Small Bowel Perforation by a Clinically Unsuspected Fish Bone: Laparoscopic Treatment and Review of Literature

Abstract

Despite the relative common incidence of accidental foreign body ingestion in the general population, foreign bodies are estimated to only infrequently result in intestinal perforation or other complications. Bowel perforations resulting from unintentional foreign body ingestion are exceedingly difficult to diagnose preoperatively, and often, the patient has no memory of foreign body ingestion. In contrast, intentional foreign body ingestions are more commonly associated with malingering in prisoners and psychiatric patients. Psychiatric disorders such as psychosis, pica, and severe personality disorders are also associated with intentional foreign body ingestion. Symptoms of unrecognized foreign body ingestion may mimic those of appendicitis or diverticulitis, resulting in diagnostic uncertainty. Clinically unsuspected accidental foreign body ingestions may be difficult to diagnose based on physical examination and standard diagnostic techniques. Multiple case reports and series have evaluated intestinal perforation due to clinically unsuspected foreign bodies. Although radiographic imaging using multidetector computed tomography (MDCT) occasionally identifies the ingested foreign body, ingested foreign body perforations are more commonly diagnosed during laparotomy for an acute abdomen. Few instances of completely laparoscopic treatment of ingested foreign body resulting in bowel perforation have previously been reported. The present report evaluates an instance of a clinically unsuspected foreign body perforation of the small bowel by a dietary fish bone in a high-risk surgical candidate. The merits of a combined diagnostic approach of radiologic imaging and laparoscopic surgical exploration are highlighted. This technique allows rapid diagnosis and therapeutic intervention while minimizing risk in patients with elevated preoperative risk.