See “Commentary: Button Batteries in Fidget Spinners: Is It Time to Push the “Panic Button”?” by Bousvaros and Rufo on page 557.
Most foreign body ingestions occur in younger children, mainly boys and less than 5 years of age (1,2). Although most objects spontaneously pass, a number of complications including bowel obstruction, perforation, and severe bleeding have been reported. The fidget spinner (FS) is a new toy made of metal or plastic and consists of a central bearing surrounded by three arm-pods, which rotate around the center. FS may be upgraded to include light-emitting diodes and button battery components. Sporadic reports have emerged warning of injuries due to the esophageal retention of FS parts (3,4). We report a gastric injury caused by an ingested FS bearing cap.
The patient is a healthy 3-year-old boy who was playing with a metallic FS. At some point, the center-bearing cap of the FS was removed. Ingestion of the FS cap by the patient was witness by the older brother. He was immediately brought to a community hospital. The FS cap was found in the antrum on abdominal x-ray. The patient was asymptomatic and thus discharged home for monitoring. Four-hour post-ingestion, the patient developed abdominal pain, nausea, and non-bilious emesis of food particles. There was no hematemesis or melena. He was brought back to the community hospital and then transferred to the academic medical center for further management. The FS cap remained in the stomach on x-ray 8 hours post-ingestion (Fig. 1 Panel A). There was no evidence of viscous perforation on the radiograph, but he failed an oral challenge. He was admitted for hydration, observation, and was fasted. His complete blood count at admission was normal (hemoglobin of 13.1 g/dL and platelet count of 193,000). Intravenous ondansetron and famotidine were given. The nausea resolved; however, he remained tender on examination. The FS cap remained in the fundus of the stomach on repeat x-ray. Because of the persistent tenderness on examination, the decision was made to remove the FS cap endoscopically.
At 17 hours post-ingestion, upper endoscopy was performed. There was minimal esophagitis. Vegetable matter, clear fluid, and the FS cap was noted in the fundus (Fig. 1 Panel B). There was prolapse gastropathy. The FS cap was removed using a Roth Net. A 13-mm linear ulcer was found at the site of removal (Fig. 1 Panel C). In the gastric body, a 3 to 4 mm circular erosion was noted. In the pre-pyloric region of the antrum, twin kissing 13 mm linear ulcers with stigmata of bleeding were noted (Fig. 1 Panel D). Histology from esophageal and gastric body biopsies was unremarkable. An antral biopsy contained chronic active inflammation, but Helicobacter pylori was not found on immunostaining. Rapid urease testing was negative.
The FS cap measured 23 to 24 mm in diameter (Fig. 1 Panels E and F). The FS cap had a 2 mm raised edge, which was fairly sharp due to its small width. There was a 4 mm tall, threaded plastic peg in the center of the cap. There were no battery components to the FS cap. The patient was treated with acid suppression for a total of 8 weeks. He remained well at the time of follow-up.
FS were first patented in 1997 but only came to market in its current form after the original patent expired in 2014 (5). The loss of patent protection has allowed companies to mass market inexpensive and largely unregulated devices. The low cost and ease of access to the FS has led to the device's fad like adoption. FS are also used as a distraction device, and thus have been labeled by some manufacturers as having properties that reduce anxiety and even attention deficit hyperactivity disorder, though these claims have not been studied. Although there have been several claims of personal injury from FS in the lay press (4), tracking these claims through the US Consumer Product Safety Commission has been difficult because of the inability to track specific manufacturers to individual spinners. A search of the SaferProducts.Gov public database for FS resulted in only 2 reports (6). The Consumer Product Safety Commission has now issued a warning on the hazards of the FS, such as choking, esophageal injury due to lithium cell battery ingestion, and fire hazards from rechargeable batteries (7).
This is the first report of an ingested FS bearing cap causing a gastric injury within 24 hours of ingestion. Other causes of gastric ulceration were excluded. Recently, the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition published a clinical report on the management of foreign bodies in children (8). The writers suggest that smooth disks (coins) under 23.5 mm were more likely to pass, whereas disks greater than 25 mm are more likely to become impacted in children less than 5 years old. The FS cap ingested in this case was a round disk that measured 24 mm, falling in the center of these recommendations. Therefore, it was less likely that the FS cap would pass the pylorus in this 3 years old patient. The raised, thin edge of the FS cap, however, resulted in a sharp surface. This configuration of the sharp edge was not recognized until the time of the endoscopy. The FS cap also had a threaded peg. Inspection of a similar FS cap at the time of presentation or a lateral abdominal x-ray may have provided additional information to the endoscopist and better classify the clinical scenario as an ingestion of a sharp object with clinical symptoms. In this scenario, emergent removal is suggested. We suspect that the raised edge and threaded peg surfaces caused the superficial lacerations observed. Other FS caps do not have raised or threaded surfaces; therefore, one may speculate that caps with smooth edge designs would be less likely to cause a mucosal injury.
In conclusion, we report a case of a gastric mucosal injury caused by the ingestion of a FS bearing cap. Given the popularity of the FS, one would expect the frequency of gastrointestinal injuries caused by ingestion of dislodged or broken toy parts to increase over time. Specific design features such as threaded pegs or raised edges on the bearing cap may increase the risk of injury. Identification of these features may raise the urgency of removal of FS parts in small children.
1. Louie MC, Bradin S. Foreign body ingestion and aspiration. Pediatr Rev
2. Bornstein AC, Spyker DA, Cantilena LR Jr, et al. 2011 annual report of the American Association of Poison Control Center's National Poison Data System (NPDS): 29th annual report. Clin Toxicol (Phila)
3. Koo J, Tamura DY. Fidget spinner battery-LED unit ingestion in a 13-month-old boy. Clin Pediatr (Phila)
4. Wesley L. Fidget spinner toy cause Oregon boy to choke. Available at: http://katu.com/news/local/fidget-spinner-toy-causes-oregon-boy-to-choke
. Accessed October 1, 2017.
5. Brustein J. How the fidget spinner origin story spun out of control. Bloomberg Technology Report. Available at: https://www.bloomberg.com/news/articles/2017-05-11/how-the-fidget-spinner-origin-story-spun-out-of-control
Accessed October 1, 2017.
6. SaferProducts.gov product search. Available at: https://www.saferproducts.gov/Search/Result.aspx?dm=0&q=fidget+spinner&srt=0
Accessed October 1, 2017.
7. Statement from acting chairman Ann Marie Buerkle regarding fidget spinners. Available at: https://www.cpsc.gov/about-cpsc/chairman/ann-marie-buerkle/statements/statement-from-acting-chairman-ann-marie-buerkle-1
. Accessed October 1, 2017.
8. Kramer RE, Lerner DG, Lin T, et al. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Endoscopy Committee. Management of ingested foreign bodies in children: a clinical report of the NASPGHAN endoscopy committee. J Pediatr Gastroenterol Nutr