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Case Report

Successful preoperative identification of fish bonecausing appendicitis using 3-dimensional
multidetector-CT ✩Souji Sane, MDPhDa, Yasuhiko Fujita, MDPhDa, Teruyoshi Amagai, MDPhDa,b,1,2,∗

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a Department of Medicine, Tokunoshima Tokushukai General Hospital, Kagoshima, Japanb Department of Clinical Engineering, Faculty of Health Care Sciences, Jikei University of Health Care Sciences,Osaka, Japana r t i c l ei n f oa b s t r a c t

Article history:

A 79 years male with fishbone-induced acute appendicitis was treated surgically with

Received 5 November 2021

laparoscopic procedure. In preoperative diagnostic study, 3-dimensional multidetector-

Revised 12 November 2021

computed tomography (3D-MDCT) demonstrated the foreign body in the appendix and 3D-

Accepted 16 November 2021

reconstructed images seemed fishbone with sharp-pointed dorsal fin directing to the tip ofAvailable online xxx

the appendix. With these findings, surgical indication of appendectomy was confirmed andlaparoscopic appendectomy was performed. He made a full recovery and was discharged inKeywords:

a satisfactory condition following 7 days of post-operative treatment. From this case expe-Fishbone

rience, 3D-MDCT seems helpful to visualize details of foreign bodies in the appendix, andAppendicitis

valuable to confirm surgical indication of complicated acute appendicitis.

3D-CT© 2021 Published by Elsevier Inc. on behalf of University of Washington.
This is an open access article under the CC BY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/)

Case report
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A 79 years old male was transferred from another outpatientclinic. His first complains was peri-umbilical pain for 6 hours
and pain was migrating to right lower quadrant (RLQ) without
nausea or vomiting. On visiting to our hospital, his temperature was 38.3 °C, blood pressure was 184/113 mmHg, heart
rate was 103 beats per minutes. On examination, he showed
abdominal pain, rebound tenderness at RLQ, and positive

Blumberg’s sign. The laboratory workup demonstrated awhite blood cell of 11,390 (count/ mm3 ), neutrophile of 86%,
and C-reactive protein of 1.63 (mg/dL). The Alvarado score[1] counted 8 point which was equivalent to high possibility ofacute appendicitis (Table 1). The plain abdominal CT showeda calcified density within the appendix with surrounding
inflammation (Fig. 1). To diagnose a complicated appendicitis
with gangrenous, perforation or stercolith, 3-dimensional
reconstruction of MDCT (3D-MDCT) imaging was added, andit visualized a sharp-pointed calcification foreign body in the✩Competing Interests: All authors have no conflicts of interest to disclose.
Corresponding author.
E-mail address: amagaipedteruyoshi@gmail.com (T. Amagai).
1
Address: 1-2-8, Miyahara, Yodogawa-Ku, Osaka city, 532-0003, Japan.
2
Present address: 1-2-8, Miyahara, Yodogawa-Ku, Osaka city, 532-0003, Japan.
https://doi.org/10.1016/j.radcr.2021.11.043
1930-0433/© 2021 Published by Elsevier Inc. on behalf of University of Washington. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)∗Please cite this article as: Souji Sane, Yasuhiko Fujita and Teruyoshi Amagai, Successful preoperative identification of fish bonecausing appendicitis using 3-dimensional multidetector-CT, Radiology Case Reports, https://doi.org/10.1016/j.radcr.2021.11.043

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Table 1 – The Alvarado score of this case. The Alvarado score of this case counted 8 point which was equivalent to the highpossibility of acute appendicitis [1].

Symptoms

Signs

Laboratory

MnemonicFindingpoint

MANTRELS

Migration
Anorexia-acetone
Nausea-vomiting
Tenderness in right lower quadrant
Rebound pain
Elevation of temperature (body temperature ≥38.3°C)
Leukocytosis (white blood cell ≥10,000/mm3 )Shift to the left (neutrophile ≥75%)

10
0
2
1
1
2
1

Total score

8The possibility of acute appendicitis in Alvarado score: total score ≥7: high, 5,6: medium, ≤4: low.

Fig. 1 – The plain abdominal computed tomography (CT) images. A calcified density within the appendix with surrounding
inflammation was observed in his right lower quadrant. Its sharp-pointed edge directed to left lower direction. (A) axialsection, (B) coronal section.

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appendix. Its detailed shape in 3D-MDCT had sharp-pointed
2 wings (Fig. 2). Synthesizing images of 3C-MDCT (Fig. 2)
with 2-dimensional plane CT (Fig. 1), a calcified body had asharp-pointed 2 wings directing to the tip of the appendix,
and it was supposed a fishbone when compared with figuresof fishbone atlas. Combining these, it seemed to be unable for2 wings of to slide out from appendix spontaneously as its
shape, location, and direction of wings and less-peristaltic appendiceal nature. Based on these findings, he was diagnosed
with fishbone-induced complicated acute appendicitis, andfollowed by an urgent laparoscopic appendectomy in which
entire appendix was removed.
The surgical material demonstrated a fishbone withsharp-pointed 2 wings directed to the tip of the appendix (Fig. 3). The fishbone-attached wall of the appendix
seemed gangrenous with pending perforation. Histologic findings were consistent with gangrenous appendicitis with nomalignancy.
He made a full recovery and was discharged in a satisfactory condition following 7 days of post-operative treatment.

During his hospitalization, we could not get information
about the date he ingested it although he gave us his likelihood of eating fish involving fishbone, and we could not identify which species fishbone’s fish is because ingested fishbone
seemed very similar among fishes to eat.

3839404142Discussion
The incidence of foreign bodies in the appendix has been reported in 0.005%-0.113% [2]. An acute appendicitis is treatedby 2 different strategies according to appendiceal comorbidities, uncomplicated or complicated. The latter consists of gangrenous, perforated, or abscess formation, and treated withsurgical appendectomy [3]. In presented case, preoperative
identification of fishbone was possible by additional reconstructed 3-dimensional MDCT imaging. This modality enabled
to visualize its location, direction, and meticulous shape andof ingested fishbone in the appendix. Moreover, this fishbone

Please cite this article as: Souji Sane, Yasuhiko Fujita and Teruyoshi Amagai, Successful preoperative identification of fish bonecausing appendicitis using 3-dimensional multidetector-CT, Radiology Case Reports, https://doi.org/10.1016/j.radcr.2021.11.043

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3Fig. 2 – The 3-dimensional multidetector-computed tomography (MDCT) images. The calcified foreign body seemed to have
sharp-pointed 2 wings. (A) Fishbone 3D-image in posterior view, with ruler and direction instruction, (B) Fishbone in
3D-reconstructed MDCT image. Synthesizing 3D-images taken with 3C-MDCT to 2-dimensional plane images (Fig. 1), acalcified body had a sharp-pointed 2 wings directing to the tip of the appendix.

Fig. 3 – The photography of fishbone embedded in the removed appendix. The fishbone has sharp-pointed 2 wings withruler. Fishbone sized 15 mm in length and 8 mm in height.

Please cite this article as: Souji Sane, Yasuhiko Fujita and Teruyoshi Amagai, Successful preoperative identification of fish bonecausing appendicitis using 3-dimensional multidetector-CT, Radiology Case Reports, https://doi.org/10.1016/j.radcr.2021.11.043

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was suspected dorsal fin of fish when compared with fishbone anatomy diagram, preoperatively. These foreign body’s
anatomic information is available not in plane axial, coronal,or sagittal viewing but in 3D-MDCT. Unless this information, it
is not concluded what is a calcified foreign body with or without pointed edge, and whether it is embedded or possibilityof moving out from appendix. The published case report offishbone-appendicitis reported that abdominal radiography is
not reliable in finding the fishbone [4]. To our best knowledge,
our case presentation of fishbone-induced acute appendicitis
is the first to visualize fishbone in the appendix to worth reporting.

Conclusion
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[mUS7b;December 8, 2021;21:15]

A 79 years male with fishbone-induced acute appendicitis wastreated surgically using laparoscopic procedure. 3D-MDCT
seems helpful to visualize details of foreign bodies in the appendix and valuable to confirm surgical indication of complicated acute appendicitis.

Source(s) of financial support in the form of grants
None.

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[2] Bababekoov YJ, Stanelle EJ, Abujudeh HH, Kaafarani HM.
Fishbone-induced appendicitis. BMJ Case Rep
2015;2015:bcr2015209562.
[3] Vons C, Barry C, Maitre S, Pautrat K, Leconte M, Costaglioli B,et al. Amoxicillin plus clavulanic acid versus appendicectomy
for treatment of acute uncomplicated appendicitis: an
open-label, non-inferiority, randomized controlled trial.
Lancet 2011;377(7):1573–9.
[4] Harhar M, Jabi R, Harroudi TE, Bouziane M. Fishbone-induced
appendicitis: a case report. Cureus 2021;13(5):e15003.
doi:10.7759/cureus.15003.

Please cite this article as: Souji Sane, Yasuhiko Fujita and Teruyoshi Amagai, Successful preoperative identification of fish bonecausing appendicitis using 3-dimensional multidetector-CT, Radiology Case Reports, https://doi.org/10.1016/j.radcr.2021.11.043

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