Objectives

To perceive the range of imaging findings associated with accidental fishbone ingestion and its abdominal complications.

Background

Accidental ingestion of a fishbone is a common event, especially in cultures with regular consumption of unfilleted fish. In most cases, fishbone passes through the gastrointestinal tract without causing any symptoms. Occasionally, GI tract perforation occurs and triggers an inflammatory process which may complicate with abscess formation, bowel obstruction or bleeding. Although these complications are more frequent in GI tract itself, they may affect adjacent organs such as liver or pancreas, since ingested fishbones have the ability to migrate.

Imaging findings OR Procedure findings

We performed a survey for abdominal complications of accidental fishbone ingestion at our institution and selected the most representative cases. MDCT was the main imaging technique used in the selected cases and the definitive diagnosis was established by surgery, after depiction of a hyperdense linear foreign body compatible with a fishbone.

Conclusion

Accidental fishbone ingestion may result in GI perforation and associated abdominal complications. Clinical symptoms are highly unspecific and provide no clue to the etiological diagnosis, which relies on the identification of the offending fishbone itself, ideally by means of an imaging technique such as MDCT. All other imaging findings are unspecific and shared with several other etiologies. Thus, a high suspicion index of the radiologist plays a pivotal role in reaching to an accurate diagnosis in this clinical scenario.

Objectives

- To briefly review the pathophysiology of biliary system related emergencies.

- To identify the imaging appearances of both usual and unusual emergent biliary conditions in distinct imaging modalities.

- To discuss differential diagnostic hypotheses in the depicted clinical scenarios.

Background

Emergent biliary conditions may occur with several clinical presentations, the most frequent being abdominal pain, fever, jaundice and/or elevated direct bilirubin and liver enzymes – the so-called cholestatic pattern. As various biliary conditions may present with similar clinical and laboratory features, imaging is frequently required to accurately achieve diagnosis.

Imaging findings OR Procedure findings

We present a wide range of emergent biliary conditions, including the most common but also several unusual presentations, using a multimodality imaging approach (ultrasound, CT, MRI, endoscopy, EUS and ERCP).

Cases are categorized in inflammatory, obstructive, fistulizing, vascular and iatrogenic, according to the main pathological mechanism involved.

When relevant, the main differential diagnoses are discussed along with their imaging features.

Conclusion

An adequate imaging workup plays a crucial role in the diagnosis and treatment referral of patients with biliary emergencies. Ultrasound and CT are the more frequently used modalities in the emergency setting, while MRI is used in selected cases to provide a more detailed characterization of the biliary system.

Recognition of the characteristic imaging findings of both common and uncommon biliary tract related pathologies is therefore a fundamental skill for the radiologist.