This case represents a common scenario of accidental ingestion of PTP but serves as an instructive case for not only gastroenterologists but also all primary care doctors. The chest X-ray did not reveal any abnormalities and the patient’s history and symptoms were unclear, the patient had almost been sent home. However, the diagnosis was made with an additional CT, and PTP removal was achieved. Delayed diagnosis could have resulted in gastrointestinal perforation due to the PTP. While diagnosing PTP with CT is typical, retrospectively, the chest X-ray also faintly showed a ring-shaped gas sign characteristic of PTP ingestion. This case suggests that a careful review of the X-ray could have led to a quicker diagnosis. Although other cases published describing the visualization of PTP on neck or abdominal X-ray [5, 6], to our knowledge, this is the first report capturing a ring-shaped gas sign on a frontal view of the chest X-ray in the real patient. Nevertheless, as demonstrated in this case, detecting a PTP in the esophagus using only X-rays can be challenging in a busy emergency department setting, and adding a CT should have been considered first. The utilization of overtubes has been shown to enhance the safety of PTP removal procedures[7]. In this case, the CT scan indicated that the PTP was relatively large, necessitating the initial insertion of an overtube. Despite multiple attempts to retract the PTP into the overtube using forceps and a snare, the suboptimal angle resulted in repeated minor esophageal lacerations at the site of the second natural constriction. Recent literature suggests that employing a large-caliber, soft oblique cap can reduce mucosal injury during foreign body retrieval [4]. We propose that if this technique had been utilized, it is conceivable that the PTP could have been effectively retracted into the cap, potentially preventing esophageal lacerations at the constriction site. The types of foreign body ingestion vary by region, with fish bones being the most common type reported in adults in some studies [8]. In Japan, PTPs account for 30% of foreign body ingestion causing the highest proportion [4]. Currently, efforts in Japan to prevent PTP ingestion include eliminating perforations in PTP sheets to discourage cutting into individual tablets and active awareness campaigns through posters by the National Consumer Affairs Center of Japan in collaboration with the Ministry of Health, Labour and Welfare. However, some patients and caregivers unaware of the risks still manage medication by cutting individual tablets [9]. PTP ingestion can sometimes lead to serious complications such as gastrointestinal perforation, making early diagnosis and removal crucial. PTP ingestion often occurs in patients with poor general health, and CT is considered useful when suspecting PTP ingestion [10]. Although some case reports suggest that X-rays can be useful for diagnosing PTP ingestion [5, 6], others report a sensitivity of 0% [10]. Polypropylene (PP) and PVC are commonly utilized materials in PTP packaging. While only PP is radiolucent on CT, both PP and PVC are radiolucent on X-ray. Consequently, if the orientation remains unchanged, the ring-shaped gas sign, indicative of air trapped between the tablet and the PTP sheet, can be detected on X-ray irrespective of the material. Looking back at this case, the diagnosis could have been made with X-ray alone, but detecting a circular gas shadow like this case would have been difficult unless the PTP was facing forward. The diagnostic utility of the ring-shaped sign in cases of accidental PTP ingestion remains indeterminate. However, it may serve as a valuable indicator in primary care settings where only X-ray imaging is available. However, it would be extremely difficult to diagnose PTP ingestion by X-ray alone in a generally busy emergency room. Therefore, in cases where PTP ingestion cannot be ruled out, emergency examinations such as CT or EGD should be considered first. If these procedures are difficult in your institutions, although X-rays may be considered first, early transfer to a higher-level medical institution should also be considered.