S6385 Gastric Perforation Secondary to Ingested Fishbone: A Case of Delayed Presentation

Introduction: Foreign body ingestion causing gastric perforation is uncommon, fishbones present unique challenges due to their radiolucent nature and ability to migrate. We present a chronic gastric perforation from an ingested fishbone resulting in hepatic adhesions and abscess formation, requiring surgical intervention after failed endoscopic management. Case Description/Methods: A 69-year-old woman with a history of a pulmonary embolism on apixaban presented with 3 months of intermittent abdominal pain, acutely worsening over several weeks. She reported fevers and chills but denied dysphagia or dietary changes. Examination revealed focal epigastric tenderness. Laboratory values were unremarkable. Non-contrast computed tomography (CT) revealed a linear radiopaque density >2.5 cm extending from the gastric wall into adjacent fat, abutting the left hepatic lobe, concerning for foreign body perforation. Endoscopic investigation on hospital day 2 identified a raised area with purulent drainage along the lesser curvature of the stomach. Despite probing, the foreign body could not be visualized. Endoscopic clip placement was performed for localization and attempted closure. Following unsuccessful endoscopic retrieval, robotic surgery was performed on hospital day 4. Dense adhesions were encountered between the left hepatic lobe and lesser gastric curvature. Dissection revealed a phlegmonous, walled-off cavity containing a 2.7 cm fishbone. Primary repair with omental patch was performed after right gastric artery ligation. The patient was discharged on hospital day 6 without antibiotics. Anticoagulation was resumed without complications. Discussion: This case illustrates unique features of fishbone perforation. The delayed presentation with chronic walled-off perforation and hepatic adhesion formation is unusual, as most present acutely. The patient's inability to recall fishbone ingestion highlights often-asymptomatic passage through the upper gastrointestinal tract. Endoscopic management proved inadequate due to extraluminal migration and inflammatory changes obscuring visualization. The development of hepatic adhesions and abscess formation necessitated surgical intervention, demonstrating the importance of multidisciplinary management. This case emphasizes the need for high clinical suspicion when linear densities are identified on imaging, even without clear ingestion history, and highlights potential chronic complications requiring surgical management when endoscopic retrieval fails.