THE BONE THAT ALMOST MADE IT: SIGMOID PERFORATION FROM INGESTED FISH/CHICKEN BONE

Objectives: Introduction
Ingestion of foreign objects is relatively common in children but less so in adults. Adult inadvertent ingestion of foreign objects such as fish or chicken bones most often presents with perforation of the oropharynx or esophagus with perforations in the lower GI tract less likely. Herein, we present a case of a multiloculated abscess in a young female secondary to sigmoid perforation from fish or chicken bone ingestion.

Case Discussion
A 30 year old female, with history of Meckel’s diverticulectomy seven months prior, presented to the Emergency Department with a 4-day history of acute onset abdominal and pelvic pain. Exam was notable for lower abdominal and suprapubic tenderness. Vital signs were significant for tachycardia of 114. Laboratory values were unremarkable. CT of the abdomen and pelvis demonstrated a lobulated structure anterior to the uterus 5.9 cm in greatest dimension associated with a linear hyperdensity of uncertain etiology. Given difficulty in determining origin of this lobulated structure, a MRI was obtained and was concerning for abscess with a curvilinear hyperdensity next to the abscess. Interventional radiology (IR) placed a drain in the collection with removal of 100 cc of purulent drainage. During the procedure a foreign body within the fluid collection was seen on fluoroscopic images. Given concern for foreign object associated with ongoing infection and potential for retained surgical material given Meckel’s diverticulectomy a few months prior, we proceeded with abdominal exploration. Lower midline laparotomy revealed non-bilious ascitic fluid and several pockets of purulence in the left lower quadrant. The previously placed IR drain was located in one of the cavities next to which a 3 cm foreign object with the appearance of animal bone was identified and removed. This abscess cavity was immediately adjacent to the mid/distal sigmoid colon. No obvious perforation was identified. A surgical drain was placed to the left paracolic gutter. The patient did well after surgery, her surgical drain was removed and she was discharged home on postoperative day 3.

Discussion
The most common sites of perforation after bone ingestion are the oropharynx and esophagus. In the lower GI tract, the most common sites are the ileocecal valve or rectosigmoid junction. Ingestion of bones often leads to a diagnostic dilemma as the physical findings are often subtle and they may not be sufficiently visualized on imaging.

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