Life-threatening pica: liver abscess from perforating foreign body

A pen in the liver

A 24-year-old woman with anxiety, depression, and emotionally unstable personality disorder was referred to a tertiary center 2 weeks after ingesting multiple foreign bodies. She had undergone a laparoscopic cholecystectomy and a laparotomy for extraction of ingested foreign bodies several years ago. A sagittal CT scan view showed a ballpen and a hair clip in the stomach. A coronal view demonstrated that a second ballpen had penetrated the duodenal wall to enter the liver parenchyma. There was no free intraperitoneal air or fluid or evidence of abscess formation. At laparotomy, a toothbrush, a broken spoon and a ballpen were extracted from the stomach via an anterior gastrotomy. The duodenum was adherent to the liver but the second ballpen had migrated into the distal duodenum, with the tip in the proximal jejunum. This was extracted via an enterotomy and the fistula was not interfered with. The enterotomy and gastrotomy were closed with 3-0 polydioxanone sutures. The hair clip had passed spontaneously and was not detected on intraoperative fluoroscopy. She made an uneventful recovery and postoperative liver function tests remained in the normal range. This is only the fourth reported case of a pen fistulizing between the upper gastrointestinal tract and the liver.

An unusual cause of pericardial effusion: A case report of a hepatic abscess following foreign body migration and duodenal perforation

INTRODUCTION AND IMPORTANCE

Although foreign bodies are a rare cause of gastrointestinal tract perforation, they may serve as a nidus for hepatic abscess. Abdominal pain is the most common presenting symptom. We present a case of an ingested pen causing duodenal perforation and hepatic abscess several months after initially presenting with a pericardial effusion.

CASE PRESENTATION

A 59-year-old female living in an intensive tertiary mental health facility was noted to have an incidental pericardial effusion during work-up for hyponatremia. Seven months later, she developed a new fever and was noted to have interval increase in the pericardial effusion size. This prompted further investigation which finally revealed that an ingested pen had perforated through the first part of the duodenum and caused an abscess in the left lobe of the liver. The pericardial effusion was presumed secondary to local inflammation. Upon discovery of the abscess, the patient underwent successful operative management including abscess drainage, foreign body extraction, and duodenal repair.

CLINICAL DISCUSSION

Reports of hepatic abscess from foreign body causing duodenal perforation are rare, with bone fragments and toothpicks the most common foreign bodies implicated. There is one other previously reported case of an ingested pen. Abdominal pain is present in up to 85% of cases, but fever may be the only presenting symptom.

CONCLUSION

Foreign body migration causing a hepatic abscess may present non-specifically with unexplained fever or even pericardial effusion. Psychiatric comorbidities may contribute to delays in diagnosis due to difficulties recalling the episode of ingestion.

Hepatic abscess caused by esophageal foreign body misdiagnosed as cystadenocarcinoma by magnetic resonance imaging: A case report

BACKGROUND

Foreign bodies stuck in the throat and esophagus can be discharged through the digestive tract. Esophageal-lodged foreign bodies can cause secondary injury or detrimental response, with hepatic abscess being one such, albeit rare, outcome. Review and discussion of the few case reports on such instances will help to improve the overall understanding of such conditions and aid in differential diagnosis to improve patient outcome.

CASE SUMMARY

A 51-year-old female patient with pre-existing diabetes visited our hospital following a 15-d experience of chills and fever. Both plain and enhanced magnetic resonance imaging and color Doppler ultrasound examination of the liver and gallbladder revealed a space-occupying lesion in the caudate lobe of the liver (7.8 cm × 6.0 cm × 5.0 cm). Initially, a malignant tumor was suspected, but differential diagnosis was unable to exclude the possibility of hepatic abscess. Conservative anti-infection therapy produced a less than ideal outcome. Additional examination by hepatobiliary imaging with computed tomography suggested a foreign body present in the upper abdomen and hepatic abscess, and subsequent endoscopy revealed a sinus tract in the anterior wall of the duodenal bulb. Therefore, surgery was performed to remove the object (fishbone) and drain the abscess. After a 2-wk uneventful recovery, the patient was discharged. The final diagnosis was foreign body-induced hepatic abscess of the caudate lobe.

CONCLUSION

Differential diagnosis is important for hepatic masses, and systematic examination and physician awareness can aid in diagnosing and curing such rare conditions.

Misdiagnosis of peripheral abscess caused by duodenal foreign body: a case report and literature review

Background

The induction of chronic inflammation, perforation, and abscess by foreign bodies (FBs) in adults is uncommon. We present a delayed diagnosis case for a patient who had a fishbone stuck in the duodenal bulb, resulting in chronic abdominal pain for nearly 3 months. We present the diagnosis and treatment procedures for chronic patients, which differ from those for acute and emergency FB ingestion, and also summarize the characteristics of such patients through a systematic literature review.

Case presentation

A 68-year-old woman was brought to our hospital with repeated right upper abdominal pain lasting for 3 months and aggravation for 9 h. Computed tomography (CT) showed a streaky high-density shadow (approximately 3 cm in length) on the posterior wall of the gastric antrum extending outside the wall. Endoscopic ultrasonography showed hyperechoic space with a cross-section of approximately 0.1 × 0.1 cm in the deep submucosal layer of the local stomach, accompanied by an acoustic shadow in the rear. The possibility of a fishbone as well as perforation was considered and the object was removed using FB forceps. Fasting as well as acid inhibition and anti-infection medication were prescribed for the patient. She eventually recovered and was discharged from the hospital.

Conclusion

Endoscopic intervention can be recommended as the first option for patients with gastrointestinal FBs.

Laparoscopic management of enterohepatic migrated fish bone mimicking liver neoplasm: A case report and literature review

RATIONALE

Accidental ingestion of a foreign body is common in daily life. But the hepatic migration of perforated foreign body is rather rare.

PATIENT CONCERNS

A 37-year-old man presented with a history of vague epigastric discomfort for about 2 months.

DIAGNOSIS

A diagnosis of the foreign body induced hepatic inflammatory mass was made based on abdominal computed tomographic scan and upper gastrointestinal endoscopy.

INTERVENTIONS

The patient underwent laparoscopic laparotomy. During the operation, inflammatory signs were seen in the lesser omentum and segment 3 of liver. B- Ultrasound guided excision of the mass (in segment 3) was performed. Dissecting the specimen revealed a fish bone measuring 1.7 cm in length.

OUTCOMES

The patient recovered uneventfully and was discharged on day 5 after surgery.

LESSONS

This study shows the usefulness of endoscopy for final diagnosis and treatment in foreign body ingestion. Early diagnosis and decisive treatment in time are lifesaving for patients with this potentially lethal condition.

Successful treatment of liver abscess secondary to foreign body penetration of the alimentary tract: A case report and literature review

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%.

An unusual zoonosis: liver abscess secondary to asymptomatic colonic foreign body

A liver abscess may arise following any insult to gut integrity allowing portal drainage of bacteria to hepatocytes. Foreign bodies such as bones, toothpicks and items of stationery have previously been implicated in compromising gut epithelium. Here we present the case of a 57 year old man suffering from a left liver abscess. This was defined on CT which incidentally also identified a chicken bone protruding through the wall of the distal sigmoid colon. Whilst unwell with upper abdominal pain and sepsis, the presumed source of portal sepsis within the colon remained asymptomatic throughout. Following percutaneous drainage, the liver abscess resolved but the chicken bone had not passed at two months, necessitating atraumatic removal at colonoscopy. A high rate of incidental diagnoses suggests that unidentified foreign bodies may be vastly under recognised in cases of hepatic sepsis. Thus, identification of the precise mechanism of the liver insult demands thorough consideration; foreign body should be considered in all cases.

Migrated foreign body liver abscess: illustrative case report, systematic review, and proposed diagnostic algorithm

Pyogenic liver abscess is a severe condition and a therapeutic challenge. Treatment failure may be due to an unrecognized ingested foreign body that migrated from the gastrointestinal tract. There has recently been a marked increase in the number of reported cases of this condition, but initial misdiagnosis as cryptogenic liver abscess still occurs in the majority of cases. We conducted the current study to characterize this entity and provide a diagnostic strategy applicable worldwide. To this end, data were collected from our case and from a systematic review that identified 59 well-described cases. Another systematic review identified series of cryptogenic-and Asian Klebsiella-liver abscess; these data were pooled and compared with the data from the cases of migrated foreign body liver abscess. The review points out the low diagnostic accuracy of history taking, modern imaging, and even surgical exploration. A fistula found through imaging procedures or endoscopy warrants surgical exploration. Findings suggestive of foreign body migration are symptoms of gastrointestinal perforation, computed tomography demonstration of a thickened gastrointestinal wall in continuity with the abscess, and adhesions seen during surgery. Treatment failure, left lobe location, unique location (that is, only 1 abscess location within the liver), and absence of underlying conditions also point to the diagnosis, as shown by comparison with the cryptogenic liver abscess series. This study demonstrates that migrated foreign body liver abscess is a specific entity, increasingly reported. It usually is not cured when unrecognized, and diagnosis is mainly delayed. This study provides what we consider the best available evidence for timely diagnosis with worldwide applicability. Increased awareness is required to treat this underestimated condition effectively, and further studies are needed.

Colonoscopic identification of a foreign body causing an hepatic abscess

BACKGROUND

Hepatic abscesses often result from a perforation of the gastrointestinal tract. Although rare, this may occur via puncture by a foreign body. The object may directly extend from the stomach or duodenum into the liver, or rarely, the object may perforate the bowel distal to the duodenum and indirectly extend to the liver leading to the formation of an abscess.

CASE REPORT

A 44-year-old man developed an hepatic abscess. Although the abscess was identified on computed tomography, various imaging studies were unable to identify the cause of the infection. After an extended ICU course, the patient was deemed stable enough to undergo a colonoscopy that demonstrated a foreign body penetrating through the wall of the sigmoid colon.

CONCLUSIONS

Here we describe the first report of a foreign body leading to a hepatic abscess where the object was identified by colonoscopy. In addition, we present a comprehensive literature review examining the method of identification of gastrointestinal foreign bodies that led to liver abscesses. These findings emphasize that in cases of hepatic abscesses of unknown etiology, direct visualization by colonoscopy may be a useful tool to elucidate the cause of the abscess.