Abstract
Aims: This study aims to report a rare cause of recurrent fever and abdominal pain in a patient with altered gastrointestinal anatomy after pancreaticoduodenectomy (Whipple procedure). The objective is to highlight the diagnostic challenges and emphasize the importance of considering gastrointestinal foreign body perforation in the differential diagnosis of post-Whipple patients presenting with recurrent febrile episodes and abdominal pain.
Methods: A case study was conducted involving a 55-year-old female patient with a history of pylorus-preserving Whipple procedure performed 10 years prior for intraductal papillary mucinous neoplasm (IPMN). The patient presented with recurrent fever and severe abdominal pain over one year. Comprehensive diagnostic workup included serial laboratory tests, liver function tests, imaging studies (ultrasound, MRCP, CT KUB), and deep push enteroscopy. Imaging was critically re-evaluated to identify subtle abnormalities. Endoscopic intervention was performed to extract the foreign body.
Results: Initial investigations, including blood tests and liver function tests, remained largely normal, and infectious workup was negative. MRCP revealed a 37-mm linear filling defect in the right intrahepatic duct, initially suspected as intrahepatic lithiasis. CT KUB, upon detailed review, identified a subtle linear hyperdense structure traversing the efferent jejunal limb near the right renal vein, consistent with a fish bone. Deep push enteroscopy confirmed the presence of an embedded fish bone in the jejunal wall, which was successfully extracted endoscopically. Post-procedural intravenous antibiotics led to marked clinical improvement with resolution of fever and abdominal pain. Follow-up demonstrated stable recovery with no recurrence.
Conclusions: This case underscores the significance of maintaining a broad differential diagnosis in post-Whipple patients with recurrent fever and abdominal pain, especially when conventional biliary causes are excluded. Critical re-assessment of imaging and utilization of advanced endoscopic techniques such as deep push enteroscopy are crucial for detecting rare causes like gastrointestinal foreign body perforation. Early multidisciplinary collaboration and vigilant diagnostic approaches can prevent delays in diagnosis and improve patient outcomes. Future implications include increased awareness of atypical etiologies and the integration of specialized imaging and endoscopic evaluations in complex postoperative cases.
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