Fish bone is the commonest cause of foreign body disease in Asian population. Esophageal perforation following fish bone foreign body accounts for 1-4% of the total reported cases. A 60-year-old lady presented with progressively worsening dysphagia and odynophagia over five days period following a fish meal. She sought treatment at two general practitioner clinic and a private hospital before being referred to Ear, Nose and Throat specialist. Repeated neck X-ray revealed a significant increase in prevertebral soft tissue thickness with large air-pocket tracking, small opacity at the prevertebral C3 level and subcutaneous emphysema anterior to the neck suggestive of retropharyngeal hematoma or abscess. A CT neck and thorax showed a 2.1 cm linear dense structure at the level of C7/T1 that appeared to protrude outside the esophagus in between the tracheoesophageal space. Direct laryngoscopy and repeat emergency esophagoscopy revealed a perforation at the right side of esophagus distal to cricopharyngeus with pus discharge upon milking of posterior lateral wall and a fish bone measuring 3.0 x 0.5 cm was removed from posterior wall of esophagus 17 cm from incisor. Gastrograffin study on day 10 was normal and was discharged on day 11 with Ryle’s tube feeding and to complete oral antibiotic. Fiber optic endoscopic evaluations of swallowing at two weeks follow up was normal. Subsequent review in the clinic showed full recovery without sequelae. Migrating fish bone can lead to esophagus penetration with serious complications. Mortality and morbidity from fish bone foreign body can be minimized with early diagnosis, referral and removal.
Acute appendicitis is one of the most common differential diagnoses for acute abdominal pain made by emergency doctors. Suspected cases require surgical referral for observation or definitive intervention to prevent complications. A high index of suspicion and good clinical skills with the aid of scoring systems allows early decision making, which includes optimal pain control. The objective of this study was to identify the pain score and is relationship to the cut-off points of the Alvarado scoring system so that justifies early surgical referral or discharge for suspected acute appendicitis from the Emergency Department of Universiti Kebangsaan Malaysia Medical Centre (UKMMC). This was a cross sectional study of acute abdominal pain from June 2007 to September 2008. All patients who fulfilled the criteria and consented to the study were assessed for Alvarado score, verbal numerical pain score (VNRS) and their subsequent management. Patients with an Alvarado score of ≥7 were likely to have acute appendicitis (80.1% sensitivity and 52.63% specificity) and those with the score of ≤3 were unlikely to have acute appendicitis. The median pain score was 7.00 (IQR: 5.00-8.50) but 72.5% did not receive any analgesia. There was no direct relationship between the pain score with Alvarado score. Oligoanalgesia in patients with acute appendicitis still exist in Emergency Department of UKMMC.