Description

We describe the case of a healthy 23-year-old man who presented to the emergency room with a 10 h history of sharp left lower chest pain occasionally radiating to the epigastrium. The pain had started acutely while he was eating dinner at a restaurant in New York City and he noticed it during swallowing. The pain was initially sharp but later became dull. There were intermittent episodes of sharp pain, exacerbated by deep inspiration and swallowing. Lying on his right side alleviated the pain. He reported no fevers, cough, nausea or vomiting. Initial evaluation including electrocardiogram, chest X-ray, liver function tests and an abdominal ultrasound was unremarkable.

The patient underwent urgent oesophagogastroduodenoscopy which showed a fin-like opaque foreign body protruding about 3 mm above the lower oesophageal mucosa (figures 1 and 2). The foreign body was removed using a cold forceps with a rubber foreign body hood protector. This foreign body was the bone of a tilapia fish which the patient had eaten at the New York restaurant (figure 3). Chest CT did not show any free or mediastinal air, abscess or fluid collection. The patient's pain resolved within a few days of removal of the fish bone.

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Figure 1

A fin-like opaque foreign body protrudes about 3 mm above the lower oesophageal mucosa.

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Figure 2

Ulceration is seen adjacent to the tip of the tilapia fish bone.

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Figure 3

The tilapia fish bone is about 50 mm long, approximately the length of two quarters.

This case describes oesophageal ulceration mimicking chest pain and highlights the importance of detailed history taking during investigation. After cardiac causes have been ruled, other causes of chest pain should be evaluated, such as pulmonary aetiology (eg, pleurisy), musculoskeletal causes (eg, costochondritis) and gastrointestinal causes (eg, peptic ulcer).

This case draws attention to the endoscopic dilemma in the management and removal of foreign bodies. Most (80–90%) ingested foreign material will pass with defecation and without intervention. However, objects with sharp edges or pointed tips can have a high risk of complications of up to 35%.1 ,2 Objects impacted in the oesophagus require urgent removal, as in this case, to prevent perforation and other complications.3

Diagnosis and management requires proper identification of the foreign body during endoscopy to rule out an abscess or polyp. The correct device to remove the foreign body must also be chosen from among different shapes and sizes of forceps, snares, Roth baskets (a mesh net used to entrap objects) and magnets placed at the end of a scope. A detailed listing of the techniques available for extraction is outside the remit of this paper.