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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 42-44

Fish bone ingestion mimicking acute coronary syndrome


1 Department of Internal Medicine, Dr. Mahalingappa Shivam Hospital and Neuro Centre, Raichur, Karnataka, India
2 Department of Gastroenterology, Rajiv Gandhi Superspeciality Hospital, Raichur, Karnataka, India

Date of Submission06-Apr-2020
Date of Decision02-May-2020
Date of Acceptance09-May-2020
Date of Web Publication06-Jan-2022

Correspondence Address:
Dr. B Mahalingappa
Dr. Mahalingappa Shivam Hospital and Neuro Centre, Raichur - 584 101, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AJIM.AJIM_26_20

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  Abstract 


Fish bone as a foreign body is the most common food-associated foreign body in Asians as compared to meat impaction in the Western population, and the most common site is upper esophagus. The impaction of fish bones in the gastrointestinal tract during ingestion is a common complaint and can mimic acute coronary syndrome (ACS). A 45-year-old man presented to our emergency department with acute-onset retrosternal pain. Electrocardiogram, Troponin I, and two-dimensional-echocardiography were normal. Computed tomography of the chest showed a lodged fish bone tenting the upper esophagus, which was removed endoscopically. He was discharged on the 3rd day of the procedure. This case showed an unusual cause of acute chest pain which was initially suspected as ACS based on American College of Cardiology/American Heart Association guidelines. This case highlights the importance of thorough history taking and a need for high level of alertness in reaching the correct diagnosis.

Keywords: Acute coronary syndrome, computed tomography, fish bone


How to cite this article:
Mahalingappa B, Hatti M. Fish bone ingestion mimicking acute coronary syndrome. APIK J Int Med 2022;10:42-4

How to cite this URL:
Mahalingappa B, Hatti M. Fish bone ingestion mimicking acute coronary syndrome. APIK J Int Med [serial online] 2022 [cited 2022 Jan 25];10:42-4. Available from: https://www.ajim.in/text.asp?2022/10/1/42/335079




  Introduction Top


Fish bone foreign body (FFB) is the most common food-associated foreign body in Asians as compared to meat impaction in the Western population.[1] The upper esophagus is the most common site of lodging of FFB. It has a wide range of clinical presentations. An FFB in the esophagus is a medical emergency and requires early treatment to prevent the complications. Here, we report a case of fish bone ingestion, which mimicked acute coronary syndrome (ACS).


  Case Report Top


A 45-year-old man presented to the emergency department with a history of chest pain of 2 h duration. It was sharp, stabbing in character, and severe in intensity in the retrosternal area. It started soon after the intake of food. Pain radiated to the back and aggravated with swallowing and talking. He had a history of chronic ethanol consumption. There was no history of any other systemic illness or any similar illness in the past. On general physical examination, the patient was restless. His pulse was 110 beats/min and blood pressure was 110/80 mmHg. Cardiovascular and respiratory system examinations were unremarkable. Neurological and gastrointestinal system examination did not reveal any abnormality. His electrocardiogram showed only sinus tachycardia. Serial serum Troponin I levels were <10 ng/ml, which was also within the normal reference limit. Total leukocyte count was 7700 cells/cubic ml with a normal differential leukocyte count. Renal function and liver function tests were within normal limits. His two-dimensional-echocardiography was normal. In view of symptoms favoring ACS, he was initiated on treatment according to American College of cardiology/American Heart Association (ACC/AHA) guidelines for the management of chest pain.[2] He was treated with antiplatelets, statins, and anti-anginal measures. However, 24 h after admission, the patient developed hypotension and developed breathlessness with fever. A possibility of aortic dissection was considered, and he underwent contrast-enhanced computed tomography of the chest. The CT ruled out aortic dissection. However, it revealed linear calcific densities in the upper esophagus in noncontrast phase of the study [Figure 1]. One of it was seen tenting the esophagus. On deep inquiry, he gave a history of consuming fish along with ethanol about 1 h prior to the onset of the chest pain. The diagnosis of fish bone ingestion mimicking ACS was made. He underwent flexible upper gastrointestinal endoscopy, and a fish bone was removed from the esophagus approximately 25 cm from the incisor. There was superficial ulceration of the esophageal mucosa [Figure 2]. The patient had an uneventful recovery with intravenous antibiotics and supportive measures. He was discharged on the 3rd day following removal of the fish bone.
Figure 1: Axial section of noncontrast phase computed tomography chest showing linear hyperdensity (arrow) in the esophagus suggesting the presence of a fish bone

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Figure 2: Fish bone noted in the esophagus with mucosal ulceration

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  Discussion Top


Among patients presenting to the emergency department with chest pain, 50% of them will be diagnosed with noncardiac chest pain.[3] Esophageal chest pain remains one of the important causes.[4] FFB ingestion is an important cause of foreign body in the oropharynx or esophagus. Its main complications are airway obstruction necessitating emergency resuscitation or esophageal injuries. Rarely, it can cause dreaded complications such as development of aorto-esophageal fistula.

Our patient presented to the emergency department with a history of acute-onset retrosternal chest pain, which initially mimicked ACS, and he was initiated on treatment according to ACC/AHA guidelines. Subsequently, he developed hypotension, which was most probably due to vagal plexus stimulation by the fish bone present in the esophagus. Patients with impacted fish bone can present with a wide range of manifestations from foreign body sensation to retrosternal pain. In the present case, the pain which increased on talking or swallowing was probably due to local injury to the throat by the fish bone. Our patient was treated with conventional treatment for ACS based on the ACC/AHA guidelines. However, when the clinical condition did not improve, other alternative possibilities that can cause similar symptoms were sought for. We evaluated for a possible aortic dissection which turned out to be negative. However, CT chest and a review of history helped in inching toward diagnosis. Hence, a thorough and detailed history taking is of utmost importance in making such diagnosis.

Plain radiography (both lateral and anteroposterior views) is the first screening investigation for FFB, however it has a low sensitivity of 32%.[5] CT chest has a high sensitivity of 90%–100% and a specificity of 93.7%.[6] Complications may increase if treatment is delayed beyond 24 h. Removal of the FFB by flexible endoscopy is the treatment of choice.


  Conclusion Top


The lodgment of fish bone in the upper esophagus is a common entity. This case demonstrated an unusual cause of acute retrosternal pain in the form of FFB ingestion, which we initially treated as ACS based on ACC/AHA guidelines for the management of chest pain. Misdiagnosis can especially occur in circumstances where proper and relevant clinical history cannot be given by the patient. In such cases, CT may facilitate early diagnosis of FFB to avoid catastrophic outcomes. This case highlights the importance of thorough history taking and a need for high level of alertness in reaching the correct diagnosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lai AT, Chow TL, Lee DT, Kwok SP. Risk factors predicting the development of complications after foreign body ingestion. Br J Surg 2003;90:1531-35.  Back to cited text no. 1
    
2.
Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, et al. ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: Executive summary and recommendations. A report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee on the management of patients with unstable angina). Circulation 2000;102:1193-209.  Back to cited text no. 2
    
3.
Stallone F, Twerenbold R, Wildi K, Reichlin T, Rubini Gimenez M, Haaf P, et al. Prevalence, characteristics and outcome of non-cardiac chest pain and elevated copeptin levels. Heart 2014;100:1708-14.  Back to cited text no. 3
    
4.
Kline M, Chesne R, Sturdevant RA, McCallum RW. Esophageal disease in patients with angina-like chest pain. Am J Gastroenterol 1981;75:116-23.  Back to cited text no. 4
    
5.
Ngan JH, Fok PJ, Lai EC, Branicki FJ, Wong J. A prospective study on fish bone ingestion. Experience of 358 patients. Ann Surg 1990;211:459-62.  Back to cited text no. 5
    
6.
Liew CJ, Poh AC, Tan TY. Finding nemo: Imaging findings, pitfalls, and complications of ingested fish bones in the alimentary canal. Emerg Radiol 2013;20:311-22.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]



 

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Abstract
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