# Retained Foreign Body Causing a Liver Abscess

Authors: Guek Gwee Sim; Sujata Kirtikant Sheth
Journal: Case Reports in Emergency Medicine
 (2019)

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## Abstract

Introduction. A liver abscess caused by fishbone ingestion is extremely rare in the Emergency Department. Case Report. We report a case of a middle-aged female who presented to the Emergency Department with nonspecific symptoms. Computed tomography showed a liver abscess that had formed secondary to a fishbone. The patient was treated conservatively initially and subsequently with percutaneous drainage and finally with open drainage. Her condition improved and she was discharged from the hospital with the foreign body still in-situ. Conclusion. This case is one of six cases in literature where the patient has been discharged successfully from the hospital with a retained fishbone. It also demonstrates the difficulty of diagnosing a foreign body causing a liver abscess and the multiple treatment modalities used to treat a liver abscess caused by fishbone.


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## Body

## 1. Case Report

A 56-year-old female presented to the Emergency Department after a fall. The patient reported that she had been having a fever for the last 2 days and there was associated dizziness which led to the fall. There was no loss of consciousness or head injury secondary to the fall. She also reported a non-productive cough, several episodes of non-bilious, non-bloody vomiting, and two episodes of diarrhea.The patient’s past medical history was that of chronic ischemic heart disease; type two diabetes mellitus, hyperlipidemia and hypertension. She did not have any known drug allergies. She denied drinking alcohol, smoking or use of any illicit drugs. Her travel history including traveling to India three months ago. On physical examination she looked diaphoretic, lethargic and in pain, with a blood pressure of 125/95 mmHg, pulse rate of 127 beats per minute, respiratory rate of 20 per minute, oxygen saturation of 97% on room air and a temperature of 39.7°C. An abdominal examination revealed that she was tender in the right lower quadrant and right upper quadrant with no rebound tenderness or guarding, and Murphy’s sign was negative. Examination of the other systems did not reveal any abnormalities.Based on the clinical history and examination the working diagnosis of pneumonia and possible acute appendicitis or diverticulitis was made. She was given intravenous normal saline fluid, intravenous antibiotics and analgesia. The electrocardiogram showed sinus tachycardia with nonspecific T wave inversion. The chest X-ray showed clear lungs fields and the heart size was normal. A renal panel, liver panel, full blood count, C-reactive protein, prolactin, and urine analysis were ordered. The patient had transaminitis, markedly raised inflammatory markers, and thrombocytopenia. The patient’s lab results are shown in Table1.Table 1
Lab values for the patient.
Renal panel (normal range)
Liver panel (normal range)
Full blood count (normal range)
Others (normal range)
Urea 6.4 (2.8–7.7 mmol/L)
Alkaline phosphate 116 (32–103 U/L)
WBC 9.6 (4.0–10.0 × 103/uL)
CRP 308.8 (<3.0 mg/L)
Sodium 122 (135–145 mmol/L)
Alanine transaminase 631 (10–55 U/L)
Platelet 94 (150–450 × 103/uL)
Procalcitonin 13.39 (0.00–0.50 ug/L)
Potassium 3.4 (3.5–5.3 mmol/L)
Aspartate transaminase 1224 (10–45 U/L)
Hemoglobin 10.7 (11.5–15.0 g/dL)
Urine WBC 2, RBC 12, esterase negative (WBC 0–6 cells/hpf, RBC 0–3 cells/hpf)
Chloride 80 (96–108 mmol/L)
Total bilirubin 26.3(5.0–30.0 U/L)
Hct 31 (36.0–46.0%)
Bicarbonate 12 (19–31 mmol/L)
Albumin 31 (37–51 g/L)
Neutrophil 8.4 (2.0–7.5 × 103/uL)
Glucose 17.1 (3.1–7.8 mmol/L)
Lymphocyte 0.6 (1.0–3.0 × 103/uL)
Creatinine 107 (50–90 umol/L)Patient was sent for a computed tomography (CT) of the abdomen and pelvis with intravenous contrast to rule out appendicitis or diverticulitis. Figure1 shows the CT findings for this patient. The results showed a linear radio dense foreign body within the hepatic segment, most likely a fishbone with the site of perforation possibly being the distal stomach. Surrounding the foreign body there is a well-defined hypodense region suggestive of a phlegmonous area of inflammation measuring 9.4 × 7.0 cm. No subcapsular hematoma, intra-abdominal free fluid or pneumoperitoneum was present.Figure 1
Computed tomography of the abdomen and pelvis with foreign body.The patient was then admitted to the general ward and was treated conservatively with intravenous antibiotics for 15 days. She was initially started on Ceftriaxone and Metronidazole and subsequently switched to Piperacillin/Tazobactam on Day 4 of illness. On day 10 of admission, the patient went for a repeat CT of the abdomen and pelvis and it was found that the abscess had significantly increased in size and a percutaneous catheter was inserted at this time. On day 18 the abscess was still the same size and the patient continued to spike fevers so the patient underwent open liver abscess drainage which showed a heterogeneous abscess in segment 4 extending to segment 8, but no liquid abscess was seen and no foreign body could be found. On day 27 a repeat CT of the abdomen and pelvis was done, because the patient was still spiking fevers, showing pockets of residual collection in right lobe of the liver with a foreign body still present and then a new percutaneous drain was placed. On day 29 the drain was removed because the drain output had dropped. An ultrasound was performed of the liver on day 34 and there was an ill-defined heterogenous hypoechoic area noted in the liver extending from segment 4 to 8. There was no new focal hepatic lesion. The repeat ultrasound on day 44 was done and the abscess cavity was now smaller and there was still a remnant foreign body.The patient was successfully discharged asymptomatic on day 55. The patient remained well on follow up. She had repeat ultrasounds done at 1 month and 3 months post discharge which showed a heterogeneously hypoechoic area which had decreased in size but still had the fishbone present.


## 2. Discussion

The formation of liver abscess secondary to a foreign body ingestion is extremely rare. Most foreign bodies that are ingested pass through the gastrointestinal tract within 1 week [1]. There are a variety of foreign bodies that are ingested that have caused liver abscess. The foreign bodies ingested range from toothpicks, fishbone, needles, chicken bones, pens, and dentures. Toothpicks are the most common foreign body ingested followed by fishbones [1]. Since the first case reported by Lambert in 1898, there have been 88 cases of hepatic abscess caused by a foreign body ingestion [2]. Of these cases 33% are due to the ingestion of a fishbone [1]. As the foreign body passes through the alimentary tract there are several locations where the foreign body tends to lodge. Once swallowed, a foreign body may lodge itself in the upper aerodigestive tract, oesophagus, stomach, small bowel or colon. The most common site of impaction is usually at the level of the tonsils, although the impacted bone may be found at the base of the tongue, the vallecula or the pyriform fossa [3]. Perforations distal to the oesophagus occur in <1% of cases [4]. Once the fish bone passes through the oesophagus and pass below the level of diaphragm, the possible sites of lodgment and thus perforation include the pylorus, the duodenum, the duodenojejunal junction, the ileocecal region or any sites of congenital anomalies [5]. In this case the CT showed fat stranding between the gastric antropyloric region and the left lobe of the liver suggesting that this is the possible site of migration and penetration.In most cases, ingested foreign bodies are asymptomatic and pass through the gastrointestinal tract without any complications within a week [6]. In Asian countries since fish is commonly consumed it is the most common foreign body that is ingested as well as the one that poses the most significant risk for gastrointestinal perforation [6]. Therefore it is difficult for the clinician to determine that this is the cause of an abscess formation. The classic signs of liver abscess fever, right upper quadrant pain and jaundice are rarely seen [7]. Instead patients present with epigastric pain, fever, chills, anorexia, nausea and vomiting or even weight loss [2]. The most common differential diagnosis before surgery is often acute appendicitis or diverticulitis [8].There are several modalities used to diagnose foreign bodies that have penetrated from the alimentary tract. In 101 cases that were analyzed for all foreign body ingestions that have caused liver abscess, CT was the most common modality used. Table2 shows the breakdown of all the modalities used [9].Table 2
Diagnostic tools used for imaging foreign bodies.
Diagnostic tools
n(%)
Computed tomography
66 (65.35)
Ultrasonography
21 (20.79)
Radiographs
14 (13.86)
Laparotomy
13 (12.87)
Autopsy
7 (6.93)
Esophagogastroduodenoscopy
4 (3.96)
Colonoscopy
3 (2.97)
Endoscopic ultrasonography
1 (0.99)There is no established imaging modality that is the gold standard but CT provides a useful way of evaluating location and complications for the foreign body [9]. In this case a CT was used to discover the foreign body since the working diagnosis on initial presentation was acute appendicitis or diverticulitis.Once the diagnosis is made there are various forms of treatment depending on the size of the abscess. Conservative management with antimicrobial agents may be attempted for abscesses less than 5 cm in size. If the liver abscess is greater than or equal to 5 cm, percutaneous drainage is recommended [3]. The bacteriological presentations of foreign-body- and nonforeign body-related pyogenic liver abscesses are different. Nonforeign body liver abscess in the majority of cases are caused by Klebsiella pneumonia and Escherichia coli. In foreign body related abscesses, pathogens include normal oral flora, with Streptococcus being the most common [12]. In this patient, both conservative as well as percutaneous treatments had failed, and this was followed by a laparotomy for open drainage. This resulted in improvement of the symptoms and reduction of the abscess size even though no foreign body could be retrieved. In our literature search of 54 cases of liver abscess caused by fishbones the procedures used for removal are listed in Table 3. To the best of our knowledge this is the fourth case of a liver abscess due to a foreign body ingestion that has successfully been treated without the removal of the foreign body [10, 11]. A table of all the cases of liver abscess caused by a fishbone foreign body are listed in Table 4.Table 3
Procedures used to remove fishbones (reference from Table4).
Procedure used to removed foreign body in 56 patients
N (%)
Laparotomy
20 (37.04)
Percutaneous abscess drainage + other procedures
16 (29.63)
Laparoscopy + other procedures
11 (20.37)
IV antibiotics
3 (5.56)
Autopsy
2 (3.70)
Endoscopy + other procedures
2 (3.70)
Colonoscopy
1(1.85)
Unknown
1 (1.85)Table 4
Cases of fishbones causing liver abscess’s and particulars on each case.
First Author
Year
Treatment
Symptoms
Suffering period
Size
Penetration
Bacteria
Mortality
Retained FB
Venkatesh [13]
2015
Laparotomy
Fever, abdominal pain RUQ tenderness
5 days
1.4 cm
Stomach, left liver lobe
Klebsiella, Proteus vulgaris, Citrobacter freundii, and Alpha hemolytic Streptococcus
No
No
Masoodi [14]
2012
Laparotomy
Fever, abdominal pain RUQ tenderness
10 days
2.5 cm
Duodenum, right liver lobe
No
No
Horii [15]
1999
Percutaneous abscess drainage and endoscopic forceps
Fever, vomiting
2 week
2.8 cm
Streptococcus constellatus
No
No
De la Vega [16]
2001
Autopsy
Abdominal pain, vomiting
2.5 cm
Right liver lobe
Yes
No
Tomimori [17]
2004
Laparotomy
Epigastric pain
4 weeks
1 cm
Stomach, left liver lobe
Streptococcus constellatus
No
No
Kessler [18]
2001
Laparotomy
Abdominal pain, vomiting
4 weeks
Duodenum, left liver lobe
Eikenella corrodens
No
No
Theodoropoulou [19]
2002
Endoscopy, laparoscopy, laparotomy
Chan [20]
1999
Laparotomy
Abdominal pain
Stomach
No
No
Tsai [21]
1999
Lapartomy
Abominal pain, fever
3.7 cm
Stomach, left liver lobe
No
No
Shuldais [22]
1992
stomach
No
No
Masunaga [23]
1991
Percutaneous abscess drainage, parcial gastrectomy and lateral segmentectomy
Abdominal pain, fever, vomiting
1 week
4 cm
Stomach, left liver lobe
No
No
Gonzalez [24]
1998
Laparotomy
Abdominal pain, fever, jaundice, nausea
1 month
Stomach, left liver lobe
No
No
Aron [25]
1966
Laparotomy
Astenia, fever, jaundice
3 month
2.2 cm
Stomach, right liver lobe
E. coli, Proteus
No
No
Tsuboi [26]
1981
Laparotomy
Epigastic pain, weight loss
1 month
4.5 cm
Stomach, left liver lobe
No
No
Dugger [27]
1990
Autopsy
Fever, right upper abdominal pain
3 week
3 cm
Stomach, right liver lobe
E. coli, Proteus
Yes
No
Lee [28]
2005
Laparotomy
Epigastric pain
5 days
3.5 cm
Stomach, left liver lobe
Streptococcus milleri
No
No
Goh [29]
2005
Laparotomy
Fever
5 days
3 cm
Duodenum, left liver lobe
Streptococcus milleri
No
No
Chen [30]
2011
Duodenum
Yang [31]
2005
IV antibiotics
Chills, fever
1 week
Left liver lobe
Klebsiella pneumoniae and aerobic, gram-positive bacilli
No
Yes
Peixoto [32]
2016
IV antibiotics
Fever, chills, RUQ pain
2 days
3.0 cm
Pylorus
No
Yes
Fan [33]
2002
Laparotomy
Fever, cough, abdominal pain
1 week
3.5 cm
Antrum, left liver lobe
Streptococcus milleri
No
No
Chen [12]
2013
Percutaneous abscess drainage and laparotomy
Abdominal pain, chills, fever
4 days
5.0 cm
Duodenum, left lobe liver
Strep viridans
No
No
Santos [2]
2007
Percutaneos abscess drainage, laparotomy
Abdominal pain, fever, asthenia
6 week
Antrum, left liver lobe
No
No
Clarencon [34]
2008
Percutaneos abscess drainage, IV antibiotics, laparotomy, hepatotomy
Abdominal pain
4 weeks
2.3 cm
Duodenum, liver
Streptococcus sp.
No
No
Ng C T [11]
2011
IV antibiotics
Acute MI
2 days
No
Yes
Chikwendu [35]
2015
Laparotomy
Abdominal pain
3 weeks
6 cm
Stomach, left liver lobe
No
No
Panebianco [1]
2015
Explorative laparoscopy
Epigastric pain, fever
2 weeks
4 cm
Antrum, left liver lobe
No
No
Kadowaki [36]
2007
Laparotomy
Fever, upper abdominal pain
1 week
2.8 cm
Hepatoduode nal fistula, left liver lobe
E. coli and anerobic gram positive cocci
No
No
Gigirey [37]
2012
Percutaneous abscess with fisbone migration to gastric lumen removal by stool
Abdominal pian RUQ pain, fever
15 days
2.5 cm
Antrum, left liver lobe
No
No
Laterre [8]
2014
Laproscopy, laparotomy
Dyspnea, fever
3 days
3 cm
duodenum
Streptococcus hemolyticus (group G) and Streptococcus sanguis
No
No
Jimenes- Fuertes [38]
2016
Laparotomy
Epigastric and RUQ pain
2 days
Duodenum, liver
No
No
Chun [32]
2016
Percutaneous abscess with laproscopy
RUQ pain, fever, chills, rigors
2 weeks
Left liver lobe
No
No
Morelli [33]
2015
IV antibiotics and laproscopy
Abdominal pain, fever, chills, jaundice
3 cm
Antrum, left liver lobe
Streptococcus constellatus
No
No
Akimori [34]
2013
IV antibiotics and laproscopy
Fever, malaise
Lesser curveture, liver
No
No
Kosar [42]
2014
Laproscopy and percutaneous drainage
Fever
Lesser curveture, left liver lobe
Wu [43]
2016
IV antibiotics, laproscopy, laparotomy
Abdominal pain, fever, epigastric, RUQ pain
6 days
Duodenum, liver
No
No
Yen [44]
2010
Laparotomy
Upper abdominal pain, fever
2 weeks
Left liver lobe
No
No
Bandeira-de- Mello [45]
2018
Percutaneous abscess drainage and laproscopy
Epigastric pain, fever
6 days
2.5 cm
Lesser curveture, left liver lobe
Group C beta-hemolytic streptococcus, streptococcus sp. (viridans)
No
No
Matrella [6]
2014
Laparotomy
Epigastric pain and fever
10 days
Motallebzadeh [46]
2014
Endoscopy and biopsy forceps
Right upper quadrant pain
Antrum, liver
No
No
Liang [47]
2011
Percutaneous drain and Laparotomy
Upper quadrant pain
1 month
Stomach, left liver lobe
No
No
Kim [48]
2010
Colonoscopy
Right upper and lower quadrant pain
2 weeks
Two 1.5 cm
Acensding colon and right liver lobe
No
No
Yu [49]
2018
Laproscopy, laparotomy
Epigastric pain, fever, anorexia, nausea and vomiting
8 days
3
Left liver lobe
No
No
Beckers [50]
2019
Percutaneous drainage and laparoscopy
Fever, right upper quadrant pain, anorexia, shivering and confusion
3 days
3.5
Left liver lobe
Streptococcus anginosus and Streptococcus constellatus
No
No
Sun [51]
2018
Laparotomy
Fever and right upper quadrant pain
3 days
3
Left liver lobe
Streptococcus anginosus
Streptococcus constellatus and Peptostreptococcus asaccharolyticus
No
No
Queiroz [52]
2019
Laparotomy
Epigastric pain and fever
10 days
Gastric antrum and left liver lobe
No
No
Jarry [53]
2011
Laparoscopy, laparotomy
Right upper quadrant pain, asthenia, anorexia and fever
2 weeks
3.5
Left liver lobe
No
No
Bekki [54]
2019
Laparoscopy
Fever and anorexia
2.4
Left liver lobe
Streptococcus anginosus
No
No
Chen [55]
2019
Laparoscopy
Epigastric pain
2 months
1.7
Left liver lobe
No
No
Dias [56]
2018
Laparotomy
Fever and abdominal pain
2.7
Left liver lobe
No
No
Burkholder [57]
2019
Percutaneous drainage
Fever, right upper quadrant pain, nausea, vomiting and diarrhoea
8 days
2.1 cm
At level of falciform fissure
Alpha hemolytic streptococcus
No
Yes
Graça [58]
2019
Laparoscopy
Shivering and fever
3 days
Left liver lobe
Streptococcus constellatus and Escherichia coli
No
No
Sivarajah [59]
2018
Percutaneous drainage and laparotomy
Epigastric pain, nausea and vomiting
3 days
3.5
Left liver lobe
No
No
Mateus [60]
2018
Percutaneous drainage and laparotomy
Abdominal pain and constipation
3 days
5
Left liver lobe
Streptococcus constellatus
No
No
Mateus [60]
2018
Percutaneous drainage
Weakness, chills, myalgia and cough
2 days
Left liver lobe
Streptococcus anginosus, Streptococcus viridans, Prevotella bivia and Bacteroides fragilis
No
Yes


## 3. Conclusion

This case is one of six cases in literature where the patient has been discharged successfully from the hospital with a retained fishbone. It demonstrates the difficulty of diagnosing an ingested foreign body as the cause of a liver abscess and the various modalities used to treat liver abscess caused by foreign bodies.



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