Clinical History
An 85-year-old woman presented with a 3-day history of epigastric and right flank pain. She experienced neither nauseas nor vomiting. No elevated leukocytosis at the blood count. No fever.
Imaging Findings
CT scan showed a lineal high-density structure measuring 23 mm located at the duodenal wall and protruding towards the omental fat. A small bubble of air and surrounding inflammatory changes were seen as a result of the small bowel perforation.
Discussion
Foreign body ingestion is a common clinical problem. Most ingested foreign bodies pass through the gastrointestinal tract uneventfully within 1 week and GI perforation is rare, occurring in less than 1% of patients. Fish bones are the most commonly ingested objects and the most common cause of perforation of the GI tract. It usually presents with nonspecific symptoms and even unusual and bizarre clinical manifestations including haemorrhage, bowel obstruction and even ureteric colic; preoperative diagnosis is therefore, unsurprisingly, seldom made. As the vast majority of fish bones are radiolucent, a negative soft tissue radiograph cannot completely exclude the presence of one. Perforation may occur at any site; however, the majority arise at sites of narrowing or acute angulation, such as the ileocaecal and rectosigmoid junctions. In cases of delayed diagnosis, perforation may lead to intraperitoneal abscess formation [1]. CT examinations proved to be clearly superior over clinical history and radiography in the detection of fish bone perforation of the GI tract. However, the accuracy of CT is limited by lack of observer awareness, and a high index of suspicion must be maintained for its correct diagnosis [2].
Differential Diagnosis List
Duodenal perforation secondary to an ingested fish bone
Diverticular abscess
Tumour abscess
Final Diagnosis
Duodenal perforation secondary to an ingested fish bone
