Abdomen Breast Cardiovascular Chest Head/Neck Musculoskeletal

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Sharp foreign bodies in GI tract
by Julien Puylaert and Frank Zijta
Amsterdam UMC and Haaglanden MC, The Hague

Introduction
Epidemiology and pathophysiology Publicationdate 15 nov 2020
GI-tract perforations
Causes of perforation This is an overview of the widely variable US and CT 
Pinprick-and-pass
presentation of sharp foreign bodies perforating the
Illustrative cases
wall of stomach or bowel.
This pictorial essay is based on a literature search
and our personal experience with 49 cases and will
enable you to make the correct diagnosis, to under‐
stand the natural course and also to help the clinician
to choose the best and least invasive treatment. 

For critical comments and additional remarks:

 j.puylaert@gmail.com

Introduction

Accidental ingestion of sharp foreign bodies is a po‐

tentially life-threatening event. 
If a sharp foreign body gets stuck in the pharynx or
esophagus, the patient will usually notice its presence
and will seek medical help immediately. 

If, however,  the sharp foreign body, unnoticed by the

patient,  is able to reach the stomach, it may penet‐
rate at some point, the wall of the stomach, small or
large bowel, giving rise to atypical and treacherous
symptoms.
This often leads to serious delay and may even be
fatal.

This table contains the key points in the history of the

patient.
The ingested foreign bodies are fish or poultry bones
and wooden sticks as tooth picks and cocktail
sticks.  
Patients virtually never remember swallowing, and
even show disbelief when confronted with the
diagnosis. 

The average age is 60 years and many patients wear

denture plates.
 Patients with perforation of small or large bowel often
Abdomen Breast have a previous laparotomy
Cardiovascular in their history.
Chest Head/Neck Musculoskeletal

Neuroradiology Pediatrics More

Perforating foreign bodies in stomach and bowel are
rarely clinically considered and are increasingly recog‐
nized by the use of US and CT, so there is a key role
for the radiologist, in primary detection and also in
guiding minimal invasive treatment. 

This table contains the key points in the clinical, US

and CT findings. 

Pain is variable and atypical.

CRP usually rises quickly in the first 24 hours. 

Perforation of the stomach always occurs in the pre‐

pyloric region.
Abscesses may occur in the peritoneal cavity, abdom‐
inal wall,  iliopsoas muscle and liver.
The foreign body itself may be rather inconspicuous
and is easily missed.
This requires awareness and active searching on CT
scan

This table contains the key points of the treatment. 

Whenever possible, endoscopical removal is the best

option, followed by minimal invasive surgery, guided
by the US and CT findings.
Abscesses can be drained percutaneously, or evacu‐
ated surgically together with removal of the foreign
body. 

In all instances, antibiotics are mandatory.

Antibiotics alone may be the definitive treatment, es‐
pecially in case of small fish bones  and after suc‐
cessful abscess drainage. 

Rarely, the sharp foreign body may cause local perfor‐

ation and yet leave the bowel naturally.
This is called pinprick-and-pass.

Epidemiology and pathophysiology

It is unknown how often sharp foreign bodies on their

journey through the GI tract actually perforate stom‐
ach and bowel.
Probably many fishbones eventually pass with the
stool without any problem.
When specifically looked for, it is not uncommon to
Hyperdense bones in three asymptomatic patients
 find hyperdense bones (arrow) in the bowel lumen, as
Abdomen Breast inCardiovascular
these three asymptomatic patients.
Chest Head/Neck Musculoskeletal

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The most frequently encountered penetrating sharp
foreign bodies are fish bones, chicken bones and
wooden sticks as toothpicks or cocktail sticks.

The vast majority of patients do not recall having

swallowed such an object, and when confronted with
the sharp object, often show remarkable disbelief. 

Many patients wear denture plates that might render

their palatum less sensitive.

It is not always possible to differentiate bones from

wooden sticks on CT, but fishbones are generally
rather hyperdense and curvilinear, while wooden
sticks are less hyperdense and more straight.

Half of the patients with small bowel perforation,

have a history of a previous abdominal surgery.

Adhesions cause local kinking of the bowel loops in‐

hibiting the sharp foreign body to “take the corner”.

Once a sharp object penetrates the wall of stomach

or bowel, omentum and mesentery will try to wall-off
the ensuing perforation. 

Often, an abscess will develop:  in the peritoneal cav‐

ity, in the liver, in the abdominal wall or  in the iliop‐
soas muscle. 

The foreign body may lie within the abscess, but also
remain at its periphery. Sometimes, significant migra‐
tion of the object may occur. 

One third of the perforating sharp foreign bodies lies

within reach of either gastroscopy or colonoscopy.

This is obviously the best option for the patient.

 A 59-year old woman with atypical upper epigastric
Abdomen Breast Cardiovascular Chest Head/Neck Musculoskeletal
pain for two days. 

US revealsMore
Neuroradiology Pediatrics remarkable wall thickening of the pre‐
pyloric antrum, harbouring a hyperechoic, curvilinear
structure (arrowheads), suspect for a fishbone. 

CT confirms the diagnosis.

Note how the fishbone (arrow) could easily be missed
on the coronal CT alone.
Uneventful  recovery after endoscopic removal.

US and CT show a fishbone perforating the stomach

wall just before the pylorus. 

At gastroscopy no fishbone was found, but only local

mucosal swelling with a central ulceration (arrow). 

Deep instrumentation with a  large forceps into this

area eventually succeeded in grabbing the fishbone.

A 74-year old woman presents with deeply located,

lower abdominal pain since 3 weeks. Lab: 15 leuko‐
cytes, CRP 150. She had multiple gynaecological op‐
erations in the past. 

CT was done and revealed a bony foreign body, which,

at both ends, appeared to perforate the sigmoid.

Endovaginal US confirmed that the foreign body tra‐

versed the sigmoid lumen, so colonoscopic removal
was possible.

During the endoscopical procedure, the chicken bone

had to be broken in two parts in order to be safely re‐
moved. Uneventful recovery with help of antibiotics. 
Abdomen Breast Cardiovascular Chest Head/Neck Musculoskeletal

Neuroradiology Pediatrics More

If the foreign body is not reachable for the endoscope

and is well accessible for the surgeon,  in principle
surgical removal of the foreign body is indicated. 

This 33-year old man (with a previous bowel resection

at age four) presented with epigastric pain and a CRP
of 155. US and CT confirmed a bony structure (ar‐
rows) perforating an adhesive small bowel. 

At mini-laparotomy a sharp 6 cm bone was removed.

The patient ate Peking duck two days earlier.

A vital 83-year old man presented with acute upper

abdominal pain and a CRP of 90. CT found a bony
structure stuck in the jejunum. After 24 hours of con‐
servative therapy with antibiotics, the pain did not di‐
minish and the CRP went up to 230. 

At surgery a sharp, perforating bone chip could easily

be removed by means of a small jejunal incision,
there was no need for bowel resection. 
 The patient made a quick recovery and now, eleven
Abdomen Breast years later, at 94,Chest
Cardiovascular he  is still in perfectMusculoskeletal
Head/Neck condition. He
can still not imagine that he ever swallowed such a
large bone chip
Neuroradiology Pediatrics More

In case of deeply located abscesses as liver abs‐

cesses, percutaneous drainage is indicated in com‐
bination with long-term antibiotics. In some patients 
this may be the definitive treatment. 

This 61-year old lady presented with a large fishbone-

related liver abscess. She was obese and had several
other contraindications for surgery. 

After multiple percutaneous drainage procedures and

ten weeks of antibiotics, she eventually recovered,
with the fishbone still in place, apparently
encapsulated. 

Now, ten years later, she is still doing fine.

At times, it may be very difficult to find the foreign

body at laparoscopy or open surgery. 

This patient presented with upper abdominal pain and

a CRP of 245. US and CT revealed a slightly hyper‐
dense, straight foreign body, probably a cocktail stick
(arrowheads) . 

At surgery two days later the liver abscess was evacu‐

ated, but the foreign body was not found. Afterwards 
the patient did well on antibiotics. 

On day 15, CT showed resolution of the abscess with

the foreign body (arrowheads) still in situ. Eventually,
the patient recovered with long-term antibiotic
treatment.

Wooden sticks incidentally may be isodense with the

bowel or liver tissue they traverse, and thus may be
hardly or not visible on CT scan. In these cases, fo‐
cused US can be of help. 

In patient A, CT findings of an air-bubble, fat stranding

and local bowel wall thickening, suggested a local
perforation, but no foreign body was seen. 

Immediate US of this area  unequivocally revealed a

sharp foreign body (arrows) piercing through the
bowel (b.) wall into the surrounding inflamed fat (*). 
 In patient B, antral wall thickening and a nearby liver
Abdomen Breast abscess, suggested
Cardiovascular a perforating
Chest Head/Neckforeign body, which
Musculoskeletal
however could not be identified on CT. 

US, performed
Neuroradiology Pediatrics Morewith knowledge of the CT findings,
easily detected the, apparently isodense, foreign body.
(st. = stomach)

Often no abscess occurs and the fishbone, after mi‐

gration, becomes encapsulated. Antibiotics may be of
help in the encapsulation process. 

This 48 year old woman was submitted with severe

periumbilical pain since 12 hours (Lab: 15 leukocytes,
CRP 7).
The next day the pain subsided, but the CRP went up
to 65. 

US of the periumbilical area, showed edematous wall

thickening of small bowel (b.) with normal peristalsis.
There was a tiny fluid collection (f.) and inflammation
of the  hyperechoic and non-compressible mesentery
(*).

Subsequent CT confirmed small bowel wall thicken‐

ing (b.) and fat stranding (*) in the mesentery. In the
left paracolic gutter, a fishbone (arrow) was found.
Apparently the fishbone, after perforating the jejunum,
did migrate to that spot.
Subsequent laparoscopical exploration was unable to
identify the fishbone.
She made an uneventful recovery with antibiotics.

CT scan, performed for other reasons 18 months

later, showed slight migration of the fish bone, appar‐
ently well-encapsulated.
Patient is still doing well eight years later.

In case of relatively mild symptoms in patients with

small, perforating fishbones without an abscess,
primary antibiotic treatment  may be a good first
option. 

These three different patients all made an uneventful

recovery with antibiotics only. 

Sometimes nature is very mild.

This 72 year old lady presented with acute epigastric
pain and a CRP of 180, caused by a fishbone, perfor‐
ating her stomach. 
 Only proton pump inhibitors were given.
Abdomen Breast Her symptoms rapidly
Cardiovascular Chest subsided
Head/Neckand Musculoskeletal
her CRP was nor‐
mal again in three days.
She  made a full recovery, and 11 years later is still do‐
ing fine.  More
Neuroradiology Pediatrics

Two different patients with an encapsulated fishbone

in the wall of the antrum as coincidental finding on
CT, performed for other reasons. 

Both patients did not recall a period of upper epigast‐

ric pain and had unchanged CT images for many
years.

In case of an abdominal wall abscess, surgery can be

done in order  to drain the abscess and remove the
foreign body. 

In this patient, only a small peri-umbilical incision al‐

lowed evacuation of pus and removal of the fishbone.

This 58-year old patient presented with pain LLQ and

a CRP of 105, suspect for diverticulitis.

US found a ovoid mass of inflamed fat (arrowheads)

lateral of the sigmoid, suggestive of epiploic
appendagitis. 

Subsequent CT revealed a straight, hyperdense for‐

eign body (arrows)  surrounded by fat stranding.
The patient was treated with antibiotics.

One week later an abscess did develop, which was

percutaneously drained.

Eight weeks later a cocktail stick was removed as an

elective procedure. 

GI-tract perforations
 Causes of perforation
Abdomen Breast IfCardiovascular
at US / CT bowelChest
wall Head/Neck
thickening isMusculoskeletal
found in combin‐
ation with fat stranding and free air configurations, it
is not always clear what is the underlying cause. 
Neuroradiology Pediatrics More
The mnemonic PSI-ABCD may be helpful: 
Peptic ulcer
Sharp foreign body
Ischemic bowel
Appendicitis
Bowel carcinoma
Crohn's disease
Diverticulitis

In the table the number of conditions that cause per‐

foration as far as they give rise to acute perforation.
In 99,99 % of cases, one of these seven conditions is
the cause of the perforation.

Our relatively large number of sharp foreign bodies, is

partially explained by a large immigrant population,
eating exotic fish species. 

Especially Surinamese people who make up 30 % of

our patients, are responsible for 70% of the fishbone
perforations. 

Pinprick-and-pass

A sharp foreign body may cause a perforation, but

may yet pass normally with the stool  (”pinprick-and-
pass”).  

This 85-year old man presented with severe localized

pain, focal peritonitis and a CRP of 200, clinically sus‐
pect for appendicitis. 
US showed a small focal area of inflamed hyper‐
echoic fat (arrowheads), harbouring  a little fluid (*)
and an ill-understood reflection (white arrow).
The presumed US diagnosis was epiploic ap‐
pendagitis with a small central area of hemorrhage.

CT confirmed local fat stranding and  detected an air

bubble as well as slight wall thickening of a neigh‐
bouring small bowel loop.  
Using the mnemonic PSI-ABCD, all conditions were
excluded, except for a sharp foreign body.  

After specific searching a fishbone was detected in

the cecum (green arrows on CT). 

Apparently, this fishbone had caused a perforation,

and was later propelled by some small bowel con‐
 tents. The patient was treated with antibiotics only
Abdomen Breast and made a full recovery. 
Cardiovascular Chest Head/Neck Musculoskeletal

Neuroradiology Pediatrics More

Illustrative cases

This 37-year old woman had progressive epigastric

pain since 4 days. 

US detected a reflective curvilinear structure (arrow‐

heads) reaching from the stomach (st.) into the
swollen pancreas, suspect for a fishbone.
(gb=gallbladder).
CT without contrast confirmed a fishbone stuck in the
pancreas. 

At gastroscopy, no fishbone was seen, only a small

mucosal defect producing some fibrin strands.
We assumed that this was the point where the fish‐
bone must have penetrated while the remaining end
of the fishbone got “buried” in the reactively swollen
mucosa of the posterior stomach wall (see drawing). 

Encouraged by this knowledge the endoscopist per‐

formed deep instrumentation with a large forceps,
which eventually was successful.
The patient made a full recovery and told us having
eaten “jarabaka”  a week earlier, a Surinamese fish,
known for its delicious taste and its sharp bones.

A 81-year old man with progressive epigastric pain for

24 hours.
US revealed an aortic aneurysm of 5.2 cm. 

Immediate CT scan excluded rupture, however some

subtle fat stranding anterior of the duodenum was
seen around a small hyperdense structure.

CT revealed a fishbone (arrow) in the duodenum, per‐

Enable Scroll forating its ventral wall.
Abdomen Breast Cardiovascular Chest Head/Neck Musculoskeletal

Neuroradiology Pediatrics More

At gastroscopy the fishbone was easily recognized

and removed. 

Note the greenish discoloration of the fishbone due to

bile pigments. 

When confronted with the results, the patient could

not imagine ever having swallowed such a large
fishbone.

A 50 year old man with pain LLQ and  a CRP of 21,

suspect for diverticulitis. 

Initial US shows wall thickening of the sigmoid, in‐

flamed fat (*) and a fecolith within a diverticulum
(white arrowhead).
Closer inspection of the area where the most in‐
flamed, non-compressible fat (green arrowheads and
*) was seen, revealed a foreign body (arrows). 

CT without contrast confirmed a piece of bone and

subtle fat stranding (*) around the sigmoid.
 Endoscopic removal was relatively easy. 
Abdomen Breast Cardiovascular Chest Head/Neck Musculoskeletal

Neuroradiology Pediatrics More

This is a 60-year old woman with high fever and clinic‐

ally possible pancreatitis. 

CT scan showed an abscess in the quadrate lobe, har‐

bouring a fishbone, migrated from the stomach to the
liver. 

Endoscopic US confirmed the fishbone entirely within

the liver abscess (arrow), so endoscopic removal was
impossible. 

At surgery, the abscess was drained and the fishbone

removed.

A 75 year old man with a clinically suspected iliop‐

soas abscess. 

CT confirms the abscess and identified a straight,

slightly hyperdense sharp foreign body, apparently mi‐
grated from the small bowel to the iliac muscle.
Shape and density suggested a wooden pen rather
than a fishbone. 

With only minimal invasive surgery, both pus and

wooden pen were removed.
 Patient had artificial denture, a previous appendec‐
Abdomen Breast tomy and had theChest
Cardiovascular habit of “shoving-off”
Head/Neck meat of his
Musculoskeletal
sateh-pen with a fork.

Neuroradiology Pediatrics More

A 53-year old man presented with a painful LLQ swell‐

ing and a CRP of 173, suspect for diverticulitis.
He had a left nefrectomy 20 years ago.

US revealed an abscess in the abdominal wall har‐

bouring a thin, curvilinear structure (arrow). 

CT without and with i.v. contrast, confirms a fishbone

(arrow) within a moderately defined, abdominal wall
abscess.
Note how easily the fishbone could have been missed
if only i.v. contrast CT had been made.

Location of abscess and fishbone were indicated on

the skin.
Using only a very small incision, pus and fishbone
could be removed. Uneventful recovery. 

A 57-year old man (previous appendectomy) with sus‐

pected diverticulitis. 

CT showed thickening of the sigmoid (s.) wall and an

unclear mass at the left side.
At this time, the small hyperechoic line (arrow) was
missed.
The CT diagnosis was sigmoid diverticulitis or sig‐
moid malignancy.
Colonoscopy was unable to reach the area. 

On a repeated CT one week later, we were lucky that

the straight and slightly hyperechoic sharp foreign
body (arrows) now presented in its full length on the
coronal CT. 

At surgery, part of the sigmoid was resected together

with a large inflammatory mass, harbouring the caus‐
ative wooden cocktail stick.
A temporary stoma was made.
The patient showed disbelief and firmly denied ever
having swallowed such a stick.
 During an endodontal procedure by his dentist, this 46
Abdomen Breast year old man accidently
Cardiovascular swallowed an
Chest Head/Neck “endofile”.
Musculoskeletal
He had no abdominal complaints, but became wor‐
ried when, after a week, he did not find it in his stool.
Neuroradiology Pediatrics More
CT without contrast confirmed perforation of a jejunal
loop, with only minimal fat stranding. 

At surgery a part of the jejunum was resected includ‐

ing the endofile. 

Young (31 years) Surinamese woman with 3 weeks of

pain LLQ and CRP 55, suspect for adnexitis or diver‐
ticulitis.
Previous history of uterine rupture. 

US shows hypoechoic mass left of the uterus (u.) sus‐

pect for tubo-ovarian abscess (TOA).
In the periphery a thin, curvilinear reflection (arrows)
is seen. 

Endovaginal US confirms a fishbone (arrows) in the

wall of the TOA. 

Non-contrast CT reveals  that the TOA  has a close re‐

lation to the sigmoid, which also shows focal wall
thickening.

At surgery, TOA  and fishbone, densely adhered to the

sigmoid, were removed. 

Apparently, the fishbone, after perforating the sig‐

moid, migrated into the left ovary, causing a TOA.
Note the greenish discoloration of the fishbone, prob‐
ably due to biliary pigments.

Obese 80 year old lady with strong clinical suspicion

of appendicitis.
 She had a previous cholecystectomy.
Abdomen Breast Lab: leukocytes 21,
Cardiovascular CRPHead/Neck
Chest 125. Musculoskeletal

US showed inflamed fat (*) around edematous small

bowel (b.),More
Neuroradiology Pediatrics containing a strange reflective structure
(arrows).
The US images in two perpendicular planes, sugges‐
ted that this foreign body had a flat nature.

CT confirmed small bowel wall thickening, fat strand‐

ing and extra-luminal air. 

Closer inspection in the axial and coronal CT plane,

revealed an intraluminally localized, slightly hyper‐
dense, double-layered flat structure (arrows) of un‐
known origin. 

Surgery revealed focal small bowel usuration by a

sharp vegetable peel.
After the operation, this was recognized by the patient
as the peel of an unripe mango, used in her self-made
mango chutney. 

Man of 79 years old, two days hospitalized for

myocardial infarction, suddenly developed pain in the
RLQ and a CRP of 70, suspect for appendicitis.
He was nursed in isolation for suspected MRSA.

US showed a normal appendix of 4 mms and wall

thickening of the terminal ileum, surrounded by in‐
flamed fat (*).
Next to the ileum a possible air bubble (green arrow)
was observed.  

Within the ileal lumen, a linear reflective structure (ar‐

rowheads) was found.
The aspect in multiple planes, suggested a flat for‐
eign body. 

On one end, a apparently sharp edge (white arrow)

stuck out into the surrounding inflamed fat (*). 
 Axial CT confirmed the US findings and identified an
Enable Scroll
Abdomen Breast odd-looking foreign
Cardiovascular body. 
Chest Head/Neck Musculoskeletal

Neuroradiology Pediatrics More

On coronal CT the odd-looking foreign body had the

Enable Scroll same shape. 

Try to figure out, what it is ...

And then continue reading

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