Asian Journal of Case Reports in Surgery

Background: Gastric perforation from foreign body ingestion is rare, as the stomach’s high acidity and robust muscular wall typically facilitate digestion or safe transit. However, chronic proton pump inhibitor (PPI) therapy induces pharmacologic hypochlorhydria. This reduced acidity may compromise the breakdown of organic objects, such as fish bones, increasing the risk of retention and transmural injury.

Aim: This case report highlights about Delayed Gastric Perforation by a Retained Fish Bone in a Patient on Chronic Pantoprazole Therapy

Case Presentation: A 47-year-old man on pantoprazole therapy for six months presented with a two-week history of worsening epigastric pain, fever, and vomiting. He had no history of Nonsteroidal anti-inflammatory drugs (NSAID) use or recent trauma. Contrast-enhanced computed tomography (CECT) revealed a 3.6 cm linear hyperdense foreign body associated with a complex fluid collection between the stomach and pancreas. Exploratory laparotomy confirmed gastric perforation at the lesser curvature caused by a fish bone, complicated by an abscess. The patient underwent distal gastrectomy with Roux-en-Y reconstruction and made a full recovery.

Discussion: Chronic acid suppression disrupts gastric defence mechanisms by elevating pH and inhibiting enzymatic degradation, which can facilitate foreign body retention and gradual perforation. Diagnosis is challenging due to nonspecific symptoms and the frequent inability of patients to recall ingestion. While plain radiography is often inconclusive, CECT is critical for identifying radiolucent bones and guiding management.

Conclusion: This case highlights the potential link between chronic PPI use and gastric perforation from occult foreign bodies. Clinicians should maintain a high index of suspicion in patients on acid-suppression therapy presenting with persistent abdominal symptoms. Timely CECT and surgical intervention are essential for successful outcomes.