Published online Feb 27, 2020. doi: 10.4240/wjgs.v12.i2.77
Peer-review started: October 1, 2019
First decision: October 23, 2019
Revised: November 18, 2019
Accepted: December 5, 2019
Article in press: December 5, 2019
Published online: February 27, 2020
Processing time: 106 Days and 20.2 Hours
Upper gastrointestinal fishbone microperforations are rare and not commonly reported in medical literature. Despite the increasing use of computer tomography (CT) imaging and the employment of the Alvardo criteria, misdiagnosis of acute appendicitis can still occur. We report the rare case of an elderly Chinese gentleman who had a fish-bone induced microperforation of the duodenum that closely mimicked the symptoms of acute appendicitis.
This 79-year-old man presented with migratory lower abdominal pain that localized at his periumbilical region and right lower quadrant. He had associated pyrexia, general malaise and was noted to have an elevated white cell count. CT investigations initially revealed a distended appendix which was resected laparoscopically but showed no obvious signs of gross inflammation. The patient then deteriorated clinically and had increased oxygen requirements immediately after the surgery. This prompted further investigations. A further review of his CT scan revealed a fine fishbone microperforation in the distal duodenum associated with retroperitoneal abscess formation and seepage extending into the right lower quadrant. He was then started on broad spectrum intravenous antibiotics and subsequently underwent a laparotomy 12 h later to manage the obscure aetiology and to drain the abscess. The post-operative course was uneventful and he was discharged 11 d later including a 2-d stay in the intensive care unit.
This case offers an insight into a potential mimic of acute appendicitis and the diagnostic difficulties experienced in such presentations.
Core tip: This case provides clinicians with a unique insight on how a patient with a fishbone induced upper gastrointestinal microperforation can mimic the lower gastrointestinal symptoms commonly seen in acute appendicitis. It highlights the difficulty that the team faced with the diagnosis and management of such pathology and provides clinicians with an alternative differential diagnosis that can be considered in this specific patient group. Additionally, it serves to remind clinicians about the importance of accurate radiological imaging and the potential of observer error (particularly that of the satisfaction-of-search error) that can occur when managing patients with seemingly straightforward presentations.