Medical treatment for a fish bone-induced ileal micro-perforation: a case report

Abstract

Ingested fish bone induced intestinal perforations are seldom diagnosed preoperatively due to incomplete patient history taking and difficulties in image evidence identification. Most literature suggests early surgical intervention to prevent sepsis and complications resulting from fish bone migrations. We report the case of a 44-year-old man suffered from acute abdomen induced by a fish bone micro-perforation. The diagnosis was supported by computed tomography (CT) imaging of fish bone lodged in distal ileum and a history of fish ingestion recalled by the patient. Medical treatment was elected to manage the patient's condition instead of surgical intervention. The treatment resulted in a complete resolution of abdominal pain on hospital day number 4 without complication. Factors affecting clinical treatment decisions include the nature of micro-perforation, the patient's good overall health condition, and the early diagnosis before sepsis signs develop. Micro-perforation means the puncture of intestine wall without CT evidence of free air, purulent peritoneum or abscess. We subsequently reviewed the literature to support our decision to pursue medical instead of surgical intervention.

Keywords: Decision-making; Fish bone ingestion; Medical treatment; Micro-perforation; Small intestine.

Figure 1

An unenhanced abdominal computerized tomography image reveals a 26 mm in length radiopaque linear shadow in the distal ileum lodged into the thickened intestinal wall at both ends (black arrow). Minimal peritoneal contamination without pneumoperitoneum, or abscess formation is noted, which is consistent with signs of fish bone induced micro-perforation.

Figure 2

Two follow-up unenhanced abdominal computer tomography images, which reveal the radiopaque shadow still lodged in the intestinal segment. The fish bone rotates and becomes parallel to the distal ileum lumen. A: Most of the fish bone is still inside the intestinal lumen (white arrow). One end of the fish bone penetrates out the intestinal wall into the mesenteric fat; B: Minimal local inflammatory infiltration contains the protruding part. No free air or abscess is noted (black arrow). The distance between these two images is 18 mm.