Can J Biomed Res & Tech

October 2019 Vol: 2, Issue:2

© All rights are reserved by Pedro Monsalve

Gastric Perforation by Fish Bone Case

Report
Open Access Case Report

Pedro Monsalve, Gabriela Lombardo P and Elaine Bastardo*

Abstract Department of plastic Surgery Service, Venezuela

Introduction *Address for Correspondence

Pedro Monsalve, Caracas Universitary Hospital at the Service of
General Surgery II, Venezuela
The ingestion of foreign bodies is usually accidental and
asymptomatic due to the non-specificity of the symptoms, it is Submission: September 23, 2019
Published: October 03, 2019
observed more frequently in patients with psychiatric illnesses,
children and elderly people. Copyright: © This work is licensed under Creative Commons
Attribution4.0 License
Case presentation
initially treated as a pancreatic head tumor, and after
A 70-year-old male patient attended the emergency due to pain performing a diagnostic laparoscopy showed a perforation by a
of high intensity localized in the epigastrium, with the presence fishbone.
of a palpable, painful mass with irregular edges.
Case Report
Discussion
A 70-year-old male patient consulted for abdominal pain of
Only in 23% of the cases the preoperative diagnosis is obtained, progressive intensity in the epigastrium and multiple febrile
therefore, it is necessary to consider the epidemiological hooks of 39 °C. Physical examination shows a loss of 2.5Kg
antecedents, perform laboratory tests, image evaluation and compared to his usual weight and a flat abdomen not irritated
correct physical examination, since this can be confused with but painful to deep palpation in the epigastrium with a mass of
tumors, for example, pancreatic head carcinoma. ill-defined edges of approximately 6cm in diameter.
Laboratory tests showed leukocytosis with deviation to the left,
Conclusion with elevation of alkaline phosphatase (ALP) without alteration
of the rest of the hepatobiliary profile, amylase / lipase, with
The perforation caused by ingestion of fishbone is observed serologies and negative tumor markers (CA-19-9, CEA, and
only in 1% of the cases and the diagnosis is usually confirmed AFP).
during the surgical act, in retrospective the interrogation always
throws information so it should be taken into account before In the ecosonogram (Figure 1), a cystic-looking image with
lesions collections or abscesses abdominals of doubtful low-level echoes in its interior, approximately 20x13mm in
etiology. diameter, was evidenced in the head of the pancreas, while in
the double-contrast tomography (Figure 2) it was observed a
Introduction space-occupying lesion behind the posterior gastric wall
towards the omentum recess, adjacent to the hypodense
80-90% of foreign bodies ingested are digested and expelled pancreatic head, with ill-defined edges, with attenuation
without causing symptoms; of the remaining percentage- coefficients within the solid and liquid range of approximately
depending on the shape and size-less than 1% remain in the 5.6x5.6cm diameter. On the other hand, upper gastrointestinal
stomach and can cause a perforation and affect adjacent organs endoscopy showed a rounded lesion that pushed the posterior
such as the pancreas [1]. This is usually manifested as an intra- aspect of the cardia. A puncture was made and a purulent fluid
abdominal abscess in 71% of cases with clinical manifestations was drained from which sample was taken for cytology and
at days and even weeks after ingestion and whose etiology is a culture, which turned out to be an inflammatory exudate with
mystery for the surgical team. Although these patients are abundant polymorphonuclears and basophil bacterial
studied exhaustively with radiological and endoscopic aggregates (Actynomices). The patient is managed with
techniques, it is not until the very surgical act where the final medical treatment and antibiotic therapy for several weeks,
diagnosis is made, and when generally very aggressive however when there is no evidence of improvement and in
approaches have been made [2,3]. In the present article, we view of the persistence of the symptoms, a diagnostic
report the case of a patient who presented with a palpable laparoscopy was planned. During the surgical act, the insertion
abdominal mass in the epigastrium who was diagnosed and of the greater omentum was dissected with the greater gastric

Citation: Pedro Monsalve. Gastric Perforation by Fish Bone Case Report 2019;2(2): 5.
© All rights are reserved by Pedro Monsalve.
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curvature to access the transcavity of the omentum and a
foreign body was found that came from the stomach,
perforating the posterior wall and making contact with the head
of the pancreas (Figure 3). It was removed and after a cavity
aspiration and washing, the surgery was completed.

Figure 1.

Figure 3.

When the foreign body was examined, it was determined that it

was a fishbone, information that was later corroborated by the
same patient when he was re-interrogated and even
retrospectively diagnosed in the tomography performed. The
patient presented immediate improvement, progressed
satisfactorily and was discharged.

Discussion

The unconscious ingestion of foreign bodies usually comes

from food, and almost two thirds of these are: fish bones,
chicken bones and rinds [4]; most go through the
gastrointestinal tract (GIT) without manifestations in about 1
week and complications, such as perforations, are not common
[5], therefore the diagnosis is difficult; In up to 23% of the
cases, the correct preoperative diagnosis is made, the other
cases being confused with pancreatic carcinoma, acute
Figure 2. cholecystitis, appendicitis, diverticulitis, intestinal obstruction,
gastric stromal tumors (GIST) or even an incarcerated

Citation: Pedro Monsalve. Gastric Perforation by Fish Bone Case Report 2019;2(2): 5.
© All rights are reserved by Pedro Monsalve.
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hernia[6-8]. The symptomatology is non-specific and clinically in the same way we could verify it in the study of our patient
it can present as an acute abdomen, peritonitis, intra-abdominal prior to the administration of the contrast (Figure 4) [16].
abscesses, fistulas, among others [9]; in addition, patients do
not refer or remember the intake of foreign bodies, there may
even be a considerable period of time (months, years) between
the intake and the appearance of symptoms, which is why it is
considered that at some point these cases will require a surgical
approach [10].

For the differential diagnosis it is necessary to thoroughly

investigate the medical and epidemiological antecedents of the
patient, the physical examination along with the anamnesis, the
results of the evaluation by image, laboratory tests and analysis
of selective tumor markers such as AFP, CA 19-9 and CEA;
The most commonly used tumor marker to identify a pancreatic
neoplasm is CA 19-9 [11]. Liver enzymes are usually within
normal or occasionally elevated limits. The people with greater
risk are patients with psychiatric illnesses such as schizophrenia
and depression, also alcoholics, children and the elderly [7-9];
It is also seen in dental prosthesis carriers that present
desensitization of the palate [4]. Most perforations occur in the
angulated areas, such as, cisura angularis, rectosigmoid
junction, pyloric region, duodenum or ileocecal valve, although Figure 4.
they have also been reported in other organs such as the bladder
and liver [1,12,13]. In this case, the patient presented only In this article the authors did not suspect the foreign body
leukocytosis with an increase in ALP. ingestion for several reasons:
Three mechanisms have been postulated to explain the a) The patient did not refer it in the interrogation;
perforation of foreign bodies: b) The patient was afebrile;
c) There was no leukocytosis; and
a) The small and sharp body is pushed through the wall d) The diagnosis of pancreatic mass by foreign body had
with minimal necrosis; not been described.
b) The body produces an area of necrosis that migrates
through the wall of the viscus; However, in this case, our patient had some indications that
c) The foreign body produces an area of necrosis that could have guided the diagnosis:
perforates secondarily after the object has crossed the
wall; A) Fish was part of his usual diet;
B) Fever was always present;
However, the foreign body does not necessarily have to pass C) There was leukocytosis and
through the wall to perforate it, but a process of necrosis and D) There are already some similar cases described in the
pressure of the wall occurs [5]. Gastric perforations are usually literature.
observed in the lesser curvature, the foreign body can partially
perforate the wall causing inflammatory changes and The second case was also described by Goh et al in a 32-year-
subsequently a perigastric abscess; In some cases, a liver old patient with peritoneal irritation and leukocytosis who was
abscess can form when the anterior gastric wall penetrates taken on a surgical shift for an emergency laparotomy where
completely or the first portions of the duodenum that are in an abscess involving the duodenum, head of the pancreas and
contact with the left hepatic lobe [14]. It has been shown that the caudate lobe of the liver, caused by a fishbone that
spines wider than 2cm and greater than 5cm in length usually perforated the duodenum. In this case the drainage and
stay housed inside the gastric cavity [3]. antibiotic therapy were the applied treatment [17].
The first abscess on account of foreign body was reported by The third case described was by Yasuda et al in a 73-year-old
Lambert in 1898, [15] and since then many cases have been patient with abdominal pain and leukocytosis, with elevated
documented including those caused by fishbone; The first case CRP who developed peritonitis and who underwent an
of secondary pancreatic mass due to foreign body migration emergency exploratory laparotomy where it was found that a
(fishbone) was described by Goh et al; in this study they 4cm fishbone penetrated the first portion of the posterior
postulate, as in our case, that the fishbone perforated the duodenal wall towards the head of the pancreas [18]. Bajwa,
posterior gastric wall and migrated to the pancreas forming an described the first case of a lesion similar to a GIST in the
abscess; in retrospect, they observed a radiopaque image on the posterior gastric wall that, when removed in a distal
CT scan that turned out to be the spine and not a blood vessel,

Citation: Pedro Monsalve. Gastric Perforation by Fish Bone Case Report 2019;2(2): 5.
© All rights are reserved by Pedro Monsalve.
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gastrectomy, reported an inflammatory infiltrate around a 747-749.
fishbone in the histological study [19]. 6. Maleki M, Evans W (1970) Foreign-body perforation of
the intestinal tract. Report of 12 cases and review of the
A prospective study of 358 patients who ingested fish bones literature. Arch Surg 01: 474-477.
showed that the use of simple radiographs to make the 7. Kim SW, Song SK (2014) Gastric pseudotumoral lesion
diagnosis is not reliable (32%) and depends on the degree of caused by a fish bone mimicking a gastric submucosal
radiopacity of the fish bone, which is usually very low. The tumor. J Gastric Cancer 14(3): 204-206.
tomography on the other hand has been more sensitive in the 8. Beecher SM, O'Leary DP, McLaughlin R (2015)
initial evaluation (71.4%) with improvement to 100% in Diagnostic dilemmas due to fish bone ingestion: Case
retrospective evaluations; revealing the spine as a linear report & literature review. Int J Surg Case Rep 13: 112-
calcification, however there must be a high suspicion [20]; The 115.
main limitation of CT is the lack of suspicion of the observer 9. Mesina C, Vasile I, Valcea DI, Pasalega M, Calota F, et al.
[13]. (2013) Problems of diagnosis and treatment caused by
ingested foreign bodies. Chirurgia 108(3): 400-406.
Recent studies have shown that mortality due to liver abscess is 10. Ali FE, Al-Busairi WA, Esbaita EY, Al-Bustan MA
approximately 11-33% and the causative agent responsible for (2005) Chronic perforation of the sigmoid colon by
the most frequent inflammatory process is Streptococcus, foreign body. Curr Surg 62(4): 419-422.
however, in most cases it is unknown [21]. When upper 11. Wang WG, Zhang Y, Wang L, Chen Y, Tian BL (2015)
gastrointestinal endoscopy was performed, the lesion was Chronic pancreatic inflammatory granuloma caused by
observed on the posterior aspect of the cardia, in contact with foreign body presenting as a pancreatic pseudotumor: A
the gastric wall, body of the pancreas and left hepatic lobe; in case report and literature review. Pancreatology 15(5):
the cytomorphological findings according to the observed 573-575.
characteristics, compatibility with Actinomyces was obtained. 12. Sierra-Ruiz M, Saenz-Copete JC, Enriquez-Marulanda A,
Ordonez CA (2016) Extra luminal migration of ingested
Conclusion fish bone to the spleen as an unusual cause of splenic
rupture: Case report and literature review. Int J Surg Case
Although practically all ingested foreign bodies are eliminated Rep 25: 184-187.
asymptomatically, it should be taken into account that 1% of 13. Goh BK, Tan YM, Lin SE, et al. (2016) CT in the
cases cause perforations, and these usually affect mainly the preoperative diagnosis of fish bone perforation of the
stomach, pancreas or liver; therefore, this possibility should be gastrointestinal tract. AJR Am J Roentgenol 187(3): 710-
considered in the case of abdominal sepsis, collections or 714.
suspicious abscesses (and particularly in infections by atypical 14. Paixao TS, Leao RV, de Souza Maciel Rocha Horvat N, et
germs). It is a difficult diagnosis that usually emerges as a al. (2017) Abdominal manifestations of fishbone
differential only if the suspicion is raised and although the perforation: a pictorial essay. Abdom Radiol 42(4): 1087-
exhaustive interrogation usually provides important data it is in 1095.
the surgical time where this suspicion is confirmed. With this in 15. Lambert A (1989) Abscess of the liver of unusual origin.
mind, it is possible to plan a minimally invasive approach and NY Med J 1898:177-8.
avoid counterproductive results derived from aggressive 16. Goh BK, Jeyaraj PR, Chan HS, Hock-Soo Ong,
behaviors. Thirvgnanam A, et al. (2004) A case of fish bone
perforation of the stomach mimicking a locally advanced
pancreatic carcinoma. Dig Dis Sci 49(11): 1935-1937.
References 17. Goh BK, Yong WS, Yeo AW (2005) Pancreatic and
hepatic abscess secondary to fish bone perforation of the
1. Nunez Martinez O, Sanz Garcia C, Perez Enciso I, duodenum. Dig Dis Sci 50(6): 1103-1106.
Holguera Ortiz L, Alberdi Alonso JM (2017) Endoscopic 18. Yasuda T, Kawamura S, Shimada E, Okumura S (2010)
resolution of gastric perforation with pancreas penetration Fish bone penetration of the duodenum extending into the
by a fish bone. Gastroenterol Hepatol 41(19): 567-568. pancreas: report of a case. Surg Today 40(7): 676-678.
2. Huang YH, Siao FY, Yen HH (2013) Pre-operative 19. Bajwa A, Seth H, Hughes F (2007) Ingested fishbone
diagnosis of pancreatic abscess from a penetrating fish mimicking a gastric submucosal tumour. Grand Rounds 7:
bone. Qjm 106(10): 955-956. 42-44.
3. Koch H (1977) Operative endoscopy. Gastrointest Endosc 20. Ngan JH, Fok PJ, Lai EC, Branicki FJ, Wong J (1990) A
24: 65-68. prospective study on fish bone ingestion. Experience of
4. Velitchkov NG, Grigorov GI, Losanoff JE, Kjossev K 358 patients. Ann Surg 211(4): 459-462.
(1996) Ingested foreign bodies of the gastrointestinal tract: 21. Bandeira-de-Mello RG, Bondar G, Schneider E, Wiener-
retrospective analysis of 542 cases. World J Surg 20: 1001- Stensmann IC, Gressler JB, Kruel CRP (2018) Pyogenic
1005. Liver Abscess Secondary to Foreign Body (Fish Bone)
5. Daniell SJ (1982) Foreign body perforation of a jejunal Treated by Laparoscopy: A Case Report. Ann Hepatol
diverticulum. Journal of the Royal Society of Medicine 75: 17(1): 169-173.

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