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World J Clin Cases. Sep 16, 2022; 10(26): 9539-9541
Published online Sep 16, 2022. doi: 10.12998/wjcc.v10.i26.9539
A rare cause of acute abdomen after a Good Friday
Leticia Pante, Luísa Gailhard Brito, School of Medicine, Universidade de Caxias so Sul, Caxias do Sul 95070-560, Brazil
Miguel Franciscatto, Proctology, Hospital Geral de Caxias do Sul, Caxias do Sul 95070-560, Brazil
Eduardo Brambilla, Jonathan Soldera, Clinical Gastroenterology, Universidade de Caxias do Sul, Caxias do Sul 95070-560, RS, Brazil
ORCID number: Eduardo Brambilla (0000-0002-4629-7095); Jonathan Soldera (0000-0001-6055-4783).
Author contributions: Pante L, Brito LG, Franciscatto M, Brambilla E, and Soldera J contributed in writing and reviewing the final manuscript; Soldera J also contributed for study supervision.
Conflict-of-interest statement: The authors declare no conflict of interest regarding the subject of this paper.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Jonathan Soldera, MD, MSc, Associate Professor, Staff Physician, Clinical Gastroenterology, Universidade de Caxias do Sul, Rua Francisco Getúlio Vargas, 1130, Caxias do Sul 95070-560, RS, Brazil. jonathansoldera@gmail.com
Received: April 10, 2022
Peer-review started: April 10, 2022
First decision: May 11, 2022
Revised: June 13, 2022
Accepted: August 15, 2022
Article in press: August 15, 2022
Published online: September 16, 2022


Small bowel perforation caused by an ingested fish bone is rare but can involve the appendix or Meckel’s diverticulum. We report the case of a 25-year-old man who presented to the emergency department with acute abdomen caused by perforation of a Meckel’s diverticulum with a fish bone ingested in a Good Friday.

Key Words: Fish bone, Foreign body, Small bowel perforation, Meckel diverticulum

Core Tip: We report the case of a 25-year-old man who presented to the emergency department with acute abdomen caused by perforation of a Meckel’s diverticulum with a fish bone ingested in a Good Friday.


In our hospital in Brazil, after the Good Friday of 2020, we admitted a 25-year-old male patient who presented with severe abdominal pain in the right lower quadrant. He had signs of peritoneal irritation on physical examination. A computed tomography (CT) scan showed pneumoperitoneum and a hyperdense structure in the ileal wall (Figure 1). This imaging finding went unnoticed until the patient underwent exploratory laparotomy, which revealed a Meckel’s diverticulum perforated by a fish bone 30 cm above the ileocecal valve (Figure 2). Diverticulectomy was performed and the patient was discharged after a few days. He later reported having eaten fish on Good Friday, a Christian holiday in which Brazilians generally eat fish instead of poultry or red meat.

Figure 1
Figure 1 Computed tomography. A: Axial; B: Coronal. Pneumoperitoneum and a hyperdense image in the ileal wall.
Figure 2
Figure 2 Surgical specimen. Perforated Meckel diverticulum by a fishbone 30 cm above the ileocecal valve.

Meckel’s diverticulum is often an asymptomatic condition. Nevertheless, 4.2% to 16.9% of patients are likely to become symptomatic[1-3]. There is a wide range of complications associated with this disease, such as acute or chronic abdominal pain, anemia, gastrointestinal bleeding, obstruction, and perforation[1,3]. Although most of these complications are not rare, small bowel perforation caused by an ingested fish bone is a rare finding, occurring in less than 1% of patients[2], because, in most cases of ingested foreign bodies, the object will pass through the gastrointestinal tract without any complications[4].

Perforation may occur in any part of the gastrointestinal tract, but cases involving the appendix or Meckel’s diverticulum are rare. In this setting, approximately 300 cases of a Meckel’s diverticulum perforated by a swallowed foreign body have been reported[3]. Surprisingly, we found one case similar to ours published in the World Journal of Gastroenterology in 2014[1].

The preoperative diagnosis of perforation of the Meckel’s diverticulum by foreign body can be challenging given the broad spectrum of differential diagnoses. In addition, patients do not always recall ingesting the foreign body, and fish bones are not easily detected on radiographs or CT scans[2,3]. The perforated Meckel’s diverticulum may also mimic acute appendicitis, acute diverticulitis, and colitis[4]. In the case presented here, the patient complained of severe abdominal pain in the right lower quadrant, similar to that of acute appendicitis.

Imaging is essential to determine the correct diagnosis prior to surgery. Radiography is not a reliable means to detect a fish bone, because it lacks sensitivity for the aerodigestive tract[4]. Although abdominal ultrasound is useful in identifying a foreign body based on high reflectivity and variable posterior shadowing, CT is the imaging modality of choice for the detection of foreign bodies and other acute abdomen conditions[4].

In a similar context, other radiological features of fish bone perforation were described in a case report published in 2022, such as thickening of the intestinal wall, fatty deposits, intestinal ileus, ascites, localized pneumoperitoneum, intra-abdominal abscess, and a linear hyperdense structure in the abdominal cavity within the gastrointestinal tract or a parenchymal organ, often surrounded by inflammation[4]. Therefore, the combination of a detailed medical history with imaging and ancillary testing (ultrasound and abdominal CT) is crucial in cases of acute abdomen that may require surgery[5,6,7].

Treatment includes exploratory laparotomy when the diagnosis of acute abdomen has been made. In addition, diverticulectomy and colectomy may be necessary to minimize complications. It is of paramount importance to explore the entire abdominal cavity intraoperatively, especially in the absence of an explanation for the clinical findings[1,5,6,8].

Therefore, bone-induced perforation should be suspected when the CT scan shows a hyperdense structure in the bowel wall, whether with signs of perforation or not.


Provenance and peer review: Unsolicited article; Externally peer reviewed.

Peer-review model: Single blind

Corresponding Author's Membership in Professional Societies: Federação Brasileira De Gastroenterologia; GEDIIB.

Specialty type: Gastroenterology and hepatology

Country/Territory of origin: Brazil

Peer-review report’s scientific quality classification

Grade A (Excellent): 0

Grade B (Very good): 0

Grade C (Good): C

Grade D (Fair): D

Grade E (Poor): 0

P-Reviewer: Martino A, Italy; Wang S S-Editor: Ma YJ L-Editor: Filipodia CL P-Editor: Ma YJ

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