Fish Bone or Cancer? 80-Year-Old's Perforation Case
An 80-year-old man presented with progressive lower left-quadrant abdominal pain. Imaging studies identified a mass adjacent to the sigmoid colon, with features suggestive of an abscess, although no definitive foreign body was detected preoperatively. Surgical exploration revealed a sigmoid colon perforation associated with a sharp foreign object, which was later confirmed to be a fish bone. Histopathological examination revealed an inflammatory response without evidence of malignancy.
The case reported by Daniel Herrera Hernández, MD, and colleagues from the Hospital General Regional No. 1 Instituto Mexicano del Seguro Social, Tijuana, Mexico, highlighted a rare cause of intestinal perforation.
The Patient and His History
The patient had a medical history of diabetes mellitus and hypertension. There was no prior surgical history or screening colonoscopy. He reported a 12-day history of lower left-quadrant abdominal pain, progressively worsening to become intolerable, prompting emergency admission.
Findings and Diagnosis
On presentation, the patient was stable but exhibited abdominal distension and tenderness on palpation of the left hemiabdomen, without signs of peritoneal irritation. Laboratory tests showed leucocytosis of 20,800/μL (4000-11,000), neutrophils at 65.1% (40%-70%) of total leukocytes, and a serum creatinine of 1.0 mg/dL (0.6-1.2). Abdominal and pelvic CT scans revealed a mass adjacent to the descending colon with peripheral enhancement dependent on the colonic wall, extending into the muscular layer, suggestive of an abscess, as well as a small radio-opaque object in the middle of the phlegmon, supportive of a foreign body. Adjacent fat stranding and free fluid were observed in the left iliac fossa. The patient underwent exploratory laparotomy, revealing a colonic perforation at the sigmoid colon with firm adhesions to the abdominal wall. A sharpened foreign body, approximately 2 cm in length, was found at the adhesion site, which was the cause of the perforation. No diverticula were identified in the colon. Left hemicolectomy with transverse colon terminal colostomy was performed. Postoperative recovery was uneventful under antibiotic therapy with meropenem and metabolic management. The patient was discharged on postoperative day 5 with clinical improvement. The histopathology report indicated chronic inflammation with no evidence of malignancy.
Discussion
'Intestinal perforation by a fish bone in the colon is a rare complication that poses diagnostic challenges. It requires a high index of suspicion from surgeons or emergency physicians. In patients with risk factors, such perforations can resemble tumours with abscess formation or perforation secondary to malignancy,' the authors wrote.
This story was translated from Univadis Germany.
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