Beyond biliary causes, fish bone perforation as a rare etiology of recurrent fever in a post-Whipple patient: A case report

Abstract

BACKGROUND

Patients who have undergone pancreaticoduodenectomy (Whipple procedure) often develop complex late complications that may be diagnostically challenging. We report a rare cause of recurrent fever and abdominal pain in such a patient: Fish bone-induced jejunal perforation. This case emphasizes the importance of maintaining suspicion for atypical, non-biliary causes in post-Whipple patients with recurrent symptoms, particularly when conventional tests suggest no biliary obstruction. A thorough linear diagnostic approach and multidisciplinary collaboration are essential. The delay in diagnosis highlights the challenges of interpreting subtle imaging findings and correlating them with clinical symptoms mimicking cholangitis.

CASE SUMMARY

A 55-year-old female with a Whipple procedure history 10 years earlier presented with recurrent fever and severe abdominal pain. An initial extensive workup, including imaging and laboratory tests, was inconclusive. Only after detailed re-evaluation of the computed tomography images revealed a subtle linear hyperdensity and subsequent deep push enteroscopy was an embedded fish bone in the efferent jejunal limb identified and removed endoscopically.

CONCLUSION

Clinicians should consider gastrointestinal foreign body perforation in the differential diagnosis of recurrent fever and abdominal pain in patients with altered anatomy after Whipple procedure. Critical image review and advanced enteroscopic techniques are invaluable for diagnosing obscure causes in complex cases.

Keywords: Pancreaticoduodenectomy; Fish bone perforation; Cholangitis; Post-surgical complications; Case report

Core Tip: This case highlights the importance of considering atypical causes like gastrointestinal foreign body perforation in patients with altered postoperative anatomy presenting with recurrent fever and abdominal pain. Despite extensive workup, the cause remained elusive until deep push enteroscopy identified an embedded fish bone in the efferent jejunal limb of a post-Whipple patient. This was only possible after a thorough review of the computed tomography imaging, which showed a subtle linear hyperdensity. This case demonstrates the value of critical image review and advanced endoscopic techniques in diagnosing obscure gastrointestinal pathology in complex post-surgical patients.