Accidental ingestion of fishbones is a common issue, especially among cultures in which unfilleted fish ingestion occurs regularly. Fortunately, most fishbones pass the gastrointestinal tract in less than a week. However, some patients may present with bowel perforation.
Although bowel perforation by a fishbone is uncommon, and fewer than 1% of ingested fishbones perforate the bowel, fishbones are the most commonly ingested objects and the most prevalent cause of bowel perforation. The perforation can occur in all segments of the bowel, but it is more prevalent in regions with angulations, such as the ileocecal valve and the rectosigmoid junction.
The diagnosis of fishbone bowel perforation may be clinically and radiologically challenging as the patient is usually not aware of having ingested a fishbone and presents with nonspecific abdominal pain. Imaging features are nonspecific, pneumoperitoneum is rare, and the fishbone is not always characterized.
A 77-year-old man with a medical history of open hiatus hernia repair and appendectomy came to the Emergency Department complaining of two days’ nausea and constipation associated with mesogastric pain. He was hemodynamically stable, with no abdominal pain and with an axillary temperature of 37.6ºC. A blood test showed 23000 leukocytes with high CRP. There were no findings in the abdominal and thoracic x-rays. A CT scan was performed which showed inflammatory changes in a bowel loop with fat stranding and pneumoperitoneum associated with a hyperdense structure compatible with a foreign body. (FIG1, FIG2)
It was decided to perform an exploratory laparoscopy, but due to adhesions was it converted into a midline laparotomy. A 10-cm bowel loop was found with inflammatory changes in its wall, a purulent abscess covered by a twist in the bowel loop, and a fishbone perforating the bowel. A bowel resection with side-to-side mechanic anastomosis was performed.
The postoperative evolution was uneventful, with a per os diet in the first postoperative day and discharge in the fourth postoperative day.