Introduction
Fishbone penetrations through the posterior gastric wall into the pancreas are very rare and represent a challenging management.
We report a unique case of an ingested fishbone that entered the pancreas and that was managed medically without removal in a patient with multiple and significant comorbidities.
Case Description
Patient is a 77-year-old male with multiple comorbidities that included chronic obstructive pulmonary disease (on 3-5 L continues home oxygen), heart failure, obesity, diabetes mellitus, hypertension, chronic kidney disease (CKD), smoking, polysubstance abuse, HIV, pulmonary embolism, and atrial fibrillation.
He was admitted to our hospital with 3 days of left upper quadrant (LUQ) pain and food intolerance. He denied any new foods or dietary changes.
On physical examination of the abdomen patient had moderate distension and LUQ tenderness. He was afebrile, normotensive, with mild tachycardia (102). His white blood cell count was 17.3 K/cmm (normal range 4.5 – 10.0) and his creatinine was 1.9 mg /dL (normal range 0.5 – 1.5) consistent with his known CKD. The remainder of the blood counts and chemistry were normal, including his amylase and lipase.
A computed tomography (CT) scan of the abdomen without contrast showed a hyperdense curvilinear 3.4-cm foreign body in the pancreas, projecting from the posterior wall of the stomach (Figure 1), with minimal surrounding fat stranding.
Upon sharing these findings with the patient, he recalled that one day prior to the onset of his symptoms, he ate a fried fish sandwich that he cooked without removing the bones. This suggested an ingested fish bone that perforated the stomach wall and lodged into the pancreas.
Patient was started on empiric, intra-venous broad-spectrum antibiotics (Cefepime + Flagyl), and consultations from our gastro-enterology and general surgery teams were obtained.
Three days after admission, patient underwent an upper endoscopy to attempt retrieval of the foreign body. However, no foreign body was visualized, with the endoscopy only showing an area of mucosal erosion in the prepyloric region of the stomach (Figure 2), suggestive of the site through which a fish bone perforated the gastric wall and migrated into the pancreas.
After a multi-disciplinary discussion and shared decision making with the patient, a decision was made to not pursue surgery to remove the fish bone from the pancreas, because the risks of pancreatic surgery in a patient with significant comorbidities were considered to outweigh the benefits of removing the foreign body. Patient quickly improved, his abdominal pain resolved, and he tolerated a solid diet. A repeat CT scan of the abdomen on hospital day #4 showed an unchanged location of the foreign body, improved mesenteric fat stranding, and no evidence of an abscess.
Patient was discharged to home 4 days after admission with oral antibiotics (Cefpodoxime + Flagyl) for 10 days. A repeat CT scan of the abdomen two weeks after discharge from the hospital redemonstrated the pancreatic foreign body at a similar location, with interval improvement in the adjacent mesenteric fat stranding.
Discussion
Foreign body ingestion can happen to anyone, but is mostly seen in pediatric populations, the elderly, and individuals with psychiatric disease.1 Examples of foreign bodies that may require intervention include toothpicks, sewing needles, and fishbones. In this case, a fishbone was ingested, which led to perforation through the posterior gastric wall. In 80-90% of cases of foreign body ingestion, the object passes with no complication. However, 10-20% of cases require endoscopic intervention with less than 1% requiring surgery. Also, less than 1% of all ingested foreign bodies result in perforation.2 It commonly occurs in regions of the gastrointestinal tract with narrowing and angulation such as the cricopharyngeal ring, aortic arch, ileocecal valve, or rectosigmoid junction.3 In this case, the fishbone perforated through the prepyloric region of the stomach which is likely due to its narrow structure. Fishbones are commonly swallowed, but rarely does it lead to perforation and pancreatitis as a complication. Upon literature search on the PubMed database, there were only 4 documented cases of fishbone induced pancreatitis.
Ingested sharp foreign bodies pose a risk of perforation, which can lead to a variety of complications. If the foreign body perforates through the stomach and embeds within the liver it can lead to infection and subsequent formation of a hepatic abscess.4,5 However in this case, the fishbone perforated through the prepyloric region of the stomach and migrated itself into the pancreas. The sharp foreign body embedded within the pancreas leads to the release of damage associated molecular patterns (DAMPs). The release of DAMPs is associated with the recruitment of neutrophils to begin the inflammatory cascade. This inflammatory response can then lead to the systemic symptoms of acute pancreatitis such as fever, nausea, and even hypotension.6 In a few documented cases, the foreign body can lead to infection and subsequent formation of a pancreatic abscess.7–10
Pancreatitis caused by foreign ingestion often presents with the symptoms of acute pancreatitis. In most documented cases patients present with epigastric pain and tenderness upon physical exam.1,3,5,7–10 The epigastric pain may also be accompanied by leukocytosis and elevated amylase and lipase levels.1,11,12 Patients may also present with fever, tachycardia, nausea, and vomiting.7,13 In this case, the patient presented with LUQ pain, mild tachycardia, food intolerance, and an elevated white blood cell count.
Diagnosis can be difficult when patients present with the symptoms of acute pancreatitis because there are many gastrointestinal conditions that present with similar symptoms. Diagnosis often begins with a physical exam and a full blood test. If the blood test reveals a high serum amylase and lipase, then pancreatic damage is indicated.6,11 In multiple documented cases, the blood tests did not reveal any abnormalities that indicate the origin of the abdominal pain. In these cases, clinicians might perform preliminary imaging such as ultrasound imaging or x-ray to identify the origin of the abdominal pain.7,10,14 However, in almost every case of a symptomatic ingested foreign body, the object is ultimately identified using a CT scan.1–14 CT scans have been shown to be more useful than plain radiography when identifying fishbones because the radiopacity of the bones depends on the species of fish.10 In this case, the patient’s blood test revealed an elevated white count. Subsequent CT scan then revealed pancreatitis as well as a 3.4-cm foreign body embedded in the pancreas.
Treatment of an ingested foreign body differs depending on the site of perforation, affected organs, and the patient’s tolerance of surgery. In multiple documented cases, the foreign body was identified endoscopically and removed with endoscopic forceps.11,15 An endoscopic approach is generally first line treatment in non-emergent cases, and cases where patients may have a contraindication to surgery.2 In this case, the patient underwent an endoscopy intended to retrieve the fishbone out of the stomach. However, the fishbone had completely perforated through the posterior wall of the stomach and migrated into the pancreas making endoscopic retrieval unlikely. There was an area of mucosal erosion where the fishbone may have perforated through the stomach, but the fishbone itself could not be visualized. In emergent cases, surgery can be performed either open or laparoscopically to remove the foreign body.1–3,9,14,15 After foreign body removals, a course of antibiotics is often prescribed to the patient for infection control.5 In this case, the patient was not a good surgical candidate due to his multiple comorbidities. Therefore, the course of action was antibiotic treatment to reduce the risk of infection and a follow up CT to monitor any changes.
Conclusions
Our report highlights the importance of a multidisciplinary approach and shared decision making in the management of foreign bodies perforating the gastrointestinal tract and lodging into the pancreas. When feasible, endoscopic retrieval of gastrointestinal foreign bodes is considered the first step, with surgical removal being reserved for situations when endoscopy is not feasible or successful. However, weighing risks and benefits of a surgical procedure is very important, with medical therapy being a safe option for patients with prohibitive surgical risks factors.