Fish out of water

A 60-year-old male patient was admitted in the emergency department complaining about mid-epigastric pain over the past six days and increased body temperature. Nausea and vomiting were present from the onset. Laboratory data and x-ray were undetermined. Abdominal computerized tomography (CT) was performed. CT revealed focal parenchymal enlargement and edema in the pancreatic head with illdefined margins and surrounding fat stranding. No liquid collections were evident. At a second look, a linear radio-opaque structure was seen traversing the duodenum bulb wall and penetrating into the pancreatic neck. No extra luminal gas bubbles were observed. Additionally, a small hypodense lesion was identified in liver segment V, considered indeterminate. These findings suggested acute pancreatitis as the most-likely diagnosis.

The causes of acute pancreatitis are extensive and include structural, metabolic and toxic etiologies. In this case, cholelithiasis or other obstructive causes were ruled out by the imaging studies performed and her history was not forthcoming for alcohol ingestion, infections or drug induced. The key to this case was the presence of the described foreign body. Although the patient could not recall swallowing any, he did recall the history of fish consumption. Based on this data, we interpreted that he probably ingested a fishbone which had penetrated through the first part of the duodenum and communicated with the pancreatic neck, resulting in pancreatitis secondary to contained perforation. Admission was decided for conservative management given the general good condition of the patient. The day after the patient underwent oral endoscopy which revealed an induration in the duodenum wall but no visible foreign body or overt perforation, thus the removal was not carried out. The case was discussed with a surgeon, but taking into account the clinical improvement an expectant attitude was adopted. Furthermore, the hepatic lesion considered indeterminate showed growth and mild decreased attenuation of the adjacent parenchyma in the control CT carried out three days later. Therefore, a liver abscess and reactive hepatitis were suspected.Perforation of the gastrointestinal tract by ingested foreign bodies is not uncommon. However, foreign body-induced acute pancreatitis is a rare disorder and the development of solid organ abscess such a hepatic abscess is extremely unusual.

In the presented case the foreign body was probably a fishbone, considering a history of fish consumption. We postulate that the ingested fishbone had penetrated through the duodenum wall and reached the pancreatic neck, resulting in fishbone-induced pancreatitis and secondary liver abscess. The perforation did not communicate freely with the peritoneal cavity explaining the subtle clinical presentation.

- Symeonidis D, Koukoulis G, Baloyiannis I, Rizos A, Mamaloudis I, Tepetes K. Ingested Fish Bone: An Unusual Mechanism of Duodenal Perforation and Pancreatic Trauma. Case Reports in Gastrointestinal Medicine. 2012,2012:3.