Endoscopic Removal of Gastric Perforating Fish Bone

Abstract

Introduction: A foreign body ingestion in adults is usually diagnosed by medical history. In most cases, the foreign body passes through the gastrointestinal tract uneventfully. Complications such as perforation are rare and usually occur in areas of angulation or narrowing such as the gastric antrum. We present a case of an unintentional perforating fish bone ingestion that was found incidentally on cross-sectional imaging and was managed endoscopically. Case description: A 51-year-old woman presented to the hospital for subacute upper abdominal pain. The patient described the pain as crampy, accompanied by waxing-waning nausea and dry heaves. She had melena 2 weeks prior, for which she underwent a colonoscopy and an EGD which revealed polyps that were removed endoscopically. Her prior surgical history included open nephrectomy for a right kidney swelling. On examination, the patient was afebrile, hemodynamically stable and in no apparent distress. Her abdomen was soft, non-distended with mild epigastric tenderness, and no guarding or rebound tenderness. Lab tests revealed a white cell count of 12,600/mm3 and hemoglobin of 13.1 g/dl. A CT scan of the abdomen revealed a 3.2 cm intramural curvilinear foreign body within the gastric antrum, with an associated thickened antrum and pylorus and no evidence of extra-luminal air or bowel obstruction. After further questioning, the patient reported having eaten fish 3 weeks ago and had a fish bone stuck in her throat, which she was able to cough out. An urgent upper endoscopy was performed - revealing a large fish bone perforating through the gastric incisura. An overtube was placed and the fish bone was removed using a rat tooth forceps. The defect was closed with an over-the-scope clip. The patient post-endoscopy course was uneventful and she was discharged home. Discussion: Since foreign body ingestion is usually uneventful, conservative treatment is warranted in the majority of cases. Complications are more likely with foreign bodies that are sharp such as fish bones. CT is the most sensitive in locating the causal fish bone, most often appearing as a high-density linear structure within inflamed tissue. In our case, the foreign body finding on abdominal CT and the history of ingested fish bone, raised a high index of suspicion for a perforating fish bone, indicating urgent endoscopic intervention. Fish bone migrating into solid organs or intraperitoneal areas would require surgical intervention.1865_A Figure 1. Abdominal CT1865_B Figure 2. No Caption available.1865_C Figure 3. Endoscopic clip