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Buried in the Deep

Endoscopic Removal of Gastric Perforating Fish Bone

Azab, Samer MD1; Hajifathalian, Kaveh MD2; Cohen-Mekelburg, Shirley MD3; Tyberg, Amy MD4; Wan, David W. MD2

doi: 10.14309/crj.0000000000000229

1Division of Gastroenterology and Hepatology, Weill Cornell Medical College, Cornell University, New York, NY

2Department of Gastroenterology and Hepatology, New York Presbyterian-Weill Cornell Medical College, New York, NY

3Division of Gastroenterology, University of Michigan, Ann Arbor, MI

4Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ

Correspondence: Samer Azab, MD, Belfer Research Building, 413 E 69th St, New York, NY 10021 (

Received April 18, 2019

Accepted August 28, 2019

Online date: October 17, 2019

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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A 51-year-old woman presented to the hospital for severe upper abdominal pain, described as crampy, accompanied by waxing-waning nausea that woke her from sleep. Two weeks earlier, a different institution evaluated her for melena, for which she underwent an unrevealing upper endoscopy and a colonoscopy revealing an adenoma in the ascending colon. The patient was afebrile and hemodynamically stable. Abdomen examination showed mild epigastric tenderness without peritoneal signs. Laboratory tests revealed a white cell count of 12,600/mm3 and a normal liver.

Abdominal computed tomography revealed a 32-mm intramural curvilinear foreign body within the gastric antrum, with an associated thickened antrum and pylorus and no evidence of extraluminal air or bowel obstruction (Figure 1). On further questioning, the patient reported having eaten fish 3 weeks earlier, followed by the sensation of a fishbone in her throat which dissipated after a coughing spell. An urgent upper endoscopy was performed, revealing a large fishbone perforating through the gastric incisura (Figure 2). An overtube was placed, and the fishbone was removed using rat-tooth forceps (Figure 3). The defect was closed with an over-the-scope clip (Figure 4). The patient's postendoscopy course was uneventful, and she was discharged home on levofloxacin and proton-pump inhibitors.

Figure 1

Figure 1

Figure 2

Figure 2

Figure 3

Figure 3

Figure 4

Figure 4

Foreign body ingestion is a common occurrence and is usually uneventful. Perforation is the most serious complication and is more likely with sharp foreign bodies such as fishbones and toothpicks.1 Unfortunately, the suspicion for foreign body ingestion is often most dependent on the clinical history, making diagnosis more challenging in the setting of occult ingestion. This can lead to misdiagnosis and delays in definitive management. Gastrointestinal tract injury caused by ingested foreign bodies most commonly presents with abdominal pain, fever, and localized peritonitis.2 Noncontrast computed tomography is the most sensitive in locating the causal ingested agent, most often appearing as a high-density linear structure within inflamed tissue.3

A management plan is influenced by the patient's age, foreign body characteristics, and location of impaction.4,5 Upper endoscopy, however, is the standard first-line therapy for the diagnosis and treatment of impacted foreign body ingestions.5 In this case, the abdominal computed tomography findings and the history of ingested fishbone raised the suspicion for a perforating fishbone. The fact that the fishbone was found to be almost completely buried into the stomach wall might account for the negative initial upper endoscopy. The patient's clinical status at the time of presentation allowed her to be managed endoscopically, avoiding the need for more invasive surgical intervention.

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Author contributions: S. Azab wrote the manuscript. K. Hajifathalian, S. Cohen-Mekelburg, A. Tyberg, and DW Wan edited and reviewed the manuscript. DW Wan is also the article guarantor.

Financial disclosure: None to report.

Previous presentation: This case was presented at the American College of Gastroenterology Annual Scientific Meeting; October 5–10, 2018; Philadelphia, Pennsylvania.

Informed consent was obtained for this case report.

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© 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.