What's Your Diagnosis? Gastrointestinal Foreign Body Ingestion

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got the previous case on Diagnosis and Management of Blast Injuries in the Emergency Department correct.

Case Presentation: Emergency Department Management of Gastrointestinal Foreign Body Ingestion

A 42-year-old woman presents with discomfort after eating fish…

The patient states that the sensation of a foreign body in the mid-chest, just above the epigastric region began 2 hours ago while eating pan-seared halibut at a local seafood restaurant. She suspects a potential fish bone ingestion.
Chest and abdominal radiographs were obtained, and the radiologist’s impression is “no acute abnormality or foreign body identified.”
The patient continues to have some moderate discomfort when swallowing, but is able to drink juice and hold down crackers and a turkey sandwich in the ED.
You wonder whether the patient can be discharged with expectant management or if further testing is needed…

Case Conclusion

Despite initial radiographs being negative for a foreign body, the patient continued to complain of symptoms. Since radiographs have a low sensitivity to detect small nonmetallic objects such as fish bones, you decided to perform a CT without oral or IV contrast. CT demonstrated a linear hypodensity in the distal esophagus with associated mild edema, suggesting fish bone impaction. Gastroenterology was consulted and the patient was taken for endoscopy within 3 hours, where the fish bone was removed, with no evidence of perforation. The patient was observed for 6 hours, was tolerating oral intake without symptoms, and was subsequently discharged.