Case report: A perforating fish bone: an unexpected cause of abdominal pain in a middle-aged woman

10^th International Conference on Surgery and Anaesthesia

May 19-20, 2025 Zurich, Switzerland

Amna Rashid and Muhammad Rafay Khan

Basildon Hospital, United Kingdom

Scientific Tracks Abstracts: Surgery

Abstract :

Patient Information: A 47-year-old female with a medical history of Type 2 Diabetes Mellitus (T2DM), Hypertension (HTN), Asthma, Hypothyroidism, Gastro-Oesophageal Reflux Disease (GORD), and a left total ankle replacement (Nuffield private) was admitted to Basildon Hospital on 25th January 2024. She presented with a 3-day history of severe abdominal pain, rating 9/10 in intensity. She had opened her bowels two days prior to admission. On examination, her fluid status was noted as dehydrated (E+D), and laboratory results showed an elevated C-reactive protein (CRP) of 81, white blood cell count (WBC) of 12, and raised inflammatory markers, indicating an active inflammatory process. Initial Imaging Findings: CT imaging performed on 25th January 2024 revealed mural thickening of the jejunal and proximal ileal loops with mesenteric stranding, which raised suspicion for inflammatory bowel disease. A 4 cm curvilinear calcific density within the mesentery, primarily extraluminal, was identified. The density was concerning for an ingested foreign body, likely a fish bone, which had perforated through the wall. Additionally, a double duct sign (dilated pancreatic duct and common bile duct) was noted, prompting the need for further evaluation for an ampullary lesion. An additional CT Mesenteric Artery Angiogram on 27th January 2024 confirmed segmental inflammation in the proximal small bowel and mesentery, with the suspicious foreign body potentially causing perforation. No evidence of bowel ischemia, free gas, or intra-abdominal collection was observed. Radiological Investigations: On 28th January 2024, an MRI of the small bowel confirmed localized inflammatory changes at the junction of the distal jejunum and proximal ileum, primarily centered in the mesentery. The study suggested the presence of a linear foreign body, most likely a fish bone, noted as a linear low signal intensity on imaging. The surrounding small bowel loops displayed subtle inflammatory changes but no signs of perforation or localized collections. Additionally, an MRCP on the same day showed a dilated common bile duct (CBD) and pancreatic duct. The abrupt termination of the CBD at the ampulla of Vater raised suspicion for a small lesion in this area, which would require further investigation via endoscopic retrograde cholangiopancreatography (ERCP). Surgical Management: Given the suspicion of a foreign body perforation and the potential for further migration, the patient underwent laparoscopic surgery on 30th January 2024. The procedure was performed by Mr. Haque, with the indication for a foreign body in the small bowel and concerns about further migration. Surgical findings included: • Adhesion between a loop of ileum and jejunum at the mesenteric side, with a small abscess at the adhesion site.• Inflammatory lump formation at the site of the adhesion. • A fish bone was identified, having perforated the mesenteric side of the ileum after adhesiolysis. The specimen was sent for biopsy, and the patient was placed on Total Parenteral Nutrition (TPN) postoperatively. Post-Operative Course: Post-surgery, the patient was managed with: • An NG tube with 4-hourly aspiration of clear fluid. • Continued intravenous antibiotics and analgesia. • Monitoring of input/output (I/O) charts. • The PICO dressing was removed on 7th post-operative day. The patient was successfully weaned off TPN, and no further complications were noted. Her hemoglobin (Hb) remained stable at 111 g/L (previously 117 g/L), and her WCC decreased to 7.2 x 10^9/L (from 11.6 x 10^9/L). She was discharged in a stable condition on 3rd February 2024, fit for discharge. Discussion: This case highlights the rare but significant clinical presentation of a foreign body perforation in the small bowel, which was initially masked by the clinical picture of inflammatory bowel disease. The patient's advanced age and multiple co-morbidities, including diabetes and hypothyroidism, may have contributed to a delayed diagnosis, making imaging crucial in identifying the foreign body. The fish bone, once identified, was removed surgically, and the patient made an uncomplicated recovery. The presence of a dilated pancreatic duct and common bile duct, coupled with the possibility of an ampullary lesion, warrants further follow-up. However, the immediate concern was the foreign body perforation, which was resolved successfully through surgical intervention. Conclusion: Foreign body ingestion leading to bowel perforation is a rare cause of acute abdominal pain. In this case, the patient's clinical and radiological findings were consistent with an ingested foreign body, most likely a fish bone, that had caused a perforation of the small bowel. Early detection and surgical intervention were key to the patient's recovery, and further monitoring of her biliary system will be essential to rule out any underlying lesions at the ampulla of Vater.

Biography :

Amna Rashid is affiliated to Basildon Hospital, United Kingdom. He is a recipient of many awards and grants for his valuable contributions and discoveries in major area of health research. His international experience includes various programs, contributions and participation in different countries for diverse fields of study. His research interests reflect in his wide range of publications in various national and international journals.