets and admitted across hospitals in Qatar, UAE, KSA, Tunisia, and Turkey between January 2011 and December 2021. Demographics, symptoms, management, and outcomes were analyzed. There were 189 magnet ingestions, of which 88 (46.6%) were multiple magnet ingestions. Most patients (55.6%) were male, and the median age was 3.9 (IQR 2-7) years. An abdominal X-ray was obtained in all cases. 119 (62%) patients were conservatively treated, 53 (28%) required surgical intervention and 17 (8.9%) underwent gastroscopy. None of the patients with single magnet ingestions experienced morbidity or severe outcomes. Multiple magnet ingestions led to significant morbidity including hospitalizations, perforations (44.3%), severe intestinal necrosis (19.3%), peritonitis (13.6%), severe abdominal infection (10.2%), and septic shock (4.5%). The rate of surgical intervention (59.1% vs. 1.0%) and gastroscopy (15.9% vs. 3.0%) was significantly higher in the multiple ingestion group compared to the single magnet ingestion group. No deaths were identified. A high risk of serious complications, including the need for surgery to remove the magnets and substantial morbidity may result from swallowing more than one magnet. Magnet safety requirements, public education, and improved legislation are urgently required.

Fatal bowel perforation caused by ingestion of high-powered magnets in a 6-year-old boy.

Foreign body ingestion in children is a frequent cause for medical consultation. Although most foreign bodies are spontaneously eliminated from the gastrointestinal tract, life-threatening complications such as gastrointestinal obstruction or perforation can occur. We report the case of a 6-year-old boy who died 2 days after the onset of nausea and abdominal pain, with no foreign body ingestion witnessed or reported in the previous days. Autopsy showed a diffuse peritonitis and a perforation of the transverse colon caused by three high-powered magnets stacked together, and attached to the outer stomach wall via a fourth magnet located in the stomach. The cause of death was peritonitis due to bowel perforation by ingested magnets, which were shown to have come from a toy belonging to the child. Ingestion of multiple high-powered magnets carries a high risk of gastrointestinal complications and can exceptionally have a fatal outcome, especially as it often goes unreported and causes non-specific gastrointestinal symptoms that can delay diagnosis and management. This case highlights the need to raise public awareness of the potential risks of ingesting such magnets and to strengthen safety standards to protect children from this serious health hazard.

Complications related to unwitnessed magnet ingestion in paediatrics: Case series.

Foreign body inges tion is one of the mo s t common problems a mo ng chi ldren. There is a great te ndency among children between the age of six months to six years to p lace objects, such as coins, fish bone, pins, button batteri es, magnets and o th er hous ehold ite ms, in their m outh and often swa llow them. Magnet ingestion is not uncommon. Hazardous effects can occur owing to the fact that these are usually unwitnessed leading to disparity in histor y an d delayed presentation. Nowadays these m agnets are made of Neodymium which is a s trong element and can be moulded into various shapes and sizes, making them more attractive to children . Single magnet ingestion may pass with out complication, bu t multip le ingested magnets pose risk of severe complications such as obstruction, inter bowel fistulae, and perforation often requiring urgent intervention. Here, we present three cases who presented to the emergency d epartment with unusu al prese nt ation s an d ultimately under went exp loratory La parotomy with surprising intra- operative findings along with magnetic objects.

An unexpected ferromagnetic foreign body in a paediatric research participant undergoing 3T MRI.

Metallic foreign bodies (FBs) are a safety risk during MRI. Here, we describe a boy in early childhood with an unexpected ferromagnetic FB discovered during a research brain MRI. Safety precautions included written and oral safety screening checklists and visual check during a structured safety pause. During introduction to the scanner, he was lifted to look at the bore. Staff became aware of an object flying into the bore. The child reached for his ear, and a 5 mm diameter ball bearing was found in the bore. The child had no external injury. We have introduced a 0.1 T handheld magnet to check for metallic FBs not known to the parent. FBs are a common paediatric emergency department presentation, particularly in younger children or those with cognitive or behavioural problems. This case highlights the importance of safety screening in paediatric MRI scanning, along with its fallibility.

Magnets and children: a dangerous combination.

BACKGROUND: Accidental ingestion of foreign bodies is a common problem in children. Fortunately, the gastrointestinal tract is quite resilient to foreign bodies. On the other hand, the ingestion of magnets can result in enormous morbidity. Because of their natural tendency to firmly adhere they can cause intestinal obstruction, pressure necrosis, fistula formation or perforation. With this case report, we aim to raise awareness of the risks that these magnets pose to children. METHODS: We describe a case of intestinal perforation caused by the separate ingestion of multiple magnets from a children's toy (buckyballs, Neodymium spheres) by a two-year-old boy. A search in the Pubmed database showed some publications and varied management guidelines. RESULTS: The boy was treated with an exploratory laparoscopy converted to a mini-laparotomy. We removed the four magnets through separate enterotomies. Postoperative recovery was uneventful. The boy was discharged on a postoperative day five and had no complications at three months follow-ups. CONCLUSION: Accidental ingestion of multiple magnets is rare but can create a life-threatening situation in children. If the magnets are still in the stomach, endoscopic retrieval is needed. If they are beyond the stomach, in asymptomatic cases close clinical and radiographic vigilance is mandatory. When symptomatic we advise urgent removal. If treated on time, the surgical outcome is good and fast recovery is expected.

Multicentre study of magnet ingestion in Spanish paediatric emergency departments.

INTRODUCTION: The ingestion of magnetic objects can cause complications in children, and there are no epidemiological or clinical data on the subject in Spain. OBJECTIVES: To determine the incidence, epidemiological characteristics and management of magnet ingestion in paediatric emergency departments in Spain. MATERIAL AND METHODS: Prospective observational multicentre study conducted over a 3-year period. The study universe consisted of patients aged less than 14 years. RESULTS: The incidence was 4.8 cases per 100 000 emergency care episodes. Of the 72 patients included (mean age, 7.2 years), 54% were male. Seven percent had neuropsychiatric disorders. Sixty-one percent of the magnets were spherical and 69% came from toys. The size was variable, most frequently between 5 and 10 mm (50%), and ranging from 3 to 30 mm. Eighty-six percent of patients were asymptomatic. The most frequent symptom was abdominal pain. Eighty-three percent of the patients sought medical care within 6 h of ingestion and 92% within 24 h. Thirty-one percent of the cases were of multiple ingestion. Endoscopy was required for extraction in 15% of cases, a proportion that rose to 36% in the group of cases of multiple ingestion. None of the patients required surgery. We did not observe any gastrointestinal complications of magnet ingestion. CONCLUSIONS: The ingestion of multiple magnets is less frequent than single magnet ingestion, and we did not observe any complications despite the lower frequency of procedures compared to other studies.

Multiple magnet ingestion in children: A problem on the rise.

AIM: Ingestion of multiple magnets is increasing these last 15 years in children. They have resulted in numerous reports of serious gastrointestinal complications such as bowel obstruction, ischaemia, necrosis, perforation and fistula formation and even led to death. The increasing number of world-wide reports of complications secondary to magnet ingestion and a frequently delayed diagnosis point to a lack of awareness about these risks among medical care-givers in our country and parents in general. METHODS: We reviewed retrospectively all cases of multiple magnet ingestion that required a gastro-intestinal or surgical procedure for removal from 2009 to 2020. RESULTS: Five children underwent gastroscopy removal and three colonoscopy removal of the magnets. Five patients required surgical (laparotomy or laparoscopy) removal of multiple magnets with intestinal perforations. CONCLUSIONS: We propose an updated management algorithm for multiple magnet ingestion to highlight awareness among primary physicians and parents of the presenting circumstances and symptoms as well as the potential complications associated with multiple magnet ingestion.

Magnet and button battery ingestion in children: multicentre observational study of management and outcomes.

BACKGROUND: Magnets and button batteries (BBs) are dangerous ingested foreign bodies in children. The scale and consequences of this public health issue in the UK are unknown. This study aims to report the current management strategies and outcomes associated with paediatric magnet and BB ingestion in the UK. METHODS: This multicentre, retrospective observational study involved 13 UK tertiary paediatric surgery centres. Children aged under 17 years, admitted between 1 October 2019 and 30 September 2020, following magnet, or BB ingestion were included. Demographics, investigations, management, and complications were recorded. RESULTS: In total, 263 patients were identified, comprising 146 (55.5 per cent) magnet, 112 (42.6 per cent) BB, and 5 (1.9 per cent) mixed magnet BB ingestions. Median (interquartile range) age was 4.8 (2.0-9.1) years and 47.5 per cent were female. In the magnet group, 38 (26.0 per cent) children swallowed single magnets, 3 of whom underwent endoscopic retrieval for oesophageal or gastric impaction. Of the 108 (74.0 per cent) children who swallowed multiple magnets, 51 (47.2 per cent) required endoscopic or surgical intervention, predominantly for failure of magnets to progress on serial imaging. Bowel perforations occurred in 10 children (9.3 per cent). Younger age and ingestion of greater numbers of multiple magnets were independently associated with surgery. BB ingestion caused morbidity in 14 children (12.5 per cent) and life-threatening injuries in two (1.8 per cent); the majority were caused by oesophageal BBs (64.3 per cent). CONCLUSION: Multiple magnet and BB ingestions are associated with significant morbidity. Action must be taken at an international level to regulate the sale of magnets and BBs, and to raise awareness of the risks that these objects pose to children.

Management of Magnet Ingestions at a Large Tertiary Care Children's Hospital.

OBJECTIVES: To review the clinical management and outcomes of magnet ingestions at a large tertiary children's hospital. To determine the association of frequency of high-powered magnet ingestion with the regulation of these magnets. METHODS: Children <18 years who presented to the emergency room and were admitted to the Children's Hospital of Philadelphia for ingestion of single or multiple magnets from January 2008 to December 2020 were included. Demographics, symptoms, management, and outcomes were analyzed. The frequency of magnet ingestion was compared over 3 eras: (1) pre-ban (2008-2012), (2) intra-ban (2013-2016), and (3) post-ban (2017-2020). RESULTS: There were 167 magnet ingestions, including 99 with multiple magnets. Most patients (59%) were male and median age was 6 (interquartile range, 3-9) years. Most single magnet ingestions (86%) were discharged with outpatient monitoring, and none experienced severe outcomes. Multiple magnet ingestions led to significant morbidity including hospitalizations (68%), endoscopic procedures (48%), surgical procedures (14%), and severe outcomes (12%). Most patients (75%) were asymptomatic, however, there was a higher risk of surgery and severe complications based on the presence of symptoms ( P = 0.003). The rate of surgical intervention was higher with ≥3 magnets (31.7%) compared to 2 magnets (2.4%) ( P < 0.003). Additionally, we found an 160% increase in children with magnet ingestions in the post-ban period ( P = 0.021). CONCLUSIONS: Multiple magnet ingestion is associated with high morbidity and rate of severe outcomes. There is a relationship between public policy of magnet sale and frequency of magnet ingestion.

High-Powered Magnet Exposures in Children: A Multi-Center Cohort Study.

BACKGROUND AND OBJECTIVES: High-powered magnets were effectively removed from the US market by the Consumer Product Safety Commission (CPSC) in 2012 but returned in 2016 after federal court decisions. The United States Court of Appeals for the 10th Circuit cited imprecise data among other reasons as justification for overturning CPSC protections. Since then, incidence of high-powered magnet exposure has increased markedly, but outcome data are limited. In this study, we aim to describe the epidemiology and outcomes in children seeking medical care for high-powered magnets after reintroduction to market. METHODS: This is a multicenter, retrospective cohort study of patients aged 0 to 21 years with a confirmed high-powered magnet exposure (ie, ingestion or insertion) at 25 children's hospitals in the United States between 2017 and 2019. RESULTS: Of 596 patients with high-powered magnet exposures identified, 362 (60.7%) were male and 566 (95%) were <14 years of age. Nearly all sought care for magnet ingestion (n = 574, 96.3%), whereas 17 patients (2.9%) presented for management of nasal or aural magnet foreign bodies, 4 (0.7%) for magnets in their genitourinary tract, and 1 patient (0.2%) had magnets in their respiratory tract. A total of 57 children (9.6%) had a life-threatening morbidity; 276 (46.3%) required an endoscopy, surgery, or both; and 332 (55.7%) required hospitalization. There was no reported mortality. CONCLUSIONS: Despite being intended for use by those >14 years of age, high-powered magnets frequently cause morbidity and lead to high need for invasive intervention and hospitalization in children of all ages.

Preoperative Imaging of Temporoparietal Scalp Thickness Predicts Off-the-Ear Sound Processor Retention in Cochlear Implants With Diametric Magnets.

OBJECTIVE: To determine if temporoparietal scalp thickness assessed via preoperative imaging predicts retention events in patients who have cochlear implants with diametric magnets and various sound processor types. STUDY DESIGN: Retrospective chart and radiological review. SETTING: Tertiary referral center. PATIENTS: One hundred forty-three adult patients who have cochlear implants with diametric magnets. MAIN OUTCOME MEASURES: Skin flap thickness, retention events, body mass index (BMI), and magnet strength. RESULTS: Of 42 patients with the most recent generation off-the-ear sound processor (OTE2), 13 (31.0%) had retention events. Of patients with a temporoparietal scalp thickness less than 8 mm, all patients could ultimately retain the device, though one of 26 was noted to have tenuous retention. Of patients with 8 to 10 mm skin flaps, 3 of 6 (50%) could not retain the device, and with more than 10 mm skin flaps, 7 of 10 (70%) could not retain the device. In the more than 10 mm group, two additional patients could not either retain the device at initial activation or were noted to have tenuous retention. Of 124 patients with behind-the-ear (BTE) sound processors, only 2 (1.6%) could not retain the device at initial activation, and 3 (2.4%) exhibited tenuous retention after 3 months of device use. Results from the first generation off-the-ear sound processor (OTE1) are also reported. CONCLUSIONS: Temporoparietal scalp thickness measured by preoperative imaging is associated with processor retention for patients with the OTE2 sound processor and diametric magnets. All patients with less than 8 mm scalp thickness could retain the OTE2, while 50% of patients with 8 to 10 mm scalp thickness and 70% with more than 10 mm scalp thickness could not retain the device. Patients should be counseled regarding their sound processor choice and/or considered candidates for skin flap reduction or other intervention as indicated. Retention events with BTE processors are rare.

Wire- and magnetic-seed-guided localization of impalpable breast lesions: iBRA-NET localisation study.

BACKGROUND: Wire localization is historically the most common method for guiding excision of non-palpable breast lesions, but there are limitations to the technique. Newer technologies such as magnetic seeds may allow some of these challenges to be overcome. The aim was to compare safety and effectiveness of wire and magnetic seed localization techniques. METHODS: Women undergoing standard wire or magnetic seed localization for non-palpable lesions between August 2018 and August 2020 were recruited prospectively to this IDEAL stage 2a/2b platform cohort study. The primary outcome was effectiveness defined as accurate localization and removal of the index lesion. Secondary endpoints included safety, specimen weight and reoperation rate for positive margins. RESULTS: Data were accrued from 2300 patients in 35 units; 2116 having unifocal, unilateral breast lesion localization. Identification of the index lesion in magnetic-seed-guided (946 patients) and wire-guided excisions (1170 patients) was 99.8 versus 99.1 per cent (P = 0.048). There was no difference in overall complication rate. For a subset of patients having a single lumpectomy only for lesions less than 50 mm (1746 patients), there was no difference in median closest margin (2 mm versus 2 mm, P = 0.342), re-excision rate (12 versus 13 per cent, P = 0.574) and specimen weight in relation to lesion size (0.15 g/mm2versus 0.138 g/mm2, P = 0.453). CONCLUSION: Magnetic seed localization demonstrated similar safety and effectiveness to those of wire localization. This study has established a robust platform for the comparative evaluation of new localization devices.

Decade of the dangers of multiple magnet ingestion in children: A retrospective review.

AIM: Magnet ingestion has become more frequent in children as magnetic toys and jewellery have been popularised, with the potential to cause significant morbidity. Our aim was to describe our experience at a tertiary paediatric surgical centre. METHODS: Retrospective review of patients admitted with multiple magnet ingestion (January 2011-December 2020). Division into an intervention group and conservative group. Comparisons included demographics, number of magnets and clinical outcomes. Data analysis with a Student's t-test and ROC Curve, P value of <0.05 was significant. RESULTS: A total of 23 patients were identified with a total of 150 magnets ingested. The majority required an intervention for magnets retrieval (15/23, 65.2%), 11/15 (73.3%) surgical and 4/15 (26.7%) endoscopic. In the surgery group, 6/11 (54%) presented with an initial perforation and 1/11 (9.1%) an entero-enteric fistula. One patient (9.1%) had a multi-site anastomotic leak post-operatively. The conservative group had a significantly lower median number of ingested magnets (2 (2-6) vs. 7 (2-40), P = 0.03) and median length of stay (1 (1-4) vs. 7 (1-24), P = 0.03). ROC curve analysis revealed ingestion of >3 magnets had a sensitivity of 86.7% (95% CI: 62.1-97.6%) and specificity of 87.5% (95% CI: 53.0-99.4%) for requiring an intervention. CONCLUSION: This series highlights a significant morbidity in children with a higher incidence of intervention following ingestion of more than three magnets. There is a strong requirement for the creation and adherence to new legislature involving industry standards.

Magnet ingestion knows no borders: A threat for Latin American children.

INTRODUCTION AND AIMS: The ingestion of foreign bodies, such as magnets, is a potentially lethal accident that affects children and is associated with bleeding and gastrointestinal perforation, as well as death. There are no Latin American reports in the literature on cases of magnet ingestion in children. Our aim was to establish whether said ingestion has been seen by pediatric endoscopists and gastroenterologists in Latin America, to determine the scope of that potential threat in their patient populations. MATERIALS AND METHODS: We collected data regarding endoscopies performed on children in Latin America, within the time frame of 2017-2019, through questionnaires that were distributed to pediatric endoscopists at the 2nd World Congress of Gastrointestinal Endoscopy (ENDO 2020). The questionnaires provided information on foreign body location, the presence and number of ingested magnets, and the description of complications and surgical interventions. RESULTS: Our cohort from 12 Latin American countries reported 2,363 endoscopies due to foreign body ingestion, 25 (1.05%) of which were the result of having swallowed one or more magnets. Mean patient age was 5.14 years (SD 2.5) and 10 (40%) of the cases were girls. Three (12%) of the patients presented with severe complications and 2 (8%) cases required surgery. CONCLUSIONS: Our preliminary study suggests that the ingestion of magnets is not common in Latin American countries, but said cases are frequently associated with complications. Constant monitoring of the incidence of such cases is extremely important, so that through education and awareness of those events, life-threatening complications in children can be prevented.

Ball magnet ingestion in children: a stronger and more dangerous attraction?

INTRODUCTION: The ingestion of small, strong, rare-earth magnets, also termed 'ball magnets', can rapidly result in life-threatening bowel injuries. The objective of this study was to report the incidence and management of 'ball magnet' ingestion in children across the UK and to discuss the potential implications for policy-makers and public awareness campaigns. METHODS: In this multi-centre survey of UK major trauma centres (MTCs), paediatric patients admitted to hospital following 'ball magnet' ingestion from 1 January 2020 to 31 December 2020 were included. RESULTS: Responses were received from 11 MTCs (52%) reporting a total of 53 children admitted with 'ball magnet' ingestion over the 1-year study period. Most patients (n=51) presented following unintentional ingestion. 36 (68%) patients presented asymptomatically following witnessed or reported ingestion. In symptomatic patients, abdominal pain and vomiting were the the most common symptoms. The median number of 'ball magnets' ingested was 5.0 (IQR 3.0-7.8), range 1 to 63. 27 (51%) patients underwent operative intervention; laparotomy being the the most common (n=24, 89%). There were no deaths reported during the study period. CONCLUSION: This multi-centre survey from the UK demonstrates the serious impact of 'ball magnet' ingestion in children. Clinicians, regulators and caregivers must work symbiotically in order to prevent, recognise and reduce life-threatening bowel injuries.