A fish bone perforation of the esophagus

A 73-year-old man presented with odynophagia and retrosternal pain of 3 days’ duration following a fish meal. Physical examination disclosed normal vital signs and a temperature of 37.2 °C. Laboratory studies showed elevated white blood cells of 13 900/μL and C-reactive protein of 14.8 mg/dL. A computed tomography (CT) of the chest revealed a suspicious fish bone that measured 3 cm in length and had perforated through the esophageal wall ([Fig. 1] and [Fig. 2]). Three-dimensional CT showed the bone (blue matter) penetrating close to the left common carotid artery ([Fig. 3]). Subsequent upper endoscopy revealed only a small submucosal nodule, which was located at 19 cm from the incisors, not an impacted fish bone in the upper esophagus ([Fig. 4]). A tiny white linear scar (arrow) was observed on its top, suggesting the site of perforation ([Fig. 5]). Surgical exploration was performed via a lateral neck incision, and the fish bone was successfully retrieved. The postoperative course was uneventful.

Fig. 1 An axial computed tomography of the chest disclosed a suspicious fish bone that measured 3 cm in length (black arrow) and had perforated the esophagus (white arrow).

Fig. 2 A coronal computed tomography of the chest showed the bone (black arrow) and the esophagus (white arrow).

Fig. 3 Three-dimensional computed tomography showed the bone (blue matter) penetrating close to the left common carotid artery.

Fig. 4 Upper endoscopy showed only a small submucosal nodule in the upper esophagus not an impacted fish bone.

Fig. 5 A tiny white linear scar (arrow) was observed on the nodule, suggesting the site of perforation.

Most ingested foreign bodies can pass through the gastrointestinal tract spontaneously. However, 10 % – 20 % of such bodies require nonoperative intervention and 1 % need surgery [1]. Based on a large-scale retrospective study including 316 cases of foreign bodies in the esophagus [2], the most common foreign bodies in the pharynx and the upper esophagus were fish bones. The risk of complications was increased with a longer duration of impaction (> 24 hours), bone type, and longer bone length (> 3 cm). The current case had all of these risk factors. As for endoscopic features of fish bones, most visible bodies can be retrieved by biopsy forceps [3]. Extremely rare cases with imbedded or perforating fish bones may present submucosal tumor-like nodules [4] [5], as in this case.

Endoscopy_UCTN_Code_CCL_1AB_2AC_3AH

Competing interests: None

• References

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