CT evaluation of gastrointestinal tract perforation by ingested fish bone. Poster No.: C-0875 Congress: ECR 2014 Type: Educational Exhibit Authors: A. B. Sanabria, R. Muñoz Carrasco, J. Escribano Fernández, A. V. Jiménez Carrasco, M. Ruza Pérez-Barquero; Cordoba/ES Keywords: DOI: Foreign bodies, Diagnostic procedure, CT, Abdomen 10.1594/ecr2014/C-0875 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 11
Learning objectives To review the CT findings of gastrointestinal perforations by ingested fish bones. To become familiar with the CT appearance of fish bones. To increase the level of awareness that allows a correct preoperative diagnosis. Page 2 of 11
Background Foreign body ingestion is common. Nevertheless most ingested foreign bodies pass through the gastrointestinal tract uneventfully and perforation only occurs in less than 1% of patients. Fish bones are the most common cause of foreign body perforation of the gastrointestinal tract. Fish bone perforation occurs in all segments of the gastrointestinal tract, although it tends to occur in regions of acute angulation, such as the ileocecal and rectosigmoid junctions. These foreign bodies may also perforate through a hernia sac, Meckel's diverticulum, or the appendix. Gastrointestinal perforations by ingested fish bones have a wide spectrum of clinical presentations, which can be acute or chronic. It has diverse clinical manifestations and patients occasionally present with unusual or even bizarre clinical manifestations such as hemorrhage, bowel obstruction, and even ureteric colic. With these varied and nonspecific clinical presentations, as well as in the vast majority of cases, the antecedent of fish bone ingestion is usually forgotten, the correct preoperative diagnosis is seldom made. Page 3 of 11
Findings and procedure details We present five patients (one man and four women with a mean age of 64 years old) with gastrointestinal perforation by fish bone. Gastrointestinal complications were correctly identified in the CT scans in all five cases. However, the cause of perforation was made in two cases preoperatively. A retrospective review of the CT scans in three patients identified the fish bone. The site of perforations was: stomach, jejunum, ileum and sigmoid colon (two cases). The CT findings were: mural thickening of an intestinal segment, surrounding infiltrated fat, localized pneumoperitoneum, free intraperitoneal fluid, abscesses and linear calcified foreign body. The first patient was a woman of 64 years old derived from another hospital for evaluation of a pancreatic body mass. This tumour was disappearing in successive CT examinations. Also histological studies were negative. A retrospective review of the CT scans in this patient identified a linear density penetrating gastric wall with adjacent areas of inflammation (Figure 1). The second patient was a woman of 83 years old with acute abdominal pain and constipation. CT scans showed a small linear calcified foreign body within a thickened jejunum bowel associated with localized pneumoperitoneum and surrounding infiltrated fat (Figure 2). The third patient was a woman of 61 years old with abdominal pain localized in the right iliac fossa and fever. CT scans showed an ileum perforation into a ventral hernia associated with extraluminal air and minor infiltration of surrounding fat (Figure 3). The fourth patient was a woman of 48 years old with suspected intra-abdominal sepsis. The first diagnosis was multiple collections in lower abdomen, unable to clearly determine their origin (probably peritonitis). No foreign body was seen. A retrospective review of the CT scans identified the fish bone into abscess (Figure 4). The last patient was a man of 65 years old with clinical suspicion of acute diverticulitis. A retrospective review of the CT scans in this patient identified the fish bone but the first diagnosis was acute diverticulitis with involvement of the abdominal wall, psoas major and sartorius muscles. Fish bone was missed initially (Figure 5). Page 4 of 11
Images for this section: Fig. 1: 64-year-old woman (patient 1) with antral perforation. (A) CT scans show a linear density (red arrow) penetrating gastric wall with adjacent areas of inflammation and an ill defined low density mass in body of pancreas (blue arrow). The fish bone was initially missed and the patient was thought to have a pancreatic tumour. In successive CT examinations this tumour was disappearing and histological studies were negative for malignancy. (B) CT scan performed for follow up shows the foreign body (3-4 cm linear density) more clearly. Hospital Universitario Reina Sofia - Cordoba/ES Page 5 of 11
Fig. 2: 83-year-old woman (patient 2) with jejunum perforation. (A) CT scan shows a small linear calcified foreign body within a thickened jejunum bowel (red arrow) associated with localized pneumoperitoneum (blue arrow) and surrounding infiltrated fat. (B) Coronal oblique reformation with MIP allows the depiction of the whole linear fish bone clearly transfixing the jejunal wall. CT findings were surgically proven. Hospital Universitario Reina Sofia - Cordoba/ES Page 6 of 11
Fig. 3: 61-year-old woman (patient 3) with ileum perforation into a ventral hernia. (A) CT scan shows a small linear hyperdensity within a thickened ileal bowel (red arrow) associated with extraluminal air (blue arrow) and minor infiltration of surrounding fat. (B) Coronal and axial oblique reformation with MIP allow the depiction of the whole linear FB (a fish bone) clearly transfixing the ileal wall and localized pneumoperitoneum. CT findings were surgically proven. Hospital Universitario Reina Sofia - Cordoba/ES Page 7 of 11
Fig. 4: 48-year-old woman (patient 4) with sigmoid colon perforation. Axial (A) and coronal (B) contrast-enhanced CT scan show free and collected intraperitoneal fluid (green arrow) with marked surrounding infiltrated fat (blue arrow) CT scan shows a abscess with linear fish bone traversing it (red arrow). Pneumoperitoneum was not detected. The first diagnosis was multiple collections in lower abdomen, unable to clearly determine their origin (probably peritonitis). The patient underwent laparotomy for management and a sigmoid colon perforation and a fish bone were found. Initially no foreign body was identified on CT scan (the offending fish bone was retrospectively identified). Hospital Universitario Reina Sofia - Cordoba/ES Page 8 of 11
Fig. 5: 65-year-old man (patient 5) with sigmoid colon perforation. (A) Axial CT scan and axial and coronal oblique reformation with MIP (B and C) show 4-5 cm linear calcified foreign body (red arrow) with adjacent areas of inflammation (surrounding infiltrated fat and abscesses) (blue arrow). A retrospective review of the CT scans in this patient identified the fish bone; the first diagnosis was acute diverticulitis with involvement of the abdominal wall, psoas major and sartorius muscles (black arrow). Fish bone was missed initially. Hospital Universitario Reina Sofia - Cordoba/ES Page 9 of 11
Conclusion The main limitation of CT in the detection of fish bones is the lack of observer awareness. A high index of suspicion must be maintained for the correct diagnosis of fish bone perforation. The radiologist should be familiar with the CT appearance of fish bones and be able to recognize them. In this way, radiologists may have an important role in first suggesting the diagnosis in order to guide the appropriate treatment. Page 10 of 11
References - Goh BK, Tan YM, Lin SE, Chow PK, Cheah FK, Ooi LL, Wong WK. CT in the preoperative diagnosis of fish bone perforation of the gastrointestinal tract. AJR Am J Roentgenol. 2006;187:710-4. - Goh BK, Chow PK, Quah HM, Ong HS, Eu KW, Ooi LL, Wong WK. Perforation of the gastrointestinal tract secondary to ingestion of foreign bodies. World J Surg. 2006;30:372-7. - Pinero Madrona A, Fernández Hernández JA, Carrasco Prats M, Riquelme Riquelme J, Parrila Paricio P. Intestinal perforation by foreign bodies. Eur J Surg. 2000;166:307-9. - Gayer G, Petrovitch I, Jeffrey RB. Foreign objects encountered in the abdominal cavity at CT. Radiographics 2011; 31:409-28. - McCanse DE, Kurchin A, Hinshaw JR. Gastrointestinal foreign bodies. Am J Surg 1981; 142:335-7. - Coulier B, Tancredi MH, Ramboux A. Spiral CT and multidetector-row CT diagnosis of perforation of the small intestine caused by ingested foreign bodies. Eur Radiol 2004; 14:1918-25. - Madrona AP, Hernandez JA, Prats MC, Riquelme JR, Paricio PP. Intestinal perforation by foreign bod- ies. Eur J Surg 2000; 166:307-309. - Drakonaki E, Chatzioannou M, Spiridakis K, Panagiotakis G. Acute abdomen caused by a small bowel perforation due to a clinically unsuspected fish bone. Diagn Interv Radiol. 2011;17:160-2. - Takada M, Kashiwagi R, Sakane M, Tabata F, Kuroda Y. 3D-CT diagnosis for ingested foreign bodies. Am J Emerg Med. 2000;18:192-3. - Zissin R, Osadchy A, Gayer G. Abdominal CT findings in small bowel perforation. Br J Radiol. 2009;82:162-71. Page 11 of 11