Perforation of the gastrointestinal tract by ingested foreign body is rare. The majority of patients do not recall ingestion of the foreign body, and dietary foreign bodies are most commonly involved. We present an interesting case where the offending foreign body gave rise to a diagnostic dilemma masquerading as a pancreatic mass. A high index of suspicion is indicated especially when dealing with atypical presentation and nonspecific symptoms as highlighted in this case.
Ingestion of foreign body is not an uncommon occurrence. The vast majority pass through the gastrointestinal tract uneventfully, and perforation is rare. We report an unusual presentation of a gastric perforation by a foreign body and discuss various issues regarding investigation and management.
A 62-year-old man presented with history of dysphagia to solids, night sweats, lethargy, and significant weight loss of 2 stones over 2 months. Apart from dyspepsia on symptomatic treatment, he did not have any significant comorbidities. He worked as a chef on ships and was recently admitted overseas with an episode of sun stroke for which he was hospitalised for a week.
On clinical examination, he had fullness in the epigastrium with minimal tenderness. Blood tests revealed leucocytosis and elevated C reactive protein with mildly deranged liver function tests characterised by raised alkaline phosphatase and lactate dehydrogenase levels. Tumour markers including CEA and CA19.9 were normal. Upper gastrointestinal endoscopy revealed inflamed and oedematous posterior gastric wall, and biopsies were positive for H. pylori infestation. Ultrasound revealed a 5 cm heterogenous mass in close relation to the head of pancreas with associated mild intra- and extrahepatic biliary dilatation. CT scan confirmed a 6 × 6 cm soft tissue mass in the pancreatic bed with a 4 cm linear calcified mass (Figure
CT scan revealing a complex soft tissue mass in relation to the pancreas with a calcified focus.
In view of diagnostic ambiguity, exploratory laparotomy was undertaken. At laparotomy, a large inflammatory mass which appeared to arise from the duodenum and in close relation to the stomach, pancreas, and the liver was encountered. The initial impression was that this was probably a lymphoma. However, on further dissection, an abscess cavity in the pancreatic bed with a 4 cm foreign body was found. This was sent for histology and a drain was placed in the abscess cavity. The patient made an uneventful recovery and was discharged home within a week.
Histology revealed soft tissue consistent with inflammatory granulation tissue, and the foreign body was reported to have haversian systems consistent with bony remodelling not found in modern bony fish and hence probably a chicken bone.
The patient recovered well and regained all lost weight. On further history review, he denied any history of foreign body or bone ingestion.
Ingested foreign body perforation in the adult population is usually secondary to involuntary accidental ingestion and is frequently caused by dietary foreign bodies [
The authors declare no conflict of interests or any grants.