Hospital: H U B U, Hospital Santos Reyes.
Aut@r o Autores: P. Velázquez Fragua, X. Leunda Ayastuy, A. Salazar Salgado, R. Hernández Caler, J. Pérez Díaz.
A 58-year-old female was admitted to the emergency department due to abdominal pain, primarily in the right iliac fossa. On the physical exploration Blumberg´s sign was positive and laboratory tests revealed leukocytosis and high C-reactive protein. The clinical suspicion was acute appendicitis and an ultrasound was performed in the first place. Despite not seeing anything pathological during the ultrasound the patient was very sore and we decided to perform a CT. Abdominal computed tomography scan showed 2 cm linear density (fishbone) in the distal ileum, which was slightly thickened, with adjacent fat stranding and extraluminal air bubbles that suggested neumoperitoneum.
The vast majority of ingested foreign bodies pass through the gastrointestinal tract uneventfully and in less than 1% of cases the ingestion of foreign bodies cause a perforation. This usually occurs in regions of acute angulations, such as the ileocecal and rectosigmoid junction. Foreign body ingestion diagnosis involves different challenges. Firstly, it can be a long time, even months, since the ingestion of the foreign body until it produces symptoms. Secondly, a perforation caused by a foreign body can have very variable clinical manifestations, as in our case even simulate acute appendicitis. Finally, the plain radiography is unreliable in the diagnosis of various types of foreign body ingestion, such as the fishbone and in addition if neumoperitoneum is present, usually is too small to identify through this technique. CT is considered the gold standard because it allows the radiologist to identify the presence, location and cause of intestinal perforation. It has some problems because if we use oral and/or intravenous contrast during CT it can cause difficulties in identifying fishbones or fishbones can be mistaken for opacified blood vessels.
Fishbones and other foreign bodies can produce an acute abdomen and simulate other pathologies (an acute appendicitis in our case). Usually it will not be the first diagnostic suspicion, but the radiologist should keep this option in mind.
- Coulier B, Tancredi MH and Ramboux A. 2004. Spiral CT and multidetector row CT diagnosis of perforation of the small intestine caused by ingested foreign bodies. European Radiology, 14:1918-1925. - Brian K.P. Goh, Yu-Meng Tan, Shueh-en Lin et al. 2006