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
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
1 of 4
The unexpected presence of a foreign body or bodies in
the liver can be an uncommon cause of recurrent liver
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,
Khalid Alsayari,
Khalid Al Mohaimeed,
Shameem Ahmad,
Abdulla Almtawa,
Ahmed Alomair,
Adel Alqutub,
Salman Khan
Gastroenterology and Hepatology Department, King Fahad Medical City, Riyadh, Saudi Arabia ;
Surgery Department, KFMC, Riyadh, Saudi Arabia
Correspondence to Dr Ibrahim Masoodi,
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
2 of 4
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.
Amoebic liver abscess
Pyogenic liver abscess
The patient was fi rst given antibiotics; then surgery was
carried out, and the fi sh bone was removed.
The patient improved after the removal of the fi sh bone
and is presently on follow-up.
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
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
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.
Lue et al
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
3 of 4
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.
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
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.
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
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
. 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
Competing interests None.
Patient consent Obtained.
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
4 of 4
This pdf has been created automatically from the fi nal edited text and images.
Copyright 2012 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit
BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission.
Please cite this article as follows (you will need to access the article online to obtain the date of publication).
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
Become a Fellow of BMJ Case Reports today and you can:
Submit as many cases as you like
Enjoy fast sympathetic peer review and rapid publication of accepted articles
Access all the published articles
Re-use any of the published material for personal use and teaching without further permission
For information on Institutional Fellowships contact
Visit for more articles like this and to become a Fellow
Keep up to date with all published cases by signing up for an alert (all we need is your email address)
  • [Show abstract] [Hide abstract] ABSTRACT: Hepatic abscess caused by foreign body penetration of the alimentary tract is rare. We report a case of gastric antrum penetration due to a toothpick complicated by liver abscess formation. A 41-year-old man was admitted to our hospital with the chief complaint of upper abdominal pain for 2 mo. Esophagogastroduodenoscopy performed at a local clinic revealed a toothpick penetrating the gastric antrum. Computed tomography (CT) of the abdomen at our hospital revealed a gastric foreign body embedded in the posterior wall of gastric antrum with regional phlegmon over the lesser sac and adhesion to the pancreatic body without notable vascular injury, and a hepatic abscess seven cm in diameter over the left liver lobe. Endoscopic removal of the foreign body was successfully performed without complication. The liver abscess was treated with parenteral antibiotics without drainage. The patient's recovery was uneventful. Abdominal ultrasonography demonstrated complete resolution of the hepatic abscess six months after discharge. Relevant literature from the PubMed database was reviewed and the clinical presentations, diagnostic modalities, treatment strategies and outcomes of 88 reported cases were analyzed. The results showed that only 6 patients received conservative treatment with parenteral antibiotics, while the majority underwent either image-guided abscess drainage or laparotomy. Patients receiving abscess drainage via laparotomy had a significantly shorter length of hospitalization compared with those undergoing image-guided drainage. There was no significant difference in age between those who survived and those who died, however, the latter presented to hospitals in a more critical condition than the former. The overall mortality rate was 7.95%.
    Article · Apr 2014
  • Full-text · Article · Jul 2015
  • [Show abstract] [Hide abstract] ABSTRACT: Introduction: The ingestion of foreign bodies is a frequently observed problem in daily clinical practice. In order to avoid complications such as perforation, endoscopic removal of potentially penetrating foreign bodies should be attempted quickly. The use of various endoscopic techniques has been reported for this purpose. However, extraction of foreign bodies from the mid gastrointestinal tract has rarely been reported. Case Report: We present the case of a patient who had swallowed a safety needle which could safely be removed from the jejunum by means of double-balloon enteroscopy (DBE). The combination of a thin p-type enteroscope with a thick t-type overtube was used in order to improve the manoeuvrability of the endoscope. The needle was pulled into the overtube which served as a protective shield during the retrieval of the endoscope. Conclusion: Our case report describes the potential of removing foreign bodies from the deep small bowel by pulling them into the overtube of a double-balloon enteroscope. If the suspicion of foreign body impaction in the small bowel is made, it may be advisable to primarily choose a balloon enteroscopy system. Through this, quick and deep insertion can be combined with a safe removal of the foreign body.
    Article · Aug 2015