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A completely imbedded fish bone presenting as an esophageal tumor-like lesion: an unusual presentation
AT THE FOCAL POINT Lawrence J. Brandt, MD, Associate Editor for Focal Points
A completely imbedded fish bone presenting as an esophageal tumor-like lesion: an unusual presentation
A 46-year-old woman was admitted to our hospital with a 1-month history of dysphagia and retrosternal discomfort. She remembered having a transient episode of chest pain 2 months before admission. No weight loss was noted during this period. Physical examination was unremarkable. An upper-GI endoscopy revealed a 1.0-cm nodular lesion in the mid esophagus (A). A biopsy of the esophageal nodular
lesion was performed, and upon withdrawal of the biopsy forceps, a fish bone became apparent. The fish bone, measuring 2.1 cm in length, was removed, along with the biopsy specimen (B). Histopathologic findings of the biopsy specimens showed only inflammatory change. The next day, CT scans of the chest showed only focal thickening of the wall in the middle third of the esophagus (C), but no
1190 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 6 : 2008
www.giejournal.org
At the Focal Point
evidence of mediastinitis. Conservative treatment, with nothing by mouth, intravenous fluids, and parenteral antibiotics, was given. Upon questioning, the patient recalled having ingested a fish bone, resulting in throat discomfort, 6 months before admission. She was discharged uneventfully on the fourth hospital day. Three weeks after discharge, a repeated upper endoscopy revealed normal esophagus (D), and the patient was symptom free.
DISCLOSURE The authors report that there are no disclosures relevant to this publication. Yuan-Chih Chu, MD, Hsin-Hui Chiu, MD, Department of Medicine, Kuo General Hospital, Tainan, Taiwan doi:10.1016/j.gie.2008.07.020
Commentary Ingested fish bone is the most common foreign body in the adult upper-GI tract. Fortunately for the gastroenterologist, most fish bones get stuck in the oropharynx and are within the province of the ear, nose, and throat (ENT) surgeon. Those fish bones that make their way distally usually lodge in the upper esophagus and present with a sticking pain at the site of penetration. Easy to suspect clinically, they are difficult to find radiologically because many are translucent, and even bones that are radiologically visible ex vivo commonly are obscured by soft tissues and by laryngeal calcification; hence, plain films are not all that useful diagnostically. In the era before endoscopy, a cotton pledget study often was done: the pledget was dipped in barium and swallowed, the hope being it would get stuck on a bone fragment that projected into the lumen, thereby allowing the bone to be detected and subsequently removed. Today, CT scanning most often is done, but here too, there is poor correlation between the radiodensity of fish bones and their visibility. Usually fish bones pass without incident, but complications can be catastrophic, including neck and thyroid abscesses, mediastinitis, esophago-aortic or esophago-carotid fistulas, and even rectal perforation. In this case, the inflammatory reaction that surrounded the ingested bone formed a mass that served to help the endoscopist find and remove the bone. In Moby Dick, Melville wrote, ‘‘chowder for breakfast, chowder for dinner, and chowder for supper, till you began to look for fish-bones coming through your clothes.’’ Now that is what I call a perforation! Lawrence J. Brandt, MD Associate Editor for Focal Points
Diagnosis of pleural malignant mesothelioma by EUS-guided FNA (with video)
www.giejournal.org
Volume 68, No. 6 : 2008 GASTROINTESTINAL ENDOSCOPY 1191
A completely imbedded fish bone presenting as an esophageal tumor-like lesion: an unusual presentation
A 46-year-old woman was admitted to our hospital with a 1-month history of dysphagia and retrosternal discomfort. She remembered having a transient episode of chest pain 2 months before admission. No weight loss was noted during this period. Physical examination was unremarkable. An upper-GI endoscopy revealed a 1.0-cm nodular lesion in the mid esophagus (A). A biopsy of the esophageal nodular
lesion was performed, and upon withdrawal of the biopsy forceps, a fish bone became apparent. The fish bone, measuring 2.1 cm in length, was removed, along with the biopsy specimen (B). Histopathologic findings of the biopsy specimens showed only inflammatory change. The next day, CT scans of the chest showed only focal thickening of the wall in the middle third of the esophagus (C), but no
1190 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 6 : 2008
www.giejournal.org
At the Focal Point
evidence of mediastinitis. Conservative treatment, with nothing by mouth, intravenous fluids, and parenteral antibiotics, was given. Upon questioning, the patient recalled having ingested a fish bone, resulting in throat discomfort, 6 months before admission. She was discharged uneventfully on the fourth hospital day. Three weeks after discharge, a repeated upper endoscopy revealed normal esophagus (D), and the patient was symptom free.
DISCLOSURE The authors report that there are no disclosures relevant to this publication. Yuan-Chih Chu, MD, Hsin-Hui Chiu, MD, Department of Medicine, Kuo General Hospital, Tainan, Taiwan doi:10.1016/j.gie.2008.07.020
Commentary Ingested fish bone is the most common foreign body in the adult upper-GI tract. Fortunately for the gastroenterologist, most fish bones get stuck in the oropharynx and are within the province of the ear, nose, and throat (ENT) surgeon. Those fish bones that make their way distally usually lodge in the upper esophagus and present with a sticking pain at the site of penetration. Easy to suspect clinically, they are difficult to find radiologically because many are translucent, and even bones that are radiologically visible ex vivo commonly are obscured by soft tissues and by laryngeal calcification; hence, plain films are not all that useful diagnostically. In the era before endoscopy, a cotton pledget study often was done: the pledget was dipped in barium and swallowed, the hope being it would get stuck on a bone fragment that projected into the lumen, thereby allowing the bone to be detected and subsequently removed. Today, CT scanning most often is done, but here too, there is poor correlation between the radiodensity of fish bones and their visibility. Usually fish bones pass without incident, but complications can be catastrophic, including neck and thyroid abscesses, mediastinitis, esophago-aortic or esophago-carotid fistulas, and even rectal perforation. In this case, the inflammatory reaction that surrounded the ingested bone formed a mass that served to help the endoscopist find and remove the bone. In Moby Dick, Melville wrote, ‘‘chowder for breakfast, chowder for dinner, and chowder for supper, till you began to look for fish-bones coming through your clothes.’’ Now that is what I call a perforation! Lawrence J. Brandt, MD Associate Editor for Focal Points
Diagnosis of pleural malignant mesothelioma by EUS-guided FNA (with video)
www.giejournal.org
Volume 68, No. 6 : 2008 GASTROINTESTINAL ENDOSCOPY 1191