Fish bone migration: An unusual cause of liver abscess

Article (PDF Available)inBMJ Case Reports 2012(mar08 1) · March 2012with128 Reads
DOI: 10.1136/bcr.09.2011.4838 · Source: PubMed
Abstract
Treating a pyogenic liver abscess is a therapeutic challenge when a patient presents with atypical symptoms. One of the rare causes of treatment failure of these abscesses is the unrecognised migration of a foreign body from the gastrointestinal tract. The authors describe a pyogenic liver abscess in a 45-year-old male who presented with a 10 day history of fever, and abdominal pain. A CT scan of the abdomen revealed a needle-like foreign body in the liver. At operation a 2.5 cm fish bone was extracted from the liver. Subsequently, his feverish symptoms disappeared, and he has remained well in the ensuing 3 month postoperative period. Fish bone-induced liver abscess is discussed in this brief report.
BMJ Case Reports 2012; doi:10.1136/bcr.09.2011.4838
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BACKGROUND
The unexpected presence of a foreign body or bodies in
the liver can be an uncommon cause of recurrent liver
abscess.
CASE PRESENTATION
A 45-year-old male presented with a 10 day history of
high-grade fever and abdominal pain. He had had no viral
prodrome, rigors or chills. His systemic examination was
normal. Laboratory data revealed leukocytosis (white
blood cell count of 14 700; 76% neutrophils), and the hae-
moglobin and platelet counts were normal. Liver function
tests revealed normal bilirubin and liver enzymes but a
mild elevation of alkaline phosphatase 141 IU (reference
50–136 IU). Serum amylase, lipase and renal function tests
were normal. His amoebic serology was negative.
An ultrasound examination of the abdomen revealed
a right lobe liver abscess, with normal intrahepatic bil-
iary ducts, and a normal gallbladder. Other viscera were
also normal. Ultrasound guided drainage of the abscess
was undertaken and the aspirate was sent for culture.
The patient was given broad-spectrum antibiotics intra-
venously for 10 days pending the culture reports, which
were reported sterile a few days later. The patient’s
fever subsided, and he was discharged from hospital.
One month later he re-presented with a 6 day history of
high-grade fever and abdominal pain. The patient does
not drink alcohol, does not indulge in high risk behaviour
and there was no history of drug abuse. Clinical exami-
nation was again unremarkable. Laboratory data again
showed a leucocytosis (16 7000 with 87.6%neutrophils).
Liver function tests revealed normal bilirubin, and normal
aspartate aminotransferase and alanine aminotransferase
levels. However, on this occasion, serum albumin levels
were reduced 31 g/l (reference 34–50 g/l), and alkaline
phosphatase levels were again elevated 157 IU (reference
50–136 U/l). An x-ray of the abdomen ( gure 1 ) revealed
no abnormality. An abdominal CT scan ( gure 2 ) showed
a peripherally enhancing irregular hypodense lesion in
segment IV of the liver, measuring about 5.6×7.5×7.7
cm, consistent with a liver abscess. A hyper-dense lin-
ear object was to be seen at the inferior edge of segment
IV B of the liver, passing through the liver tissue and
measuring about 2.5 cm in length. The gallbladder was
unremarkable. The pancreas, spleen, adrenals and both
kidneys were normal. The fi ndings were consistent with
Unusual presentation of more common disease/injury
Fish bone migration: an unusual cause of liver abscess
Ibrahim Masoodi,
1
Khalid Alsayari,
1
Khalid Al Mohaimeed,
2
Shameem Ahmad,
1
Abdulla Almtawa,
1
Ahmed Alomair,
1
Adel Alqutub,
1
Salman Khan
1
1
Gastroenterology and Hepatology Department, King Fahad Medical City, Riyadh, Saudi Arabia ;
2
Surgery Department, KFMC, Riyadh, Saudi Arabia
Correspondence to Dr Ibrahim Masoodi, ibrahimmasoodi@yahoo.co.in
Summary
Treating a pyogenic liver abscess is a therapeutic challenge when a patient presents with atypical symptoms. One of the rare causes of
treatment failure of these abscesses is the unrecognised migration of a foreign body from the gastrointestinal tract. The authors describe a
pyogenic liver abscess in a 45-year-old male who presented with a 10 day history of fever, and abdominal pain. A CT scan of the abdomen
revealed a needle-like foreign body in the liver. At operation a 2.5 cm fi sh bone was extracted from the liver. Subsequently, his feverish
symptoms disappeared, and he has remained well in the ensuing 3 month postoperative period. Fish bone-induced liver abscess is discussed
in this brief report.
Figure 1 X-ray abdomen, no radio opaque shadow seen.
BMJ Case Reports 2012; doi:10.1136/bcr.09.2011.4838
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a liver abscess consequent upon the presence of an int-
rahepatic foreign body. Accordingly, a laparotomy was
performed. The abscess was drained and a 2.5 cm long
sh bone was removed ( gure 3 ). By way of incidental
operative fi ndings, the omentum was observed to be
adhering to the gall bladder in the duodenal area and seg-
ment IV B of liver. These adhesions were removed. The
gallbladder was seen to be thick-walled and cholecystec-
tomy was performed. On repeat questioning, the patient
admitted eating the fi sh 5 months earlier, but denied any
major discomfort at the time. Upper GI endoscopy was
then undertaken, which showed chronic infl ammation,
but a healed scar in the duodenal bulb, thus indicating
the possible site of the fi sh bone migration ( gure 4 ).
However, no fi stulous communication was seen in either
the stomach or the duodenum. The gall bladder histol-
ogy was suggestive of chronic cholecystitis. The patient
experienced an uneventful postoperative period, and has
been attending our clinic for the last 3 months without
any further complaints.
DIFFERENTIAL DIAGNOSIS
Amoebic liver abscess
Pyogenic liver abscess
TREATMENT
The patient was fi rst given antibiotics; then surgery was
carried out, and the fi sh bone was removed.
OUTCOME AND FOLLOW-UP
The patient improved after the removal of the fi sh bone
and is presently on follow-up.
DISCUSSION
We have described a recurrent liver abscess in a healthy
person, following the migration of a fi sh bone from the
duodenum to the liver. The patient admitted eating fi sh
5 months prior to the current presentation; however, he
denied having any severe symptoms at the time that he
ate the fi sh. However, the patient’s liver abscess recurred,
despite percutaneous drainage and antibiotics. Because
of the presence of the fi sh bone in the liver, he was oper-
ated on. His feverish symptoms disappeared after sur-
gical drainage of the liver abscess, and the removal of
the fi sh bone. Usually most small fi sh bones which have
been eaten pass without any obstruction through the
gut in a week or so or patient comes to medical atten-
tion once migration of the fi sh bone causes liver abscess
1
as in the index case. When obstruction does occur, the
oesophagus is often implicated and local injury can be
found. More rarely; mediastinal abscesses have been
reported.
2
The extremely unlikely event of foreign body
migration and liver abscess development is very diffi cult
to establish unequivocally. The results of routine labora-
tory studies are often non-specifi c, and unless the foreign
body involved is radio-opaque it will not be identifi ed
on plain radiography.
2
3
Lue et al
4
conducted a study on
the capability of plain radiography to detect fi sh bones
in human soft tissues. They observed that x-ray had a
sensitivity of 39% and specifi city of 72% to detect a fi sh
bone. However, when compared with an x–ray, a CT
Figure 2 CT scan abdomen showing foreign body in the left lobe
of liver.
Figure 3 Fish bone removed after laprotomy.
Figure 4 Upper gastrointestinal endoscopy of the index case.
BMJ Case Reports 2012; doi:10.1136/bcr.09.2011.4838
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scan shows itself to be a better means of discovery, due
to its high resolution and accuracy in the diagnosis of
the presence of a foreign body.
5
7
Endoscopy may be
helpful when performed early, and before migration of
the foreign body has taken place. In addition, it could
detect non-specifi c gastric /duodenal infl ammation,
which is the tell tale sign of migration from gut lumen
to viscera, as in the index case. In a recent review by
Sofi a et al
8
sh bone migration was the commonest type
of foreign body to give rise to the development of liver
abscesses. Other foreign bodies described as causing liver
abscesses are chicken bones and toothpicks.
8
10
In most
cases, fi sh bone migration occurs through the stomach
and the duodenum. The migration of a fi sh bone to the
liver in the index case had possibly occurred through
the duodenum, as adhesions near the duodenum were
observed during the operation. Preoperatively CT evi-
dence of a thickened gastrointestinal wall contiguous
to the abscess, and the presence of adhesions seen dur-
ing surgery are all clues to the possible migration of a
foreign body as a cause of the liver abscess. Invariably,
liver abscesses develop in the left lobe of the liver.
Usually, oropharyngeal microfl ora from the initial aspi-
rates of a liver abscess are grown in a culture; however,
in this case, the culture from the aspirates of the liver
abscess was sterile. Laparotomy is usually required, as
has been reported in most of the cases described in the
literature. However, Horii et al
11
described percutaneous
removal of fi sh bone from the tract under fl uoroscopic
and ultrasound guidance by endoscopic biopsy forceps.
Patients have a good prognosis, once the fi sh bone has
been removed, and the liver abscess resolves. However,
a fatal liver abscess due to fi sh bone migration has
been reported by Theodoropoulou et al
12
. The authors
reported high-grade fever in a 46-year-old male with no
co-morbidities, who succumbed to septicaemia within
46 h of hospital admission. It was only after an autopsy
that a fi sh bone was discovered in the liver. Their report
indicates just how vigilant a clinician must be in each
particular case.
In conclusion, it is very diffi cult to diagnose foreign
body migration as a cause of recurrent liver abscess, as the
symptoms are non-specifi c. When a liver abscess does not
respond to aspiration and antibiotic therapy, migration of
a foreign body like a fi sh bone, etc. should be considered
among the potential aetiological factors despite its admit-
ted rarity.
Learning points
Foreign body migration is an unusual cause of liver
abscess, but it does happen.
Careful history taking is always complementary in
clinical management.
A CT scan of the abdomen is a better modality to
diagnose liver abscess caused by migration of foreign
body than an x-ray.
Surgery is the corner stone management in the
removal of foreign body induced liver abscess.
Acknowledgements Authors thank Mr Khalid Abdullah Naseer Alomair from
Almadina Kingdom of Saudi Arabia for his contribution to the preparation of this
manuscript.
Competing interests None.
Patient consent Obtained.
REFERENCES
1 . Shaw PJ, Freeman JG . The antemortem diagnosis of pyogenic liver
abscess due to perforation of the gut by a foreign body. Postgrad Med J
1983 ; 59 : 455 – 6 .
2 . Ngan JH, Fok PJ, Lai EC, et al . A prospective study on fi sh bone ingestion.
Experience of 358 patients. Ann Surg 1990 ; 211 : 459 – 62 .
3 . Tsui BC, Mossey J . Occult liver abscess following clinically unsuspected
ingestion of foreign bodies. Can J Gastroenterol 1997 ; 11 : 445 – 8 .
4 . Lue AJ, Fang WD, Manolidis S . Use of plain radiography and computed
tomography to identify fi sh bone foreign bodies. Otolaryngol Head Neck Surg
2000 ; 123 : 435 – 8 .
5 . Cheung YC, Ng SH, Tan CF, et al . Hepatic infl ammatory mass secondary to
toothpick perforation of the stomach: triphasic CT appearances. Clin Imaging
2000 ; 24 : 93 – 5 .
6 . Masunaga S, Abe M, Imura T, et al . Hepatic abscess secondary to a fi shbone
penetrating the gastric wall: CT demonstration. Comput Med Imaging Graph
1991 ; 15 : 113 – 6 .
7 . Chan SC, Chen HY, Ng SH, et al . Hepatic abscess due to gastric perforation
by ingested fi sh bone demonstrated by computed tomography. J Formos Med
Assoc 1999 ; 98 : 145 – 7 .
8 . Santos SA, Alberto SC, Cruz E, et al . Hepatic abscess induced by foreign body:
case report and literature review. World J Gastroenterol 2007 ; 13 : 1466 – 70 .
9 . Griffi ths FE . Liver abscess due to foreign-body migration from the alimentary
tract; a report of two cases. Br J Surg 1955 ; 42 : 667 – 8 .
10. Chiang TH, Liu KL, Lee YC, et al . Sonographic diagnosis of a toothpick
traversing the duodenum and penetrating into the liver. J Clin Ultrasound
2006 ; 34 : 237 – 40 .
11. Horii K, Yamazaki O, Matsuyama M, et al . Successful treatment of a hepatic
abscess that formed secondary to fi sh bone penetration by percutaneous
trans-hepatic removal of the foreign body: report of a case. Surg Today
1999 ; 29 : 922 – 6 .
12. Theodoropoulou A, Roussomoustakaki M, Michalodimitrakis MN, et al . Fatal
hepatic abscess caused by a fi sh bone. Lancet 2002 ; 359 : 977 .
BMJ Case Reports 2012; doi:10.1136/bcr.09.2011.4838
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Masoodi I, Alsayari K, Al Mohaimeed K, Ahmad S, Almtawa A, Alomair A, Alqutub A, Khan S. Fish bone migration: an unusual cause of liver abscess.
BMJ Case Reports 2012;10.1136/bcr.09.2011.4838, Published XXX
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