Fishbone impaction in Meckel’s diverticulum.

Clinical History

A 50-year-old male patient arrived at the emergency department with a 48-hours history of lower abdominal pain, maximal in the left iliac fossa, accompanied by fever and elevation and an increased white blood cell count. The past medical history was unremarkable.

Imaging Findings

Contrast-enhanced computed tomography (CT) of the abdomen revealed a blind-ended saccular structure arising from the anti-mesenteric border of the distal ileum filled with water-density fluid. It measured approximately 30 mm in length and showed thickened wall with stranding of the adjacent mesenteric fat and furthermore locorregional lymphadenopathies. Features were in keeping with an inflammatory process in relation to a complicated Meckel’s diverticulum.
Inside of the Meckel’s diverticulum a linear focus of high attenuation structure was identified. It measured 25 x 2 mm and crossed the intestinal wall. It was highly suspicious for a retained foreign body, most likely a fish bone, which perforated the wal of Meckel’s diverticulum. No radiological signs of pneumoperitoneum were observed.
On direct questioning, the patient admitted to eating fish on the days prior to his admission.
During surgical procedure a Meckel's diverticulum was found with a long fish bone crossing its wall.
No other relevant radiological findings were detected.

Discussion

Meckel’s diverticulum is a small bowel excrescence typically located on the anti-mesenteric border of the ileum located to 30-90 cm from the ileocaecal valve, which usually measures between 0.5 and 1.5 cm [1]. Its prevalence in the general population is between 2-3%, being the most frequent congenital malformation of the gastrointestinal tract. [2]. An uncomplicated Meckel's diverticulum is asymptomatic but in case of complication it usually causes non-specific abdominal symptoms. We show an atypical complication of Meckel’s diverticulum due to a fish bone impaction.
The presence of a fish bone in the intestinal lumen is a common radiological finding of all foreign bodies unintentionally ingested. Most patients are asymptomatic, but when a complication appears they go to the emergency department with abdominal pain and raising of acute phase reactants in blood test. To identify a linear high attenuation structure inside of the intestinal tract should make us think of animal bones at first sight. In our clinical case, the impacted fish bone perforated the intestinal wall of the Meckel’s diverticulum with the radiological findings previously described.
Imaging techniques are very useful when there is a suspicion of foreign body ingestion. It has been demonstrated that CT is better than the clinical history and the simple radiography in the detection of foreign bodies in the gastrointestinal tract [4]. CT findings of a fish bone impaction include intestinal wall thickening, regional fat stranding with or without signs of obstruction, ascitis or penumoperitoneum. Pneumoperitoneum is unusual due to a gradual fibrous reaction that appears secondary to the erosion of the bowel wall plugging the wall perforation [1, 3]. A delayed diagnosis in a perforation case may turn out in a migration to other locations even affecting to other organs or formation of intraperitoneal abscesses [5].
The management of a fish bone impaction with perforation of Meckel’s diverticulum is the same as with a perforation in any other part of the bowel and it use to need surgical treatment [6].
To conclude, fish bone impaction within Meckel’s diverticulum is an unusual clinical picture but a CT exam is very useful to make a quickly and precise diagnosis.
‘Written informed patient consent for publication has been obtained.’

Differential Diagnosis List

Final Diagnosis

Fish bone impaction within Meckel’s diverticulum.

URL:	https://www.eurorad.org/case/16166
DOI:	10.1594/EURORAD/CASE.16166
ISSN:	1563-4086