Figure 3. Full image of the fishbone.
Patients do not often think they could suffer from intestine perforation
due to a fishbone. Therefore, it is hard for doctors to take a medical
history of the disease. The fishbone is often only found during an
imaging examination or surgical exploration (6). Imaging examination is
usually unreliable in the diagnosis of these cases. High-density shadow,
free gas, and abscess formation are often used to determine the presence
of inflammatory changes or perforation (9). However, the fishbone
gradually penetrates the intestinal wall through extrusion. The
perforation site is often covered by fibrin or adjacent intestines,
limiting the outflow of intestinal contents and reducing the possibility
of the free gas appearance in abdominal X-ray films (10). Free
intestinal gas found in X-ray films accounted for only 20% of patients
(8). In another study with 358 patients suffering from fishbone
perforation, X-rays were only 32% sensitive (3). The fishbone is also
affected by radiation doses, inflammatory tissues, or liquids around the
damage (4).
His most essential symptoms were abdominal pain, clear abdominal muscle
guarding in the right iliac region with constipation, and fever in our
patient. Diagnostic imaging results were not sensitive. Therefore, this
patient’s symptoms are somewhat close to those of a patient with acute
appendicitis, perhaps leading to a misdiagnosis of abdominal pain caused
by acute appendicitis.
Almost all gastrointestinal foreign bodies can be removed by gastroscopy
or enteroscopy. Only 1% of cases need surgical excision. However,
depending on the perforation site and clinical symptoms, treatment could
be chosen through suture perforation site, bowel resection, or Hartman
procedure (8). In general, surgeons prefer to remove a small bowel part
to prevent perforation caused by inflammation. Laparoscopic surgery
caused less damage than traditional laparoscopic surgery, so it has
gradually replaced the traditional method of abdominal open exploration.
Currently, laparoscopic surgery is the preferred method of choice (11).
Back to our case, because there was no precise diagnosis, we chose
laparoscopic surgery. During the surgery, we found a sharp fishbone
punctured the intestine from the lumen of the intestine to the outside,
about 35 cm from the ileum - cecum, and the patient’s appendix was
normal. We removed the fishbone, stitched the hole, cleaned the abdomen,
and closed incisions.
The boy recovered very well and was discharged after 7 days of treatment
with a stable condition. Nevertheless, after all of this, his family
still cannot remember clearly that whether their son ate fish that day
or not. All they can make sure that their family regularly ate fish for
dinner.