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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 51  |  Issue : 5  |  Page : 209-212

Fishbone-related liver abscess


1 Department of Surgery, Cheng Ching General Hospital, Taichung City, Taiwan
2 Department of Surgery, Lin Shin General Hospital, Taichung City, Taiwan

Date of Submission21-Feb-2018
Date of Decision15-Mar-2018
Date of Acceptance02-May-2018
Date of Web Publication17-Oct-2018

Correspondence Address:
Dr. Chih-Jen Huang
Department of Surgery, Lin Shin General Hospital, Taichung City
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_18_18

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  Abstract 

Liver abscess caused by foreign-body penetration of the alimentary tract is rare. Preoperative diagnosis is difficult as patients are often unaware of the foreign-body ingestion and the unusual characteristic is often being paucisymptomatic until secondary complications occur. We report a patient with fishbone-related liver abscess. Preoperative demonstration of a hyperdense, linear lesion was performed by computed tomography. He was treated successfully after removal of the foreign body and drainage of the abscess.

Keywords: Fishbone, foreign body, liver abscess


How to cite this article:
Sun HP, Huang CJ. Fishbone-related liver abscess. Formos J Surg 2018;51:209-12

How to cite this URL:
Sun HP, Huang CJ. Fishbone-related liver abscess. Formos J Surg [serial online] 2018 [cited 2018 Dec 12];51:209-12. Available from: http://www.e-fjs.org/text.asp?2018/51/5/209/243583


  Introduction Top


Perforation of the gastrointestinal tract caused by ingested foreign bodies is uncommon, and consequent development into liver abscess is even rarer.[1],[2],[3]

Chong et al. reviewed the literature for cases of liver abscess secondary to foreign-body penetration. They searched the PubMed database for English literature from 1955 to 2013 using the keywords “liver abscess,” “hepatic abscess,” and “foreign body.” Only 88 patients were reported in the literature.[4]

We report a male patient with fishbone-related liver abscess. He was treated successfully after diagnosis by computed tomography (CT) and prompt surgery.


  Case Report Top


A 57-year-old male presented to the emergency department with right upper abdominal pain accompanied by fever noted for 3 days. The patient had been admitted to another hospital 2 weeks ago for similar complaints. He had received upper gastrointestinal endoscopy, and only shallow gastric ulcer was noted then. The abdominal ultrasound was also performed without obvious abnormality found. He was discharged 4 days later as his symptoms improved after medical treatment with the diagnosis and acute gastroenteritis and peptic ulcer. However, recurrent right upper abdominal pain, fever, and chills with anorexia were noted this time. His vital signs were within normal limits except fever up to 38.5°C noted. The abdomen was soft to palpation yet mildly tender in the right upper quadrant.

The laboratory data included white blood cell 12780/μL (neutrophils: 75.8%), glutamic oxaloacetic transaminase/glutamate pyruvate transaminase: 60/100 U/L, and C-reactive protein: 12.56 mg/dl. No obvious abnormality was found in the plain abdominal X-ray. The abdominal ultrasound revealed a hypoechoic lesion in the left lobe liver. A contrast-enhanced CT scan demonstrated a multiloculated, hypodense mass measuring 4.6 cm at the left lobe of liver [Figure 1], and a linear, hyperdense object was found between the lesion and gallbladder [Figure 2]. The findings were consistent with a liver abscess consequent upon the presence of an intrahepatic foreign body. Then, laparotomy was arranged accordingly. Intraoperatively, mild thickening of the gallbladder wall with induration of hepatoduodenal ligament was noted. As the abscess located between the gallbladder and the liver, we performed cholecystectomy first to gain better access to the abscess. After cholecystectomy, the abscess cavity [Figure 3] was opened and a 3-cm linear foreign body, a fishbone, was retrieved from the abscess cavity [Figure 4]. No obvious perforation hole was found in the gastrointestinal tract nearby. Chronic cholecystitis and liver abscess were reported by a pathologist. Three microorganisms were isolated from the abscess cavity including Streptococcus constellatus, Streptococcus anginosus, and Peptostreptococcus asaccharolyticus. The blood culture was negative. The patient recovered smoothly after antibiotics treatment and was discharged under stable condition 10 days later. He had no recollection of ingesting the fishbone.
Figure 1: Transverse abdominal computed tomography image of the liver revealing a hypodense mass, measuring 46 mm in width

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Figure 2: A linear, hyperdense object found between the abscess and gallbladder; marked by dark arrows on transverse and sagittal views

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Figure 3: Intraoperative view. After cholecystectomy, the white needle-like foreign body removed and the abscess cavity showed

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Figure 4: Clinical images showing the retrieved fishbone

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  Discussion Top


The majority of ingested foreign bodies pass through the gastrointestinal tract smoothly within 1 week. However, gastrointestinal perforation as a result of foreign-body ingestion occurs in about 1% of these patients.[5]

An ingested foreign body that perforated the gastrointestinal tract, migrated to the liver, and caused an abscess was first described by Lambert in 1898.[6] In this index case, it was discovered upon autopsy that a pin had migrated through the stomach wall into liver, resulting in fatal hepatic abscess. Foreign bodies tend to lodge at the esophageal sphincters, pyloric canal, duodenum, ileocecal valve, and anus. Perforation of the gastrointestinal tract by foreign bodies can occur at any location, but the most common sites reported in the literature related to fishbone migration occurs through the stomach and the duodenum.[2],[4],[7] Fishbone migration was also found to be the most common type of foreign body as the culprit in the development of liver abscesses,[3] accounting for approximately 33% of cases.[4] Due to its anatomical proximity with the stomach, the left lobe of the liver is the most frequent site where fishbones get impacted.[4],[8] Specific medical history related with perforation was suggestive in only a limited number of cases (7/60; 12%).[3] In our case, no obvious evidence of perforation or scar could be identified during operation. It is presumed that the most possible location of fishbone penetration was via the stomach or duodenum. It is very likely that the previous epigastric pain episode is related to the penetration. Only 5% of patients with foreign-body abscesses recall the ingestion.[3] It is difficult to establish the time until the onset of symptoms as patients rarely recall the episode of ingestion,[1] and the migrating foreign body may remain silent until an abscess formation.

The clinical manifestations and laboratory tests of patients with liver abscess resulting from gastrointestinal perforation by foreign bodies are variable. Abdominal pain (77.3%) and fever (58%) were the most common, followed by vomiting (19.3%) and nausea (13.6%).[4],[8] Most patients have nonspecific symptoms, which are the features of a general response against an intra-abdominal inflammatory process.[2],[9]

Plain roentgenogram will sometimes highlight radiopaque foreign bodies. The ultrasonography and CT scans are useful in localizing the abscess and planning the surgical approach. CT scan is currently the gold standard for diagnosis for liver abscess related with fishbones, appearing as calcified linear structures.[10],[11] It is excellent in the detection of foreign bodies due to its high resolution and accuracy.[1],[7]

A retained and unrecognized foreign body might lead to the recurrence of a liver abscess even after adequate drainage and antibiotic treatment. The cure rate without removal of the foreign body is low (9.5%).[3] Successful treatment relies greatly on the removal of the nidus of infection and ranges from laparotomy, laparoscopy,[9] to percutaneous[7] and endoscopic removal via upper[4] or lower gastrointestinal tract,[4],[7],[9] along with adjunctive antibiotics. Surgical drainage of the abscess at the time of removal of the foreign body appears to be an adequate mean of infection source control (i.e. eradicating the focus of infection).[3] Open surgery and abscess drainage remain the mainstay of the treatment for patients with foreign bodies lodged in the liver. Minimally invasive techniques such as interventional radiology or laparoscopic surgery should be reserved for carefully selected cases, where both sepsis control and foreign-body retrieval can be performed safely.[2],[7],[9],[12]

Delayed diagnosis of liver abscess due to a foreign body may lead to poor therapeutic outcome. In the previous report, the mortality rate was 7.95% (7/88) with liver abscess due to fishbones.[4]

The bacteriological presentations of foreign-body- and nonforeign-body-related pyogenic liver abscesses are different. Gram-negative aerobes, such as Klebsiella pneumonia and  Escherichia More Details coli, constitute the majority of bacteria in nonforeign-body-related pyogenic liver abscess. On the contrary, normal oral flora, especially Streptococcus spp., are the most common pathogens of foreign-body-related pyogenic liver abscess.[4],[8] These organisms are commensal to the oral cavity and would be compatible with a swallowed foreign body with gastric penetration as the mechanism of infection.

Migrated foreign body-induced liver abscess is a specific entity and an increasingly recognized cause of treatment failure in liver abscess. Delayed diagnosis is a major concern despite extensive workup. The first step toward the correct diagnosis is increased awareness.[3],[7] This unusual condition should be kept in mind when dealing with cases of hepatic abscess or even sepsis of unknown origin. Early recognition and in-time removal of the foreign body are the key points for successful treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kanazawa S, Ishigaki K, Miyake T, Ishida A, Tabuchi A, Tanemoto K, et al. A granulomatous liver abscess which developed after a toothpick penetrated the gastrointestinal tract: Report of a case. Surg Today 2003;33:312-4.  Back to cited text no. 1
    
2.
Chintamani, Singhal V, Lubhana P, Durkhere R, Bhandari S. Liver abscess secondary to a broken needle migration – a case report. BMC Surg 2003;3:8.  Back to cited text no. 2
    
3.
Leggieri N, Marques-Vidal P, Cerwenka H, Denys A, Dorta G, Moutardier V, et al. Migrated foreign body liver abscess: Illustrative case report, systematic review, and proposed diagnostic algorithm. Medicine (Baltimore) 2010;89:85-95.  Back to cited text no. 3
    
4.
Chong LW, Sun CK, Wu CC, Sun CK. Successful treatment of liver abscess secondary to foreign body penetration of the alimentary tract: A case report and literature review. World J Gastroenterol 2014;20:3703-11.  Back to cited text no. 4
    
5.
Henderson FF, Gaston EA. Ingested foreign body in the gastrointestinal tract. Arch Surg 1938;36:66-95.  Back to cited text no. 5
    
6.
Lambert A. Abscess of the liver of unusual origin. N Y Med J 1898;177-8.  Back to cited text no. 6
    
7.
Lau CW, Wong KM, Gogna A. Image-guided percutaneous transhepatic removal of fish bone from liver abscess. J Radiol Case Rep 2017;11:1-7.  Back to cited text no. 7
    
8.
Santos SA, Alberto SC, Cruz E, Pires E, Figueira T, Coimbra E, et al. Hepatic abscess induced by foreign body: Case report and literature review. World J Gastroenterol 2007;13:1466-70.  Back to cited text no. 8
    
9.
Tan CH, Chang SY, Cheah YL. Laparoscopic removal of intrahepatic foreign body: A novel technique for management of an unusual cause of liver abscess – fish bone migration. J Laparoendosc Adv Surg Tech A 2016;26:47-50.  Back to cited text no. 9
    
10.
Lue AJ, Fang WD, Manolidis S. Use of plain radiography and computed tomography to identify fish bone foreign bodies. Otolaryngol Head Neck Surg 2000;123:435-8.  Back to cited text no. 10
    
11.
Liu HJ, Liang CH, Huang B, Xie SF, Wang GY. Migration of a swallowed toothpick into the liver: The value of multiplanar CT. Br J Radiol 2009;82:e79-81.  Back to cited text no. 11
    
12.
Riani EB, Tancredi I, Sempoux C, Hubert C, Goffette P, Gigots JF, et al. From interventional radiology to laparoscopic liver resection as complementary strategies in the treatment of hepatic abscess caused by ingested foreign bodies. Hepatogastroenterology 2012;59:558-60.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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