An 82-year-old male presented with per-rectal bleeding. He had a significant medical history for chronic hepatitis B, chronic kidney disease, pancolonic diverticular disease, prostate cancer status post radiotherapy, intestinal obstruction secondary to a phytobezoar status post exploratory laparotomy, and removal of phytobezoar complicated by incisional hernia status post mesh repair.

He denied abdominal pain and his abdominal examination was unremarkable. Digital rectal examination and proctoscopy revealed altered blood. Hemoglobin on admission was 10.0 g/dL (normal values: 14.0–18.0 g/dL).

The patient underwent endoscopic evaluation of his rectal bleeding, for which esophagogastroduodenoscopy was unremarkable, and colonoscopy identified pancolonic diverticulosis with a descending colon polyp that was removed, but otherwise the patient had no significant source of bleeding. The impression was that of resolved diverticular bleeding. However, he had persistent per-rectal bleeding over the next week, with a repeat colonoscopy negative for colonic bleeding. The decision was then made for small bowel evaluation. In view of his history of intestinal obstruction, gastroenterology arranged for trial of a patency capsule prior to capsule endoscopy. The patient did not pass out the patency capsule, and abdominal radiographs confirmed retention of the patency capsule, precluding use of the capsule endoscopy, and gastroenterology proceed with endoscopic small bowel evaluation. Double balloon enteroscopy identified a jejunal ulcer, and hemostasis was achieved via endoscopic clipping. A nuclear medicine tagged red blood scan was also performed during this time, which confirmed no further localized sources of bleeding.

Unfortunately, the patient suffered from subsequent per-rectal bleeding with hemodynamic instability, and a computed tomographic mesenteric angiogram (CT MA) was performed which demonstrated intestinal obstruction potentially from the retained patency capsule (Figure 1). The intestinal obstruction was managed conservatively with complete resolution, and repeat CT showed migration of the foreign object to the proximal rectum (Figure 2), which required endoscopic retrieval (Figure 3). This bleeding episode resolved spontaneously with no intervention required.

Examination of the foreign object and corroborative history from the family revealed that the foreign object was in fact a blunt duck leg bone ingested by the patient prior to admission (Figure 4). Review of a CT scan of the kidney ureters and bladder (KUB), done for acute kidney injury, prior to the ingestion of the patency capsule confirmed presence of the duck bone intra-luminally in the small intestine (Figure 5). Impression was that of a jejunal ulcer secondary to a duck bone ingestion and impaction, complicated by small bowel obstruction, confounded by the possibility of retained patency capsule. The patient was discharged home with resolution of his bleeding and intestinal obstruction.

Gastrointestinal ulcers, obstruction, and perforation secondary to ingested foreign bodies, while uncommon, can have devastating consequences. Furthermore, in a case such as ours with persistent symptoms, attention must be paid to consider all other possibilities and not be eased into the simple likelihood of the common diverticular bleeding. Majority of perforations occur from a sharp-pointed foreign body, most commonly a fish bone, however, has also been reported to occur with the blunt natured duck bones, with one case causing bowel perforation and another anal impaction [1]. To our knowledge, there has been no case of duck bone causing gastrointestinal hemorrhage. Mechanical compression is the primary mechanism of mucosal injury in the development of bezoar-related ulcers and occurs with hard material such as this duck bone [2]. This unique case highlights a rare occurrence of ulcer development with both ensuing hemorrhage and gastrointestinal obstruction from a single duck bone.

This patient’s diagnosis was confounded by the possibility of a retained patency capsule, whereby retention and gastrointestinal obstruction is a known complication and has been reported in the literature [3]. However, the manufacturer has stated that the latest version of the patency capsule is fully dissolvable. That being said, retention of a patency capsule or capsule endoscopy needs to be on the differential list when the diagnosis remains unclear.

Furthermore, the diagnosis was delayed as knowledge of the duck bone was not offered by the patient, potentially attributable to his age and poor memory. Foreign bodies are known to be more prevalent in the elderly due to impaired swallowing controls, reduced intraoral sensitivity, as well as poorer vision and tooth loss resulting in mis-swallowing [4]. In atypical presentations such as in this case, a thorough history taking should have been considered by including the patient’s family or caregivers, as an elderly patient may not always be able to provide the clues to the underlying cause.

Foreign body ingestions especially in the elderly can have devastating consequences and need to be included in a clinician’s differential diagnosis in atypical presentations. A high level of clinical suspicion and thorough history taking are paramount to obtaining an accurate diagnosis. Clinicals must stay vigilant especially in cases with persistent symptoms and require a thorough diagnostic approach to consider atypical causes in such complex cases.