Ingested fish bone with sealed duodenal perforation

Case contributed by Dr Ammar Ashraf

Presentation

Sever colicky epigastric pain for 5 days, associated with anorexia and relative constipation. Past medical history of hepatitis A. High C-reactive protein (CRP) in laboratory work up. No other significant clinical or laboratory findings.

Patient Data

Age: 60 years
Gender: Female

A linear radiopaque structure measuring approximately 4.2 cm in length is seen along the third part of the duodenum. It has an average density of 140 Hounsfield units (HU). Its proximal 1.6 cm is lying within the duodenal lumen whereas its remaining part is penetrating through the anterior wall of the duodenum and lying extra-luminally. Mild focal thickening of the third part of the duodenum is seen. Mild fat stranding is seen in the surrounding mesentery. No oral contrast extravasation is seen. No free fluid or collection is seen. No pneumoperitoneum is seen as well.

Enlarged coarse liver with cirrhotic changes and associated features of portal hypertension (splenomegaly, enlarged portal vein & splenic hilum varices).

Based on those radiological findings, possibility of sealed perforation of third part duodenum caused by ingested fish bone was raised. After CT scan, a detailed history was taken again which was positive for fish meal a few weeks back.

The patient underwent upper GI endoscopy, and 4.5 cm long fish bone was removed from third part of the duodenum and perforated site was sealed by two metallic endoclips.

Upper GI series after endoscpoic removal of fish bone

Fluoroscopy

Upper GI series (gastrografin) was performed 24 hours after endoscopic removal of fish bone which did not show any oral contrast extravasation. Two metallic endoclips are seen in third part of duodenum on scout film. 

Case Discussion

Fish is not only the most commonly ingested foreign bodies (46-88% of all adult foreign body admissions, in emergency department) but also the most common cause of gastrointestinal tract perforation 1,2. The most important risk factor for fish bone ingestion is the use of artificial dentures (80% cases) 3.  

Perforation most commonly occurs in areas of physiological angulation or narrowing, such as terminal ileum (up to 83% of all cases), followed by recto-sigmoid colon and duodenum 1,3.  Clinical presentation is quite variable and correct preoperative diagnosis is made in only 23% cases and the remaining patients are diagnosed as other common clinical entities, like peptic ulcer disease, pancreatitis, cholecystitis, appendicitis or diverticulitis 3

Computed tomography (CT) scan is currently the imaging modality of choice in cases of suspected fish bone ingestion 2. In addition to the site of perforation, direct visualization of culprit fish bone is also possible with careful evaluation with a “bone window” setting. If an impacted fish bone is visualized in the proximal gastrointestinal tract (esophagus & stomach); then it should be further evaluated whether it has an endoluminal component or not (important point regarding its management) 4

Management depends on the location of fish bone in the digestive tract and the presence or absence of associated complications (perforation, hemorrhage or obstruction) 1. Fish bones impacted in proximal gastrointestinal tract (esophagus or stomach) having a clear endoluminal component and no signs of complications are preferably removed endoscopically, whereas those located in distal small bowel are surgically (laparoscopically) treated 1,4

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