A fish bone perforation of the esophagus.

A 73-year-old man presentedwith odynophagia and retrosternal pain of 3 days’ duration following a fish meal. Physical examination disclosed normal vital signs and a temperature of 37.2°C. Laboratory studies showed elevated white blood cells of 13 900/μL and C-reactive protein of 14.8mg/dL. A computed tomography (CT) of the chest revealed a suspicious fish bone that measured 3cm in length and had perforated through the esophageal wall (●" Fig.1 and●" Fig.2). Three-dimensional CT showed the bone (blue matter) penetrating close to the left common carotid artery (●" Fig.3). Subsequent upper endoscopy revealed only a small submucosal nodule, which was located at 19cm from the incisors, not an impacted fish bone in the upper esophagus (●" Fig.4). A tiny white linear scar (arrow) was observed on its top, suggesting the site of perforation (●" Fig.5). Surgical exploration was performed via a lateral neck incision, and the fish bone was successfully retrieved. The postoperative course was uneventful. Most ingested foreign bodies can pass through the gastrointestinal tract spontaneously. However, 10%–20% of such bodies require nonoperative intervention and 1% need surgery [1]. Based on a largescale retrospective study including 316 cases of foreign bodies in the esophagus [2], the most common foreign bodies in the pharynx and the upper esophagus were fish bones. The risk of complications was increased with a longer duration of impaction (>24 hours), bone type, and longer bone length (>3cm). The current case had all of these risk factors. As for endoscopic features of fish bones, most visible bodies can be retrieved by biopsy forceps [3]. Extremely rare cases with imbedded or perforating fish bones may present submucosal tumor-like nodules [4, 5], as in this case.