Omental Inflammatory Mass Secondary to a Migrating Fish Bone: A ...

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J Emerg Crit Care Med. Vol. 22, No. 1, 2011
Omental Inflammatory Mass Secondary to a
Migrating Fish Bone: A Case Report
Chung-hunk nee 1 , Ching-Wen huang 1 , Shih-Cheng Chou 2
Most ingested fish bones pass through the gastrointestinal tract without major complications.
Migration of an ingested sharp fish bone from the site of entry into the surrounding soft tissue is a rare
complication. Inflammatory diseases of the omentum are usually caused by intra-abdominal conditions,
such as colon diverticulitis, omental torsion and infarction, and bowel perforation. We report a 63-yearold
woman who suffered from intermittent dull abdominal pain over the left lower quadrant for about 2
months. Abdominal computed tomography revealed an omental inflammatory mass with a foreign body.
An omental inflammatory mass with abscess was noted during laparotomy, and was excised totally. No
gastrointestinal tract perforation was noted. Pathology examination confirmed a fish bone in the omental
inflammatory mass. The post-operative course was uneventful. The patient was discharged on the 6 th day
after the operation. [Dear Author: Please briefly add patient outcome.]
Key words: omentum, inflammatory mass, migrating, fish bone
Introduction
Inflammatory diseases of the omentum are
usually caused by intra-abdominal conditions,
including omental disease (infarction, adhesions,
cysts, and torsion), gastrointestinal (GI) tract
inflammatory disease, GI tract perforation, colon
diverticulitis with / without perforation, previous
abdominal surgery, and pelvic inflammatory
disease. Perforation of the GI tract caused by an
ingested fish bone is not common, because most
fish bones pass uneventfully through the GI tract
without complications (1) . Herein, we report a rare
case of an omental inflammatory mass secondary to
a migrating fish bone without any complication in
the GI tract.
Received: April 26, 2010 Accepted for publication: September 2, 2010
From the 1 Departments of Surgery, 2 Pathology, Yuan’s General Hospital
Address reprint requests and correspondence: Dr. Ching-Wen Huang
Departments of Surgery, Yuan’s General Hospital
162 Chengkung 1st Road, Kaohsiung 80249, Taiwan (R.O.C.)
Tel: (07)3351151 Fax: (07)5354527
E-mail: baseball5824@yahoo.com.tw
Case Report
A 63-year-old woman presented to our
emergency department with intermittent dull
left lower quadrant abdominal pain with chills
for two months. She had been well being before
and denied any previous operations. She had a
history of diabetes mellitus and hypertension. She
had no recall of fish bone ingestion in the past 2
months. There was no nausea, vomiting, anorexia,
constipation, or diarrhea. On clinical examination in
the emergency department, she was mildly febrile
with a temperature of 37.6℃, and had a heart
rate of 77 beats per minute with a blood pressure
of 133/81 mmHg. Physical examination revealed
severe tenderness, rebound pain and muscle

guarding in the left lower quadrant of the abdomen,
and decreased bowel sounds. A tender palpable
mass of about 8 cm was noted at the left lower
quadrant of the abdomen. Chest radiography did not
reveal any active lung lesion or pneumoperitoneum.
Abdominal radiography demonstrated nonspecific
gas-distended bowel loops. Laboratory examination
revealed an elevated white blood cell count of
12400/μL, a hemoglobin level of 13 g/dl, and a
Omental inflammatory mass from a fish bone
C-reactive protein level of 201.1 mg/l. Diverticulitis
of the sigmoid colon was suspected. An abdominal
computed tomography (CT) scan revealed an
infiltrative mass (5.6 cm) in the left lower quadrant
of the abdomen surrounding a linear high density.
An inflammatory mass, probably from a fish bone-
induced perforation of jejunum, was suspected.
(Fig. 1). The inflammatory mass was just beneath
the anterior abdominal wall and adhered to the
Fig. 1 An abdominal computed tomography scan shows
an inflammatory process with an immature abscess
(Arrowhead) in the left lower quadrant of the abdomen,
probably due to an animal bone (Arrow)
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J Emerg Crit Care Med. Vol. 22, No. 1, 2011
abdominal wall. There were no penumoperitoneum
and ascites on the abdominal CT scan. Surgery
was performed. During laparotomy, a well-
circumscribed omental inflammatory mass, about 9
cm × 7 cm, was noted over the left lower quadrant
of the abdomen. The omental mass did not adhere
to the bowel wall or any other structures. There
was no ascites or pus in the abdominal cavity.
The stomach, duodenum, small intestine, colon,
and rectum were examined carefully. No bowel
perforation was noted. Therefore, we excised the
omental inflammatory mass. A 2.5-cm-long sharp,
linear fish bone was noted in the excised omental
mass, with small amount of pus. The postoperative
course was uneventful. Oral intake began on the 3 rd
day after surgery. The patient was discharged on
the 6 th day after the operation. The patient has been
followed up for 5 months and has recovered well.
On gross pathological examination, the excised
specimen showed acute suppurative inflammation
of the fat tissue, and measured 9.4 cm × 6.8 cm. A
histological examination (Fig. 2) revealed chronic
Fig. 2 A. The omentum tissue shows acute suppurative
inflammation with peripheral fibrosis. (H&E, 40x)
B. Acute and chronic inflammatory cells infiltrate with
granulation tissue between the adipocytes. (H&E, 200x)

and acute inflammatory cell infiltration, granulation
tissue, fibrosis, necrosis, bacterial colonies, and
aggregation of degenerative leukocytes. The culture
of the abscess revealed Klebsiella pneumoniae.
Therefore, a diagnosis of omental inflammatory
mass secondary to a migrating fish bone was made.
Discussion
Omental inflammatory diseases frequently
occur secondary to omental infarction, noepalsms,
cysts, torsion, and adhesions. Other intra-
abdominal causes include conditons with a GI
tract origin (enteritis, colitis, perforation, and
colon diverticulitis), pelvic inflammatory disease,
and previous abdominal surgery. Ligation of
the omentum from a previous herniorrhaphy or
abdominal surgery has also been reported as a
predisposing factor for an omentum abscess (2) .
Linen sutures, fragments of gauze, and a foreign
body (3-5) have all been reported in omental
abscesses. Primary omental abscesses are rare.
Wang et al (6) reported a case of primary omental
abscess with abdominal wall involvement
successfully treated by resection of the abscess.
Otagiri et al (7) reported on the difficulty of
accurately diagnosing this disease preoperatively.
In their literature review (6-18) , they found that only 1
of 13 cases of primary omental abscess of unknown
etiology had been diagnosed as an omental abscess
preoperatively. An omentectomy was performed in
all 13 patients, and an additional bowel resection
was done in two cases.
Accidental ingestion of foreign bodies such
as fish and chicken bones is common. However,
most digested foreign bodies pass through the
GI tract within a week, and seldom cause major
complications. Perforation of the GI tract occurs in
less than 1% of patients (1,19-22) . Commonly ingested
foreign bodies include fish bones, chicken bones,
dentures, and toothpicks. Perforations from these
Omental inflammatory mass from a fish bone
foreign bodies can occur throughout the GI tract,
but they tend to develop at sites of acute angulation
such as the ileocecum or rectosigmoid (1) . Goh et al
reported that the most common site of perforation
was the terminal ileum (1) . Other rare sites of perforation
have included a hernia sac, Meckel’s diverticulum, the
appendix (23) , esophagus (24) , and pharynx (25) . Ingested
foreign bodies can migrate from their entry point
in the GI tract into adjacent tissues. Chung et al (14)
reported four unusual cases of ingested fish bones
that migrated out of the upper digestive tract to the
neck causing retropharyngeal abscesses. Joshi et
al (26) reported a rare case in a 45-year-old woman
who had swallowed a sharp pointed metallic
foreign body while eating meat. The foreign body
had migrated from the cricopharynx through the
parapharyngeal space and penetrated the internal
jugular vein over a period of 10 days, presenting
as a tender neck swelling. Santo et al (27) reported a
liver abscess resulting from perforation and intra-
hepatic migration of a bone.
43
Clinical presentations of GI tract perforation
caused by digested foreign bodies vary from
case to case, and can be acute, subtle, or
chronic. The clinical presentations include acute
peritonitis, abdominal wall tumor or abscess (1,28) ,
intraabdominal mass and abscess formation (1,23,29) .
Henderson (30) and Goh (1) reported that chronic
perforation and abscess formation seemed to
occur more commonly with perforation of the
duodenum, stomach, and colon compared with
the jejunum and ileum. However, there have
been totally asymptomatic cases (1,31,32) . Moreover,
Chung (33) reported a patient with subtle esophageal
perforation caused by a chicken bone, who was
successfully treated with endoscopic dislodgement
f o l l o w e d b y c o n s e r v a t i v e t r e a t m e n t w i t h
intravenous antibiotics. Because of the variety of
clinical manifestations, the correct preoperative
diagnosis is seldom made. Goh (1) reported that a
correct preoperative diagnosis was made in only

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J Emerg Crit Care Med. Vol. 22, No. 1, 2011
10 (23%) of 44 patients. Furthermore, only few
patients can recall foreign body ingestion. In
Goh’s (1) report, only one (2%) patient provided a
definitive history of foreign body ingestion. Our
patient also could not recall any fish bone ingestion.
The diagnosis of radiolucent nonmetallic
foreign bodies, for example fish bones and chicken
bones, can be difficult. Plain radiography is usually
unreliable in the diagnosis of GI tract perforation
caused by nonmetallic foreign bodies (1,34,35) . Ngan (36)
reported that plain radiography had a sensitivity
of 32% in their prospective study of 358 patients.
However, Goh (1) reported that only one (5.6%) of
the reported nonmetallic foreign bodies was seen
on plain radiography and reaffirmed its poor utility
for diagnosis of this condition. CT scan is superior
to plain radiography in the diagnosis of GI tract
perforation caused by a foreign body. Coulier et
al (35) reported the use of CT scan to diagnose 7
patients with GI tract caused by perforation of a
nonmetallic foreign body, including 3 patients with
perforation by a fish bone. Goh et al (37) reported
that the sensitivity of a CT scan in the detection
of intraabdominal fish bones was 71.4% (5/7) in
initial reports. They also concluded that the clinical
presentation and radiography were unreliable in
the preoperative diagnosis of GI tract perforation
caused by a fish bone. However, this limitation
can be overcome with the use of CT, which is
accurate in showing the offending fish bone. A
high index of suspicion is needed to obtain the
correct diagnosis (37) . Moreover, a CT scan can
also show the depth of penetration, location of
both ends of the foreign bodies, the region of
perforation as a thickened segment of bowel,
localized pneumoperitoneum, regional mesentery
infiltration, and associated intestinal obstruction.
In our case, the fish bone was not shown on plain
radiography, but was suggested on the abdominal
CT scan. In addition, abdominal CT also revealed
an inflammatory mass with an immature abscess
in the left lower quadrant of the abdomen.
However, there was no evidence of a thickened
intestinal segment, localized pneumoperitoneum,
or mesentery infiltration on CT. Ultrasonography
is also a useful diagnostic tool in the detection
of ingested foreign bodies. Rioux and Langis (38)
reported ultrasonographic detection of 4 cases
of surgically (2 cases) and endoscopically (2
cases) -proven toothpick-related gastrointestinal
perforation. The sonographic appearance of the
toothpick was a linear, hyperechoic (3 cases) or
hypoechoic (1 case) image of variable length
(mean: 2.5 cm) with inconsistent posterior
shadowing in the longitudinal axis. In the transverse
section, a hyperechoic dot (4 cases) with clear,
thin, sharp, posterior shadowing (3 cases) was
seen. Coulier (39) reported six cases of complicated
foreign bodies very successfully and specifically
diagnosed by sonography at six different sites in
the gastrointestinal tract. They recommended the
systematic ultrasonographic investigation of foreign
bodies in close relation with the gastrointestinal
tract in all atypical inflammatory processes or the
use of ultrasonography as a complement to CT.
We examined the whole GI tract during
laparotomy. No bowel perforation or adhesions
were noted. Because the fish bone was sharp and
linear, it could have penetrated the small intestinal
wall and migrated into the omentum. Then, the
small intestinal wall could have quickly sealed
off, with later formation of the omental mass.
Therefore, we excised the omental mass totally.
The postoperative recovery was uneventful.
Pathology confirmed the diagnosis of omental
inflammatory mass secondary to a migrating fish
bone. To our knowledge, ours is the first reported
case of omental inflammatory mass secondary to
a migrating fish bone without an evident GI tract
perforation.
Treatment of GI tract perforation caused by
ingested foreign bodies includes conservative

treatment and surgical intervention, depending on
the etiology, size of the perforation, and severity
of symptoms. When the perforation of the GI tract
is subtle and there is no peritonitis, conservative
treatment with intravenous antibiotics and no
oral intake might be considered. In recent years,
endoscopic clips have been used to treat small
perforations of the stomach after foreign body
removal (40,41) . The reported indications for surgical
intervention are as follows: (1) bowel perforation,
(2) peritonitis due to bowel perforation, (3)
migration to other organs adjacent to the perforation
site, (4) bleeding or severe inflammation in the
abdominal cavity, (5) penetration of vessels, and
(6) abscess formation (40) . Surgery usually involves
resection of the perforated bowel in most cases with
severe peritonitis.
In conclusion, ingestion of a foreign body is a
common entity. However, perforation of the GI tract
by fish bones is not common. Clinical symptoms
vary from severe peritonitis to subtle symptoms.
Most patients cannot recall foreign body ingestion,
so the clinical presentation and radiography are
unreliable in the preoperative diagnosis of fish bone
perforation of the GI tract. When this situation is
suspected, abdominal CT plays a potential role in
detecting the nonmetallic fish bone and associated
bowel or mesentery abnormalities. A systematic
ultrasonographic investigation can be a complement
to CT and a convenient follow-up tool.
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