Malignant lymphoma incidentally diagnosed due to the perforation of the small intestine caused by a fish bone: A case report
Identifieur interne : 001D23 ( Pmc/Corpus ); précédent : 001D22; suivant : 001D24Malignant lymphoma incidentally diagnosed due to the perforation of the small intestine caused by a fish bone: A case report
Auteurs : Masatsugu Hiraki ; Atsushi Miyoshi ; Go Anegawa ; Hiroshi Kubo ; Osamu Ikeda ; Keiichi Ohira ; Shinya Azama ; Shinichi Kido ; Daisuke Mori ; Hitoshi Aibe ; Toshiya Tanaka ; Kenji Kitahara ; Seiji SatoSource :
- International Journal of Surgery Case Reports [ 2210-2612 ] ; 2017.
Abstract
Perforation due to an ingested foreign body can occur at some point of physiological narrowing or angulation of the intestinal lumen, such as the ileocecal and rectosigmoid junctions. We experienced an unusual case of malignant lymphoma incidentally diagnosed after perforation of the jejunum by a fish bone. In cases of perforation of the jejunum with an ingested foreign body, careful observation during the surgery may be needed in order to avoid missing the accompanying malignancy.
Url:
DOI: 10.1016/j.ijscr.2017.10.042
PubMed: 29096353
PubMed Central: 5686217
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Malignant lymphoma incidentally diagnosed due to the perforation of the small intestine caused by a fish bone: A case report</title><author><name sortKey="Hiraki, Masatsugu" sort="Hiraki, Masatsugu" uniqKey="Hiraki M" first="Masatsugu" last="Hiraki">Masatsugu Hiraki</name><affiliation><nlm:aff id="aff0005">Department of Surgery, Saga Medical Center Koseikan, Saga, Japan</nlm:aff></affiliation></author><author><name sortKey="Miyoshi, Atsushi" sort="Miyoshi, Atsushi" uniqKey="Miyoshi A" first="Atsushi" last="Miyoshi">Atsushi Miyoshi</name><affiliation><nlm:aff id="aff0005">Department of Surgery, Saga Medical Center Koseikan, Saga, Japan</nlm:aff></affiliation></author><author><name sortKey="Anegawa, Go" sort="Anegawa, Go" uniqKey="Anegawa G" first="Go" last="Anegawa">Go Anegawa</name><affiliation><nlm:aff id="aff0005">Department of Surgery, Saga Medical Center Koseikan, Saga, Japan</nlm:aff></affiliation></author><author><name sortKey="Kubo, Hiroshi" sort="Kubo, Hiroshi" uniqKey="Kubo H" first="Hiroshi" last="Kubo">Hiroshi Kubo</name><affiliation><nlm:aff id="aff0005">Department of Surgery, Saga Medical Center Koseikan, Saga, Japan</nlm:aff></affiliation></author><author><name sortKey="Ikeda, Osamu" sort="Ikeda, Osamu" uniqKey="Ikeda O" first="Osamu" last="Ikeda">Osamu Ikeda</name><affiliation><nlm:aff id="aff0005">Department of Surgery, Saga Medical Center Koseikan, Saga, Japan</nlm:aff></affiliation></author><author><name sortKey="Ohira, Keiichi" sort="Ohira, Keiichi" uniqKey="Ohira K" first="Keiichi" last="Ohira">Keiichi Ohira</name><affiliation><nlm:aff id="aff0010">Department of Radiology, Saga Medical Center Koseikan, Saga, Japan</nlm:aff></affiliation></author><author><name sortKey="Azama, Shinya" sort="Azama, Shinya" uniqKey="Azama S" first="Shinya" last="Azama">Shinya Azama</name><affiliation><nlm:aff id="aff0010">Department of Radiology, Saga Medical Center Koseikan, Saga, Japan</nlm:aff></affiliation></author><author><name sortKey="Kido, Shinichi" sort="Kido, Shinichi" uniqKey="Kido S" first="Shinichi" last="Kido">Shinichi Kido</name><affiliation><nlm:aff id="aff0015">Department of Pathology, Saga Medical Center Koseikan, Saga, Japan</nlm:aff></affiliation></author><author><name sortKey="Mori, Daisuke" sort="Mori, Daisuke" uniqKey="Mori D" first="Daisuke" last="Mori">Daisuke Mori</name><affiliation><nlm:aff id="aff0015">Department of Pathology, Saga Medical Center Koseikan, Saga, Japan</nlm:aff></affiliation></author><author><name sortKey="Aibe, Hitoshi" sort="Aibe, Hitoshi" uniqKey="Aibe H" first="Hitoshi" last="Aibe">Hitoshi Aibe</name><affiliation><nlm:aff id="aff0010">Department of Radiology, Saga Medical Center Koseikan, Saga, Japan</nlm:aff></affiliation></author><author><name sortKey="Tanaka, Toshiya" sort="Tanaka, Toshiya" uniqKey="Tanaka T" first="Toshiya" last="Tanaka">Toshiya Tanaka</name><affiliation><nlm:aff id="aff0005">Department of Surgery, Saga Medical Center Koseikan, Saga, Japan</nlm:aff></affiliation></author><author><name sortKey="Kitahara, Kenji" sort="Kitahara, Kenji" uniqKey="Kitahara K" first="Kenji" last="Kitahara">Kenji Kitahara</name><affiliation><nlm:aff id="aff0005">Department of Surgery, Saga Medical Center Koseikan, Saga, Japan</nlm:aff></affiliation></author><author><name sortKey="Sato, Seiji" sort="Sato, Seiji" uniqKey="Sato S" first="Seiji" last="Sato">Seiji Sato</name><affiliation><nlm:aff id="aff0005">Department of Surgery, Saga Medical Center Koseikan, Saga, Japan</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">29096353</idno><idno type="pmc">5686217</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5686217</idno><idno type="RBID">PMC:5686217</idno><idno type="doi">10.1016/j.ijscr.2017.10.042</idno><date when="2017">2017</date><idno type="wicri:Area/Pmc/Corpus">001D23</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">001D23</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Malignant lymphoma incidentally diagnosed due to the perforation of the small intestine caused by a fish bone: A case report</title><author><name sortKey="Hiraki, Masatsugu" sort="Hiraki, Masatsugu" uniqKey="Hiraki M" first="Masatsugu" last="Hiraki">Masatsugu Hiraki</name><affiliation><nlm:aff id="aff0005">Department of Surgery, Saga Medical Center Koseikan, Saga, Japan</nlm:aff></affiliation></author><author><name sortKey="Miyoshi, Atsushi" sort="Miyoshi, Atsushi" uniqKey="Miyoshi A" first="Atsushi" last="Miyoshi">Atsushi Miyoshi</name><affiliation><nlm:aff id="aff0005">Department of Surgery, Saga Medical Center Koseikan, Saga, Japan</nlm:aff></affiliation></author><author><name sortKey="Anegawa, Go" sort="Anegawa, Go" uniqKey="Anegawa G" first="Go" last="Anegawa">Go Anegawa</name><affiliation><nlm:aff id="aff0005">Department of Surgery, Saga Medical Center Koseikan, Saga, Japan</nlm:aff></affiliation></author><author><name sortKey="Kubo, Hiroshi" sort="Kubo, Hiroshi" uniqKey="Kubo H" first="Hiroshi" last="Kubo">Hiroshi Kubo</name><affiliation><nlm:aff id="aff0005">Department of Surgery, Saga Medical Center Koseikan, Saga, Japan</nlm:aff></affiliation></author><author><name sortKey="Ikeda, Osamu" sort="Ikeda, Osamu" uniqKey="Ikeda O" first="Osamu" last="Ikeda">Osamu Ikeda</name><affiliation><nlm:aff id="aff0005">Department of Surgery, Saga Medical Center Koseikan, Saga, Japan</nlm:aff></affiliation></author><author><name sortKey="Ohira, Keiichi" sort="Ohira, Keiichi" uniqKey="Ohira K" first="Keiichi" last="Ohira">Keiichi Ohira</name><affiliation><nlm:aff id="aff0010">Department of Radiology, Saga Medical Center Koseikan, Saga, Japan</nlm:aff></affiliation></author><author><name sortKey="Azama, Shinya" sort="Azama, Shinya" uniqKey="Azama S" first="Shinya" last="Azama">Shinya Azama</name><affiliation><nlm:aff id="aff0010">Department of Radiology, Saga Medical Center Koseikan, Saga, Japan</nlm:aff></affiliation></author><author><name sortKey="Kido, Shinichi" sort="Kido, Shinichi" uniqKey="Kido S" first="Shinichi" last="Kido">Shinichi Kido</name><affiliation><nlm:aff id="aff0015">Department of Pathology, Saga Medical Center Koseikan, Saga, Japan</nlm:aff></affiliation></author><author><name sortKey="Mori, Daisuke" sort="Mori, Daisuke" uniqKey="Mori D" first="Daisuke" last="Mori">Daisuke Mori</name><affiliation><nlm:aff id="aff0015">Department of Pathology, Saga Medical Center Koseikan, Saga, Japan</nlm:aff></affiliation></author><author><name sortKey="Aibe, Hitoshi" sort="Aibe, Hitoshi" uniqKey="Aibe H" first="Hitoshi" last="Aibe">Hitoshi Aibe</name><affiliation><nlm:aff id="aff0010">Department of Radiology, Saga Medical Center Koseikan, Saga, Japan</nlm:aff></affiliation></author><author><name sortKey="Tanaka, Toshiya" sort="Tanaka, Toshiya" uniqKey="Tanaka T" first="Toshiya" last="Tanaka">Toshiya Tanaka</name><affiliation><nlm:aff id="aff0005">Department of Surgery, Saga Medical Center Koseikan, Saga, Japan</nlm:aff></affiliation></author><author><name sortKey="Kitahara, Kenji" sort="Kitahara, Kenji" uniqKey="Kitahara K" first="Kenji" last="Kitahara">Kenji Kitahara</name><affiliation><nlm:aff id="aff0005">Department of Surgery, Saga Medical Center Koseikan, Saga, Japan</nlm:aff></affiliation></author><author><name sortKey="Sato, Seiji" sort="Sato, Seiji" uniqKey="Sato S" first="Seiji" last="Sato">Seiji Sato</name><affiliation><nlm:aff id="aff0005">Department of Surgery, Saga Medical Center Koseikan, Saga, Japan</nlm:aff></affiliation></author></analytic><series><title level="j">International Journal of Surgery Case Reports</title><idno type="eISSN">2210-2612</idno><imprint><date when="2017">2017</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><title>Highlights</title><p><list list-type="simple"><list-item id="lsti0005"><label>•</label><p>Perforation due to an ingested foreign body can occur at some point of physiological narrowing or angulation of the intestinal lumen, such as the ileocecal and rectosigmoid junctions.</p></list-item><list-item id="lsti0010"><label>•</label><p>We experienced an unusual case of malignant lymphoma incidentally diagnosed after perforation of the jejunum by a fish bone.</p></list-item><list-item id="lsti0015"><label>•</label><p>In cases of perforation of the jejunum with an ingested foreign body, careful observation during the surgery may be needed in order to avoid missing the accompanying malignancy.</p></list-item></list></p></div></front><back><div1 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Int J Surg Case Rep</journal-id><journal-id journal-id-type="iso-abbrev">Int J Surg Case Rep</journal-id><journal-title-group><journal-title>International Journal of Surgery Case Reports</journal-title></journal-title-group><issn pub-type="epub">2210-2612</issn><publisher><publisher-name>Elsevier</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">29096353</article-id><article-id pub-id-type="pmc">5686217</article-id><article-id pub-id-type="publisher-id">S2210-2612(17)30550-3</article-id><article-id pub-id-type="doi">10.1016/j.ijscr.2017.10.042</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>Malignant lymphoma incidentally diagnosed due to the perforation of the small intestine caused by a fish bone: A case report</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Hiraki</surname><given-names>Masatsugu</given-names></name><email>masatsuguhiraki@hotmail.com</email><xref rid="aff0005" ref-type="aff">a</xref><xref rid="cor0005" ref-type="corresp">⁎</xref></contrib><contrib contrib-type="author"><name><surname>Miyoshi</surname><given-names>Atsushi</given-names></name><xref rid="aff0005" ref-type="aff">a</xref></contrib><contrib contrib-type="author"><name><surname>Anegawa</surname><given-names>Go</given-names></name><xref rid="aff0005" ref-type="aff">a</xref></contrib><contrib contrib-type="author"><name><surname>Kubo</surname><given-names>Hiroshi</given-names></name><xref rid="aff0005" ref-type="aff">a</xref></contrib><contrib contrib-type="author"><name><surname>Ikeda</surname><given-names>Osamu</given-names></name><xref rid="aff0005" ref-type="aff">a</xref></contrib><contrib contrib-type="author"><name><surname>Ohira</surname><given-names>Keiichi</given-names></name><xref rid="aff0010" ref-type="aff">b</xref></contrib><contrib contrib-type="author"><name><surname>Azama</surname><given-names>Shinya</given-names></name><xref rid="aff0010" ref-type="aff">b</xref></contrib><contrib contrib-type="author"><name><surname>Kido</surname><given-names>Shinichi</given-names></name><xref rid="aff0015" ref-type="aff">c</xref></contrib><contrib contrib-type="author"><name><surname>Mori</surname><given-names>Daisuke</given-names></name><xref rid="aff0015" ref-type="aff">c</xref></contrib><contrib contrib-type="author"><name><surname>Aibe</surname><given-names>Hitoshi</given-names></name><xref rid="aff0010" ref-type="aff">b</xref></contrib><contrib contrib-type="author"><name><surname>Tanaka</surname><given-names>Toshiya</given-names></name><xref rid="aff0005" ref-type="aff">a</xref></contrib><contrib contrib-type="author"><name><surname>Kitahara</surname><given-names>Kenji</given-names></name><xref rid="aff0005" ref-type="aff">a</xref></contrib><contrib contrib-type="author"><name><surname>Sato</surname><given-names>Seiji</given-names></name><xref rid="aff0005" ref-type="aff">a</xref></contrib></contrib-group><aff id="aff0005"><label>a</label>Department of Surgery, Saga Medical Center Koseikan, Saga, Japan</aff><aff id="aff0010"><label>b</label>Department of Radiology, Saga Medical Center Koseikan, Saga, Japan</aff><aff id="aff0015"><label>c</label>Department of Pathology, Saga Medical Center Koseikan, Saga, Japan</aff><author-notes><corresp id="cor0005"><label>⁎</label>Corresponding author at: Department of Surgery, Saga Medical Center Koseikan, Address: 400 Nakabaru, Kasemachi, Saga City, Saga, 849-8571, Japan.Department of SurgerySaga Medical Center KoseikanSagaJapan <email>masatsuguhiraki@hotmail.com</email></corresp></author-notes><pub-date pub-type="pmc-release"><day>26</day><month>10</month><year>2017</year></pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on .</pmc-comment>
<pub-date pub-type="collection"><year>2017</year></pub-date><pub-date pub-type="epub"><day>26</day><month>10</month><year>2017</year></pub-date><volume>41</volume><fpage>238</fpage><lpage>242</lpage><history><date date-type="received"><day>10</day><month>9</month><year>2017</year></date><date date-type="accepted"><day>24</day><month>10</month><year>2017</year></date></history><permissions><copyright-statement>© 2017 The Authors</copyright-statement><copyright-year>2017</copyright-year><license license-type="CC BY-NC-ND" xlink:href="http://creativecommons.org/licenses/by-nc-nd/4.0/"><license-p>This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).</license-p></license></permissions><abstract abstract-type="author-highlights" id="abs0005"><title>Highlights</title><p><list list-type="simple"><list-item id="lsti0005"><label>•</label><p>Perforation due to an ingested foreign body can occur at some point of physiological narrowing or angulation of the intestinal lumen, such as the ileocecal and rectosigmoid junctions.</p></list-item><list-item id="lsti0010"><label>•</label><p>We experienced an unusual case of malignant lymphoma incidentally diagnosed after perforation of the jejunum by a fish bone.</p></list-item><list-item id="lsti0015"><label>•</label><p>In cases of perforation of the jejunum with an ingested foreign body, careful observation during the surgery may be needed in order to avoid missing the accompanying malignancy.</p></list-item></list></p></abstract><abstract id="abs0010"><sec><title>Introduction</title><p>The ingestion of a foreign body is relatively common. However, it rarely results in the perforation of gastrointestinal tract. We herein report an unusual case of malignant lymphoma incidentally diagnosed after the perforation of the small intestine by a fish bone.</p></sec><sec><title>Presentation of case</title><p>A 90-year-old woman was admitted to our hospital because of abdominal pain and vomiting. Abdominal computed tomography demonstrated free air and ascites in the abdominal cavity. In the pelvic cavity, a radiopaque linear shadow about 35 mm in diameter was shown in the small intestine, and the stricture was exposed to the abdominal cavity. Therefore, a diagnosis of perforation of the small intestine due to ingestion of a foreign body and panperitonitis was made. Emergent laparotomy was performed. The intraoperative findings revealed perforation of the small intestine with a fish bone in the jejunum. Local inflammation at the perforation site was seen, and circulated wall thickness was observed at the distal side of the jejunum. Partial resection of the jejunum and anastomosis of jejuno-jejunostomy was performed. A pathological examination and immunohistochemical study of the resected specimen resulted in a diagnosis of malignant lymphoma of follicular lymphoma Grade 1.</p></sec><sec><title>Discussion</title><p>It is very difficult to identify the existence malignancy accompanied with gastrointestinal perforation with ingestion of a foreign body.</p></sec><sec><title>Conclusion</title><p>In cases suspected of involving malignancy, careful observation during surgery is needed in order to avoid missing the accompanying malignancy.</p></sec></abstract><kwd-group id="kwd0005"><title>Keywords</title><kwd>Fish bone</kwd><kwd>Perforation</kwd><kwd>Small intestine</kwd><kwd>Malignant lymphoma</kwd><kwd>Foreign body</kwd><kwd>Ingestion</kwd></kwd-group></article-meta></front><body><sec id="sec0005"><label>1</label><title>Introduction</title><p>The ingestion of a foreign body, especially animal bone, is relatively common <xref rid="bib0005" ref-type="bibr">[1]</xref>. However, it rarely results in the perforation of the gastrointestinal tract and the need for emergent operation. Perforation due to an ingested foreign body can occur anywhere in the gastrointestinal tract, such as at angulations or at the narrowing of the lumen. We herein report an unusual case of malignant lymphoma incidentally diagnosed after perforation of the small intestine by a fish bone. This work has been reported in line with the SCARE criteria <xref rid="bib0010" ref-type="bibr">[2]</xref>.</p></sec><sec id="sec0010"><label>2</label><title>Case presentation</title><p>A 90-year-old woman was admitted to our hospital because of abdominal pain and vomiting. She had a medical history of hypertension and pneumonia. A physical examination showed tenderness at the lower abdomen. However, neither muscular defense nor Blumberg’s sign were clearly shown. Her body temperature, blood pressure, heart rate, respiratory rate and SpO<sub>2</sub> were, 38 °C, 104/54 mmHg, 98/min, 21/min and 99% (3 L of oxygen), respectively. Laboratory studies on admission showed elevated levels of inflammation (white blood cells: 16,100/μl, CRP: 10.13 mg/dl) and renal dysfunction (serum creatinine: 1.48 mg/dl, BUN: 27.7 mg/dl). Abdominal computed tomography (CT) demonstrated free air and ascites in the abdominal cavity (<xref rid="fig0005" ref-type="fig">Fig. 1</xref>A, B). In the pelvic cavity, a radiopaque linear shadow about 35 mm in diameter was shown in the small intestine, and that stricture was exposed to the abdominal cavity (<xref rid="fig0005" ref-type="fig">Fig. 1</xref>C, D). Therefore, a diagnosis of perforation of the small intestine due to ingestion of a foreign body and panperitonitis was made.<fig id="fig0005"><label>Fig. 1</label><caption><p>Free air and ascites around the liver (A). Free air and ascites in the pelvic cavity (B). A radiopaque linear shadow about 35 mm in diameter (arrow) was observed in the small intestine, and the stricture was exposed to the abdominal cavity in the pelvic cavity (C). Ingested foreign body (arrow) on CT with 3D reconstruction (D).</p></caption><alt-text id="at0005">Fig. 1</alt-text><graphic xlink:href="gr1"></graphic></fig></p><p>Emergent laparotomy was performed. The intraoperative findings revealed perforation of the small intestine with a fish bone in the jejunum, at a site some 70 cm distal from the Treitz ligament. Local inflammation of the small intestine at the perforation site was seen, and circulated wall thickness was observed at the distal side of the jejunum. Therefore, both partial resection of the jejunum and anastomosis of jejuno-jejunostomy were performed. No other abnormalities were seen in the peritoneal cavity, including the rest of the intestine and lymph nodes.</p><p>The resected specimen showed perforation of the small intestine due to a fish bone 35 mm in length (<xref rid="fig0010" ref-type="fig">Fig. 2</xref>A, B). The anal side of the perforation site showed circulated thickness of the wall (<xref rid="fig0010" ref-type="fig">Fig. 2</xref>C). A pathological examination revealed diffuse spreading of medium-sized lymphocytes in the mucosa and submucosa, and a follicular structure was seen (<xref rid="fig0015" ref-type="fig">Fig. 3</xref>A, B). An immunohistochemical study showed CD20, CD79a, CD10 and bcl-2 positivity (<xref rid="fig0015" ref-type="fig">Fig. 3</xref>C, D, E). The specimen was negative for CD3. Therefore, malignant lymphoma of follicular lymphoma Grade 1 was made. The patient was discharged from the hospital on the ninth postoperative day. No additional imaging examinations nor treatments for the malignant lymphoma were performed, considering patient’s age and background, after receiving her informed consent.<fig id="fig0010"><label>Fig. 2</label><caption><p>Perforation of the small intestine due to the fish bone (A). The foreign body (fish bone), 35 mm in diameter (B). The anal side of the perforation site, showing circulated thickness of the wall (C).</p></caption><alt-text id="at0010">Fig. 2</alt-text><graphic xlink:href="gr2"></graphic></fig><fig id="fig0015"><label>Fig. 3</label><caption><p>Hematoxylin and eosin staining showing diffuse spreading of lymphocytes in the mucosa and submucosa and in the follicular gland (A, B). An immunohistochemical study showing positivity for CD20 (C), CD10 (D) and bcl-2 (E).</p></caption><alt-text id="at0015">Fig. 3</alt-text><graphic xlink:href="gr3"></graphic></fig></p></sec><sec id="sec0015"><label>3</label><title>Discussion</title><p>Ingestion of a foreign body is a common occurrence in daily life and most commonly happens in elderly people <xref rid="bib0005" ref-type="bibr">[1]</xref>. Most foreign bodies pass through the gastrointestinal tract uneventfully if they reach the stomach. However, <1% of such ingestions result in perforation at some point from the mouth to the anus <xref rid="bib0015" ref-type="bibr">[3]</xref>. Perforation due to an ingested foreign body is likely to occur at some point of physiological narrowing or angulation of the intestinal lumen, such as the ileocecal and rectosigmoid junctions <xref rid="bib0020" ref-type="bibr">[4]</xref>, <xref rid="bib0025" ref-type="bibr">[5]</xref>. However, our patient developed perforation of the jejunum due to a fish bone accompanying malignant lymphoma, which had caused narrowing of the tumorous lumen. Given the aging of society, the number of patients with neurological disorders such as dementia and cerebrovascular disorders and/or edentulous elderly patients is expected to increase. Therefore, we may also more frequently encounter patients with ingestion of a foreign body and its associated complications or accompanying malignancy.</p><p>Five previous reports of gastrointestinal tumor incidentally found due to perforation caused by an ingested bone were found in PubMed through August 2017 after searching with the key words “perforation” and “ingested bone” <xref rid="bib0020" ref-type="bibr">[4]</xref>, <xref rid="bib0030" ref-type="bibr">[6]</xref>, <xref rid="bib0035" ref-type="bibr">[7]</xref>, <xref rid="bib0040" ref-type="bibr">[8]</xref>, <xref rid="bib0045" ref-type="bibr">[9]</xref>. <xref rid="tbl0005" ref-type="table">Table 1</xref> shows a summary of these five previous cases and our present case. Five cases (83%) occurred in elderly patients ( >75 years of age). The accompanying malignancies were sigmoid colon cancer (4 cases; 67%); gastrointestinal stromal tumor (1 case; 17%) and malignant lymphoma (1 case; 17%). A total of 67% of cases were preoperatively diagnosed with perforation with a foreign body. However; none were diagnosed with gastrointestinal tumor in advance. In our case; wall thickness in the small intestine was suspected based on a retrospective examination of the CT images. However; such thickness can be difficult to distinguish from inflammatory or edematous changes caused by perforation. Kriegshause et al. <xref rid="bib0040" ref-type="bibr">[8]</xref>. reported a patient with an ulcerated gastrointestinal stromal tumor of the small intestine who had ingested a foreign bone. However; this tumor was considered difficult to distinguish from an abscess preoperatively. Terrace et al. <xref rid="bib0020" ref-type="bibr">[4]</xref> also recently reported that their case of sigmoid colon perforation with ingestion of a bone seemed to be complicated with malignancy and ultimately diagnosed the patient with sigmoid colon cancer.<table-wrap id="tbl0005" position="float"><label>Table 1</label><caption><p>Previous reports of gastrointestinal tumor incidentally found after perforation caused by an ingested bone.</p></caption><alt-text id="at0020">Table 1</alt-text><table frame="hsides" rules="groups"><thead><tr><th align="left"></th><th align="left">Refs.</th><th align="left">Year</th><th align="left">Age</th><th align="left">Sex</th><th align="left">Preoperative diagnosis</th><th align="left">Emergency operation?</th><th align="left">Perforated organ</th><th align="left">Malignancy</th><th align="left">Ingested foreign body</th><th align="left">Diagnosed malignancy preoperatively?</th></tr></thead><tbody><tr><td align="left">1</td><td align="left">Osler et al. <xref rid="bib0030" ref-type="bibr">[6]</xref></td><td align="left">1985</td><td align="left">78</td><td align="left">F</td><td align="left">Perforation</td><td align="left">Yes</td><td align="left">Sigmoid colon</td><td align="left">Sigmoid colon cancer</td><td align="left">Chicken bone</td><td align="left">No</td></tr><tr><td align="left"><bold>2</bold></td><td align="left">Vardaki et al. <xref rid="bib0035" ref-type="bibr">[7]</xref></td><td align="left">2001</td><td align="left">69</td><td align="left">M</td><td align="left">Sigmoid colon perforation, foreign body</td><td align="left">Yes</td><td align="left">Sigmoid colon</td><td align="left">Sigmoid colon cancer</td><td align="left">Chicken bone,<break></break>15 mm</td><td align="left">No</td></tr><tr><td align="left"><bold>3</bold></td><td align="left">Kriegshauser et al. <xref rid="bib0040" ref-type="bibr">[8]</xref></td><td align="left">2006</td><td align="left">84</td><td align="left">F</td><td align="left">Ulcerated mass or abscess, ingested bone</td><td align="left">No</td><td align="left">Small intestine</td><td align="left">GIST</td><td align="left">Animal bone,<break></break>16 mm</td><td align="left">No</td></tr><tr><td align="left"><bold>4</bold></td><td align="left">McGregor et al. <xref rid="bib0045" ref-type="bibr">[9]</xref></td><td align="left">2011</td><td align="left">86</td><td align="left">M</td><td align="left">Sigmoid colon obstruction, possible perforation, mass</td><td align="left">Yes</td><td align="left">Sigmoid colon</td><td align="left">Sigmoid colon cancer</td><td align="left">Bone<break></break>26 × 2 mm</td><td align="left">No</td></tr><tr><td align="left"><bold>5</bold></td><td align="left">Terace et al.<xref rid="bib0020" ref-type="bibr">[4]</xref></td><td align="left">2013</td><td align="left">85</td><td align="left">M</td><td align="left">Sigmoid colon perforation, ingested bone</td><td align="left">Yes</td><td align="left">Sigmoid colon</td><td align="left">Sigmoid colon cancer</td><td align="left">Chicken bone</td><td align="left">No</td></tr><tr><td align="left"><bold>6</bold></td><td align="left">Our case</td><td align="left">2017</td><td align="left">90</td><td align="left">F</td><td align="left">Small intestine perforation, ingested bone</td><td align="left">Yes</td><td align="left">Small intestine</td><td align="left">Malignant lymphoma</td><td align="left">Fish bone,<break></break>35 mm</td><td align="left">No</td></tr></tbody></table></table-wrap></p><p>Regarding operative procedure, Sarmast et al. <xref rid="bib0025" ref-type="bibr">[5]</xref>. reviewed 21 cases of gastrointestinal tract perforation due to ingestion of foreign bodies. In their study, 52.4% of patients with perforation of the small intestine underwent removal of a foreign body and primary repair of their perforations after minimal debridement. In cases with malignancy accompanying perforation, simple primary closure might miss the opportunity to diagnose and resect the malignancy. The most common sites of perforation in the gastrointestinal tract are the ileo-cecal junction and sigmoid colon <xref rid="bib0025" ref-type="bibr">[5]</xref>. Regarding perforation of the small intestine in particular, most cases are reported to occur at the ileo-cecal junction, which has a narrowing lumen <xref rid="bib0025" ref-type="bibr">[5]</xref>. These findings suggest that perforation of the jejunum due to a foreign body can happen but may be relatively infrequent.</p><p>In cases of perforation of the jejunum with an ingested foreign body, careful observation during the surgery may be needed in order to avoid missing the accompanying malignancy. In addition, if wall thickness is observed at the perforation site of the anal side of the jejunum in cases suspected of having malignancy, resection of the small intestine and an intraoperative histological examination should be considered, and lymph node dissection may be needed in confirmed cases of cancer.</p></sec><sec id="sec0020"><label>4</label><title>Conclusions</title><p>In conclusion, we experienced a case of malignant lymphoma incidentally diagnosed due to perforation of the small intestine by a fish bone.</p></sec><sec id="sec0025"><title>Author contribution</title><p>All the authors contributed to diagnose and treat the patient. Masatsugu Hiraki contributed in drafting the manuscript. Atsushi Miyoshi edited the manuscript. Kenji Kitahara supervised and made the final approval of the manuscript. All authors read and approved the final manuscript.</p></sec><sec id="sec0030"><title>Conflicts of interest</title><p>The authors declare that they have no competing interests.</p></sec><sec id="sec0035"><title>Funding</title><p>None.</p></sec><sec id="sec0040"><title>Ethical approval</title><p>This case report is not research study. That is not applicable in this case report.</p></sec><sec id="sec0045"><title>Consent</title><p>The patient was informed and informed consent was obtained.</p></sec><sec id="sec0050"><title>Guarantor</title><p>Dr. Kenji Kitahara.</p></sec></body><back><ref-list id="bibl0005"><title>References</title><ref id="bib0005"><label>1</label><element-citation publication-type="journal" id="sbref0005"><person-group person-group-type="author"><name><surname>Geraci</surname><given-names>G.</given-names></name><name><surname>Sciume</surname><given-names>C.</given-names></name><name><surname>Di Carlo</surname><given-names>G.</given-names></name><name><surname>Picciurro</surname><given-names>A.</given-names></name><name><surname>Modica</surname><given-names>G.</given-names></name></person-group><article-title>Retrospective analysis of management of ingested foreign bodies and food impactions in emergency endoscopic setting in adults</article-title><source>BMC Emerg. 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