Post written by Abel Joseph, MD, and Joo Ha Hwang, MD, PhD, from the Division of Gastroenterology and Hepatology, Stanford University,  Stanford, California, USA.

A 49-year-old woman with systemic lupus erythematosus and pulmonary hypertension presented with severe odynophagia after accidentally ingesting a fish bone. Initial CT imaging revealed linear density in the upper esophagus. Although an initial endoscopy did not identify the fish bone, persistent symptoms and repeat imaging suggested a developing submucosal abscess.

During repeat endoscopy, a small submucosal bulge 15 cm from the incisors was found, with purulent drainage indicating abscess formation. Endoscopic submucosal dissection (ESD) was chosen to allow drainage and retrieval of the embedded foreign body.

After submucosal injection with indigo carmine to delineate the dissection plane, a 1.5-mm ESD knife was used to make a precise incision, releasing pus. Interestingly, the fish bone’s entry point was located 3 cm proximally to the abscess, suggesting migration and localized infection at the distal tip. Careful dissection exposed the bone, which was removed using mini-rat-tooth forceps.

The dissection site was left open for continued drainage. Postprocedural care included broad-spectrum antibiotics, proton pump inhibitor therapy, and dietary progression. A follow-up esophagram showed no evidence of fistula or residual abscess, and the patient recovered uneventfully.

This case is an example of how modern endoscopic techniques can safely treat challenging situations that once required surgical intervention. Even when findings of the first endoscopic examination appeared normal, persistent symptoms can signal something hidden beneath the surface, quite literally.

ESD as a therapeutic option allows precise mucosal incision, controlled drainage, and safe retrieval of embedded objects without the morbidity of surgery.

In conclusion, ESD offers a safe, minimally invasive approach for abscess drainage and foreign body retrieval. Early recognition, technical precision, and multidisciplinary care are key to optimal outcomes.

Computed tomography scan demonstrating linear density in upper esophagus.

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