CT Changed the Diagnosis: Temporal Trends in Recognition and Management of Fish Bone–Induced Gastrointestinal Perforation

Fish bone perforation of the gastrointestinal tract is rare and frequently misdiagnosed—not because it is inherently difficult to recognize, but because it is not considered. Symptoms are nonspecific, patients may not recall ingestion, and the condition can mimic acute abdomen. We performed a systematic review of published case reports and case series with individual patient-level data extraction; 220 patients from 199 publications were included. The small bowel, including Meckel’s diverticulum, was the most frequent perforation site (46.3%), followed by the colorectum (22.9%) and upper gastrointestinal tract (20.4%). Contained perforation was most common (48.1%); free perforation occurred in 22.8%. Initial misdiagnosis occurred in 38.1% and decreased over time (OR 0.54; 95% CI: 0.40-0.71; P < .001). Absence of recalled ingestion was not independently associated with misdiagnosis, suggesting that nonspecific symptoms and inflammatory mimicry play a larger role than history alone. CT identified the fish bone in 78.5% of patients who underwent CT, with increasing yield over time. Abscess predicted surgery (OR 4.07; 95% CI: 1.35-13.2; P = .014). Surgery was used in 86.2%. No severe outcomes occurred among 20 patients treated with endoscopy alone. The accompanying case extends these findings to the postoperative setting: CT identified the foreign body and guided the decision to avoid reoperation, with endoscopic removal as definitive treatment. Fish bone perforation should be considered in any patient with unexplained localized intra-abdominal inflammation, regardless of ingestion history. CT is the diagnostic cornerstone, and endoscopic treatment is feasible in selected stable patients with contained injury.