Pre-operative diagnosis of pancreatic abscess from a penetrating fish bone

Abstract

A 53-year-old woman presented to our emergency department because of worsening abdominal pain and fever for 2 days. She had suffered from intermittent, dull abdominal pain over the epigastric area in the previous 3 months. Previous examination, including upper endoscopy and abdominal X-ray film, did not disclose significant abnormality. On examination, she was febrile with severe tenderness over the epigastric area. Abdominal sonography revealed a hypoechoic mass around the pancreas with a linear hyperechoic structure in it (Figure 1, arrow). Abdominal computed tomography revealed a 3 cm multiloculated abscess between the stomach and the pancreas. A linear calcified foreign body suggestive of a fish bone was noted (Figure 2, arrow). The patient received surgery and an abscess containing a 3.2 cm fish bone was confirmed (Figure 3). The post-operative course was smooth and she was discharged on the 12th post-operative day. Abdominal sonography revealed hypoechoic mass around the pancreas with a linear hyperechoic structure in it (arrow). Abdominal tomography revealed abscess formation around the pancreas with a linear shaped foreign body (arrow). Photography of the removed fish bone. Perforation occurs in <1% of all cases of ingested foreign bodies.1,3 The perforation can occur at any site in the alimentary tract, and the most common site is within the terminal ileum.1–3 A fish bone is the commonest type of foreign body causing gastrointestinal perforation. Long fish bones, as seen in this case as well as in those that caused gastric perforation, are less likely to pass through the pylorus;1–3 it is usually embedded in the gastric wall with subsequent perforation. Foreign body perforations in the stomach and duodenum are usually innocuous and cause less acute symptoms than perforations in the jejunum or ileum.3 Patients are usually unable to provide a clear history of fish bone ingestion, as in our case. They usually present with chronic symptoms and are diagnosed after the development of intra-abdominal, hepatic or pancreatic abscess. Ultrasound examination is helpful to diagnose the abscess,1 and the presence of a linear hyperechoic structure is highly suggestive of a foreign body. A computed tomography scan is probably most useful to demonstrate the foreign body and its associated complications.1–3 Early diagnosis and prompt treatment, including surgery or endoscopic drainage and removal of the foreign body are mandatory to improve the prognosis of this rare condition. A mortality rate of 10% has been reported because of missed or delayed diagnosis.1–3 Conflict of interest: None declared.