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.