BAD DENTITION AND RISK OF JEJUNAL PERFORATION BY FISH BONE

Abstract

To the Editor: Despite the frequency and variety of foreign bodies ingested, secondary intestinal perforation is a rare occurrence. Preoperative diagnosis using computed tomography (CT) scan is rarely made because of the lack of radiographic contrast of nonmetallic foreign objects. A case of jejunal perforation by a fish bone is reported. Diagnosis was made using abdominal helical CT scan, and surgery was immediately performed. This clinical case allows us to discuss the several fish bone perforation sites and the patient precipitating factors. Coloenteric perforation by foreign bodies is a rare occurrence and therefore a difficult preoperative diagnosis. A case of jejunal perforation by a fish bone in an old man with bad dentition is reported. Diagnosis was made using computed tomography (CT) scan before operating. An 81-year-old male patient suffering from lower left quadrant abdominal tenderness associated with fever (>38.5°C) and elevated white blood cell count (15,000/mm3) was admitted to the emergency service. His medical history included several laparotomies for cholecystectomy, obstruction of the bowel caused by adhesions, and incisional hernia. Plain abdominal x-ray showed gas shadows in the lower left quadrant without pneumoperitoneum. The CT scan revealed jejunal perforation by a nonmetallic foreign body suggestive of a fish bone (Figure 1). The laparotomy revealed lower left quadrant peritonitis and jejunal perforation by the fish bone, as seen on the CT scan. Removal of the fish bone, suture of the jejunal perforation, debridement, and washing and drainage of the abdominal cavity were performed. The postoperative course was uneventful, and the patient was discharged 12 days after his surgery. The patient was well at his 1-year follow-up. He reported retrospectively that he had eaten fresh fish 2 days before the surgical intervention and did not feel any pain during his lunch. Abdominal computed tomography scan (frontal view) showing the fishbone (white arrow) perforating the small bowel and the macroscopic view of the fishbone. This case is particularly interesting because the peritonitis was discovered preoperatively using a CT scan. The patient's bad dentition certainly contributed to this complication. Ingestion of nonmetallic foreign bodies leading to intestinal perforation is a rare occurrence because most foreign bodies pass spontaneously per anus.1 Perforation by foreign bodies can occur anywhere in the gastrointestinal tract. Fish bones are more often responsible for perforation of the esophagus, complicated by mediastinitis.1 Other parts of the upper digestive tract, such as the stomach or the duodenum, may be perforated.2 Fish bones may also pass through the gastrointestinal tract and enter other organs of the abdominal cavity such as the liver and the pancreas. One case of a fish bone totally integrated into the hepatic parenchyma has been recently reported.3 The small bowel4 or the large bowel5,6 may be perforated too, and cases of Meckel's diverticulum7 perforation have been described. The clinical manifestations of gastrointestinal perforation by foreign bodies are variable. Symptoms may be acute, showing signs of peritonitis associated with pneumoperitoneum visible on plain abdominal x-ray,7 although the patient may present more-indolent symptoms attributable to carcinoma or chronic disease. One study reported a clinical case of an 80-year-old woman presenting a painless, hard epigastric mass on physical examination 8 days after fish ingestion.5 She received an antibiotic treatment for abdominal pain secondary to the initially unsuspected perforation of the large bowel by a fish bone. Diagnosis was made at laparotomy. In the case of late diagnosis, a fish bone located inside the duodenum and pancreas was found several months after ingestion.2 As with the current patient, elderly persons are more at risk because of the bad quality of their dentition, which is responsible for a lack of mastication.5,8 Some cases of intestinal perforation by fish bone discovered using helical CT scan have been previously described.1,4,6 Ileal or jejunal perforation by fish bone is a rare occurrence of gastroenteric perforation. Preoperative diagnosis may be made using abdominal helical CT scan in an emergency. It is necessary to carefully remove the bones from fish that elderly persons eat because of the lack of mastication and the bad quality of dentition. Financial Disclosure: None. Author Contributions: Brice Dugas: preparation of manuscript. Bénédicte Bernard: preparation of manuscript. Pierre-Jean Valette: acquisition of subjects and data and analysis and interpretation of data. Emmanuel Odet: preparation of manuscript. Alain Naouri: preparation of manuscript. Pierre Bernard: acquisition of subjects and data, analysis and interpretation of data, and preparation of manuscript. Sponsor's Role: none.