https://orcid.org/0000-0003-0001-9070
Abstract
Meckel’s diverticulum is the most common congenital abnormality of the gastrointestinal tract, caused by incomplete obliteration of the omphalomesenteric duct during the seventh week of gestation, and occurs in up to 4% of the general population. Most patients are asymptomatic; however, in a few cases, patients present with gastrointestinal bleeding and intestinal obstruction. Perforation of the diverticulum due to a foreign body is a very rare complication since most ingested foreign bodies may pass through the gastrointestinal tract without consequences. We present the unusual case of a 73-year-old female who inadvertently ingested a fishbone that lodged and perforated a Meckel diverticulum. After surgery, the patient fully recovered.
Introduction
Perforation of Meckel’s diverticulum by a foreign body is an extremely rare occurrence [1]. For this to happen, the patient must have an asymptomatic diverticulum and must have swallowed a sharp foreign body that perforates it [1, 2]. This is an extremely rare combination, but a very serious one if left unaddressed. We present the case of a 73-year-old female who inadvertently ingested a fishbone that lodged and perforated a Meckel diverticulum. After prompt diagnosis, surgery was decided, and the patient fully recovered.
Case report
Patient is a 73-year-old female with a past medical history of cholecystectomy. She presented with a 4-day history of lower abdominal pain and diarrheoa. Since she had eaten seafood during those days, she thought it was food poisoning and took over-the-counter pain medication that partially relieved her pain. However, as days passed, the pain became unbearable and was accompanied by severe nausea and vomiting. Therefore, she was brought immediately by her family to the emergency room.
On clinical evaluation, a tachycardic patient with severe pain and tenderness in her lower abdomen was encountered. Complementary exams were needed, revealing a normal leukocyte count (5.33 × 109/L) without neutrophilia but an elevated C-reactive protein (120 mg/L). An abdominal computed tomography was needed due to her pain, which revealed a small, 2 × 1 cm hyperdense foreign body inside the intestinal lumen that was attached to the abdominal wall, causing dilatation of the bowel (Fig. 1A and B). There were no signs of pneumoperitoneum or free liquid.
(A) CT, a hyperdense foreign body is seen in the bowel. (B) CT, a hyperdense foreign body is seen in the bowel and in close contact with the abdominal wall.
With these findings and due to her pain, surgery was decided.
On laparoscopy, severe adhesions were noted in the terminal ileum, 50 cm from the ileocecal valve. The small bowel was attached to the abdominal wall, and a 5-cm Meckel diverticulum was identified and released from these adhesions. At its end, a fishbone was discovered that perforated its wall.
With these findings, after releasing the adhesions, a complete resection of the narrow-based diverticulum was performed with a mechanical stapler, the abdominal cavity was thoroughly washed, and the surgical procedure was completed without complications (Fig. 2A–C).
(A) Laparoscopy, multiple adhesions are seen between the bowel and the abdominal wall. (B) Laparoscopy, the diverticulum is seen and stapled. (C) Meckel diverticulum perforated at its tip with a fishbone.
Fishbone perforation of a Meckel diverticulum in an adult patient was the final diagnosis.
The patient’s postoperative course was uneventful. After completing a short course of broad-spectrum antibiotics, she was discharged without complications. On follow-ups, the patient is doing well.
Discussion
Foreign body ingestion is a common health concern that primarily affects children and toddlers [1, 2]. Adults are rarely affected by this condition except in special circumstances such as schizophrenia or suicide attempts [1]. However, most healthy adult patients don’t even realize they have ingested a foreign body, making clinical history and prompt diagnosis difficult [2].
Fortunately, most cases do not require treatment, as most foreign bodies pass through the intestine without injury [1, 2]. Nonetheless, few foreign bodies with sharp ends, such as toothpicks, chicken and fish bones, or nails, can cause severe complications [2, 3].
Less than 1% of all ingested foreign bodies cause complications such as mucosal injury, impaction, and perforation, and 63% of these complications are related to fishbones [4].
Injury can occur anywhere from the mouth to the anus, especially with adhesions, diverticula, or stenosis [2, 4]. But due to its anatomical configuration, the small intestine is the most frequently affected segment (75.9%), particularly the ileum [1].
Meckel’s diverticulum is the most common congenital anomaly, with an incidence of 2.2% in the general population [1, 5]. Of these patients, 4% will develop complications (obstruction, intussusception, and ulceration), especially in childhood; nonetheless, due to its anatomical features, it can easily trap a foreign body [4, 5].
Although bowel foreign body perforation is well documented, perforation of the Meckel’s diverticulum caused by a fishbone remains extremely rare, with <50 cases reported in the English literature [2].
In many low- and middle-income countries, fish is a primary source of animal protein and nutrients, making these complications highly relevant in countries like our own [6].
Diagnosis is difficult, as foreign body ingestion is rare and most adult patients don’t even recall the foreign body ingestion [1, 5]. Less than half of patients give any history of previous ingestion [1, 2]. Many patients can present with a broad range of clinical features, from completely asymptomatic to an acute abdomen, with signs of abdominal, colorectal, or colovesical abscesses, fistulas, or an abdominal mass [1, 3]. Therefore, most patients are misdiagnosed with other conditions due to their nonspecific clinical presentations [2, 4].
In our case, the patient recalled eating seafood; however, she attributed it to food poisoning and delayed seeking care. Once the pain became unbearable, she went to the emergency department, and an acute abdomen was diagnosed. Once dissection was completed, the perforated Meckel diverticulum was discovered and successfully treated.
Imaging, particularly computed tomography (CT), can aid in diagnosis; however, the fishbone can be easily missed, depending on the size and location of the perforation [1, 2]. Pneumoreitoneum is not always reliable, as the erosion of the foreign body through the bowel wall is progressive and allows the omentum of adjacent loops of bowel to cover the perforation, limiting the passage of air into the abdomen [3].
Treatment will be surgical, either through laparoscopic or conventional approach, with resection of the perforated diverticulum as the treatment of choice [2]. Prompt diagnosis is needed to prevent dangerous complications that can impact patient quality of life [1, 2].
Even though rare in the adult population, perforation of a Meckel diverticulum should always be considered in the differential diagnosis.
Complications
This case stresses the importance of keeping foreign body perforation in mind, as well as adequate knowledge of the embryological, clinical, and pathological characteristics of unexpected pathologies such as Meckel’s diverticulum, which may have a poor prognosis if diagnosis and treatment are delayed.
Conflicts of interest
None declared.
Funding
None declared.
