Case Report Open Access
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World J Gastroenterol. Mar 7, 2007; 13(9): 1466-1470
Published online Mar 7, 2007. doi: 10.3748/wjg.v13.i9.1466
Hepatic abscess induced by foreign body: Case report and literature review
Sofia A Santos, Sara CF Alberto, Elsa Cruz, Eduardo Pires, João R Deus, Department of Gastroenterology, Fernando Fonseca Hospital, IC19, Amadora 2720-276, Portugal
Tomás Figueira, Élia Coimbra, Department of Radiology, Fernando Fonseca Hospital, IC19, Amadora 2720-276, Portugal
José Estevez, Department of Surgery, Fernando Fonseca Hospital, IC19, Amadora 2720-276, Portugal
Mário Oliveira, Department of Pathology, Fernando Fonseca Hospital, IC19, Amadora 2720-276, Portugal
Luís Novais, Center for the Study of Esophageal Diseases, Carnaxide, Portugal
Author contributions: All authors contributed equally to the work.
Correspondence to: Dr. Sofia A Santos, Department of Gastroenterology, Fernando Fonseca Hospital, Estrada Serra da Mira, N22, 3ºDTO 2700-786, Amadora, Portugal. sofiasantos_md@sapo.pt
Telephone: +351-965-628190
Received: June 3, 2006
Revised: September 5, 2006
Accepted: February 7, 2007
Published online: March 7, 2007

Abstract

Hepatic abscess due to perforation of the gastrointestinal tract caused by ingested foreign bodies is uncommon. Pre-operative diagnosis is difficult as patients are often unaware of the foreign body ingestion and symptoms and imagiology are usually non-specific. The authors report a case of 62-year-old woman who was admitted with fever and abdominal pain. Further investigation revealed hepatic abscess, without resolution despite antibiotic therapy. A liver abscess resulting from perforation and intra-hepatic migration of a bone coming from the pilorum was diagnosed by surgery. The literature concerning foreign body-induced perforation of the gastrointestinal tract complicated by liver abscess is reviewed.

Key Words: Liver abscess; Foreign body; Gastrointestinal perforation



INTRODUCTION

Perforation of the gastrointestinal tract caused by ingested foreign bodies is uncommon and formation of posterior hepatic abscess is even more rare[1-5]. In the majority of cases an early diagnosis is difficult to make by laparotomy due to the variability of clinical presentation and non specificity of complementary examinations. The authors report a rare case of gastric perforation induced by a chicken bone with hepatic perforation and abscess formation. Despite computed tomography scan (CT) showed possible perforation, laparotomy established the diagnosis.

CASE REPORT

A 62-year old woman presented in March 2005 to our emergency room with abdominal pain, fever and asthenia. She had a history of hypertension, gastro-oesophageal disease and hemorrhoids and was treated with ramipril and lansoprazole.

She had a 6-wk history of intermittent epigastric pain that progressively worsened, asthenia, anorexia and more recently developed mild fever. There was no history of chills, nausea, vomiting, thoracic pain, jaundice, respiratory or urinary complaints.

Physical examination revealed stable vital signs. And lung examination was unremarkable. Her abdomen was soft and tender to palpation but the liver was mildly tender and enlarged.

Laboratory investigations revealed a haemoglobin level of 10 g/dL, leukocytosis with granulocytosis (16 600/mm3 and 87%), C-reactive protein 24 mg/dL, elevated aspartate aminotransferase and alanine aminotransferase (43 and 35 IU/mL; normal < 31), γ-glutamil transferase 93 UI/L (N < 55), with normal bilirrubin and alkaline phosphatase. Plain radiographs of the chest and abdomen were normal. Abdomen ultrasound (US) revealed a hypoechoic lesion in the left lobe containing both gas and fluid. Contrast enhanced CT scan showed a large collection, measuring approximately 8.5 cm × 7.0 cm, consistent with left-sided intra-hepatic abscess extending up to the gastric antrum, that presented parietal thickening (Figure 1). An abdominal RM did not rule out a liver tumor, but failed to show continuity with the gastric antrum (Figure 2).

Figure 1
Figure 1 Contrast en-hanced CT scan showing a low-density area with gas and fluid, measuring approximately 8. 5 cm x 7.0 cm, consistent with left-sided intra-hepatic abscess.
Figure 2
Figure 2 Abdominal RM demonstrating a large collection with gas and fluid.

Using CT guidance, the hepatic abscess was drained percutaneously and pus and blood cultures were obtained. Microbiological examination of the drained fluid was negative and biopsies taken only revealed inflammatory process (Figure 3). Upper GI endoscopy revealed a pre-pyloric thickened fold (Figure 4), with normal histological evaluation. Entamoeba histolytica serology was negative.

Figure 3
Figure 3 Biopsy of the liver abscess showing fibrosis, fibrin and acute inflammatory cells, consistent with abscess wall (HE).
Figure 4
Figure 4 Upper GI endoscopy revealing a thickened gastric fold (pre-pyloric).

The patient started on antibiotherapy (ampicilin, gentamicin and metronidazole) with clinical improvement. Four weeks later abdominal ultrasonography showed abscess size reduction (3 cm) and the patient was discharged and maintained antibiotic therapy.

Three weeks later the patient presented with fever, abdominal pain and elevated C-reactive protein. Abdominal ultrasonography and CT scan showed enlargement of the abscess cavity (8.4 cm × 5.3 cm), which extended to the gastric antrum. Laparotomy was then performed and a foreign body (bone) was found embedded in the left lobe of the liver, resulting in a gastric antrum perforation (Figure 5). The bone was removed, the abscess drained, the stomach defect closed and a drain placed. The post-operative course was uneventful.

Figure 5
Figure 5 Removed foreign body (chicken bone, with 3. 3 cm x 0.5 cm).
DISCUSSION

About 80%-90% of ingested foreign bodies pass trough the gut without discovery within 1 wk[1,2,4]. When symptoms arise they are usually secondary to obstruction[1,2]. Gastrointestinal perforation has been reported in less than 1% of patients[3-5] and the most commonly affected areas are the ileocecal and rectosigmoidal regions[4,5] and duodenum[2]. Development of hepatic abscess due to penetration induced by a foreign body is even more rare, the first case was published in 1898[6]. Since then, the world literature has been increased, with 46 cases reported until now. The most common sites of perforation of the gut are stomach and duodenum[5] which can induced by sharp foreign bodies like fish bones, chicken bones, needles or toothpicks[2,4,5,6] although pens or dental plates have also been reported[6,7].

It is difficult to establish the time until the onset of symptoms as patients rarely recall the episode of ingestion[1,3,4] and the migrating foreign body may remain silent until an abscess formation[5].

Most patients have non specific symptoms such as abdominal pain, fever, vomiting, anorexia or weight loss[4,5,8] which are features of a systemic response against an infection or abscess formation[4]. Furthermore, the classical presentation of hepatic abscess (fever, abdominal pain and jaundice) is only present in a few cases[5].

The results of routine laboratory studies are also non specific and unless the foreign body is radio-opaque it will not be identified on plain radiography[3,4].

An abdominal US or CT scan is preferred techniques for the diagnosis, the latter is excellent in detection of foreign bodies due to its high resolution and accuracy[1,2,4]. Endoscopy may be helpful when performed early, before the foreign body migration and mucosal healing[2,9] (which happened in our patient). In addition, endoscopy does not allow examination of the mid-gut[2]. Therefore, pre-operative diagnosis is difficult and a high degree of suspicion is required[1,3].

We reviewed the world literature, and summarized it in Table 1. We found that fish bones were the most common foreign body and the stomach was the principal site of perforation. Abscess formation occurs more often on the left lobe. Microorganisms isolated on abscess or fluid cultures are usually part of the normal flora of human oropharynx[4,5,6,10-12]. Prognosis depends on a quick diagnosis, not only for morbidity but also for mortality[5,6].

Table 1 World literature review of hepatic abscess induced by foreign bodies.
RefYearAuthorSymptomsSufferingperiodForeignbodySize(cm)PenetrationLiverBacteriaLaparotomyTreatmentMortality
[1]2003KanazanaEpigastralgia1 moToothpick5.5StomachLeft lobeUnknownYesAbscess drained and removal of a small part of the liverNo
[2]2000CheungEpigastralgia, fever3 moToothpick-StomachLeft lobeUnknownYesremoval of the toothpick and a small part of the liverNo
[3]2000BroomeEpigastralgia, anorexia, fever7 dChicken bone4.0StomachLeft lobeUnknownYesRemoval of the chicken bone and abscess drainageNo
[4]1999HoriiFever, vomiting2 wkFish bone2.8UnknownLeft lobeStreptococcus constellatusNoPercutaneous abscess drainageNo
[5]2003ChintamaniFever, vomiting1 yrNeedle3.0UnknownRight lobeStreptococcus pyogenes, E. coliYesRemoval of the needle and abscess drainageNo
[6]2001La VejaAbdominal pain, vomitingUnknownFish bone2.5UnknownRight lobe-AutopsyYes
[7]1999PerkinsFever, anaemia2 wkPen-DuodenumRight lobeStreptococcus malleri (group C), Sreptococcus malleriNoRemoval of the pen and abscess drainageNo
[8]1983ShawFeverDental plate-Descending colonUnknown
[9]1997TsuiClothespin, Tooth pick-Duodenum StomachUnknown
[10]1993ChenEpigastralgia, fever, weight loss3 moChicken bone4.0DuodenumLeft lobeUnknownYesRemoval of the chicken bone and abscess drainageNo
[11]2003BilimoriaRight upper abdominal pain, feverUnknownToothpick-Sigmoid colonRight lobeEstreptococcusYesRemoval of the toothpick and abscess drainageNo
[12]2004TomimoriEpigastralgia4 wkFish bone1.0StomachLeft lobeSreptococcus constellatusYesRemoval of the fish bone and abscess drainageNo
[13]2001KesslerAbdominal pain4 wkFish boneUnknownDuodenumLeft lobeEikenella corrodensYesRemoval of the fish bone and abscess drainageNo
[14]2000ParaskevaAbdominal pain4 moFish bone3.7Sigmoid colonRight lobeSreptococcus malleriNoRemoval of the fish boneNo
[15]1999DrnovsekAbdominal pain, vomiting1 dToothpickUnknownDuodenumBothStreptococcus viridensYesRemoval of the toothpickNo
[16]1999Guglielminet tiToothpick-StomachLeft lobeUnknownNoEndoscopic toothpick removal and percutaneous abscess drainage
[17]2002Theodoropo ulouRight upper abdominal pain, fever, jaundice3 dFish bone5.5StomachLeft lobeUnknownAutopsyYes
[18]1981WoodFever, diarrhea9 moNeedle-Retrocecal appendixRight lobeStreptococcus viridensYesRemoval of the needle and abscess drainage
[19]2005StarakisRight upper abdominal pain, fever3 wkChicken bone-DuodenumLeft lobeSreptococcus viridans, Eikenella corrodensYesRemoval of the chiken bone and abscess drainageNo
[20]2003HouliRight upper abdominal pain, fever2 wkChicken bone3.5Transverse colonRight lobeStreptococcus angiosus and mixed anaerobic floraYesAbscess drainage, removal of the chicken bone and a small part of the liverNo
[21]2001ByardAbdominal pain, feverSeveral yearsChicken bone3.8DuodenumBothE. coli, mixed anaerobes and Candida albicansAutopsyYes
[22]1999ChanAbdominal pain, feverUnknownFish bone-StomachUnknownYesRemoval of the fish bone, abscess drainage and parcial gastrectomyNo
[23]1999TsaiAbdominal pain, feverFish bone3.7StomachLeft lobeUnknownNoAbscess drainage and simple closure of the perforated holeNo
[24]1992ShuldaisFish bone-StomachUnknown
[25]1991MasunagaAbdominal pain, fever, vomiting1wkFish bone4.0StomachLeft lobeUnknownYesPercutaneous abscess drainage, parcial gastrectomy and lateral segmentectomy
[26]1990AllimantFever, astenia3 wkToothpick-StomachLeft lobeUnknownYesDrainage and removal of the tooth pick and a small part of the liverNo
[27]1986PendersonAbdominal pain, shockUnknownToothpick3.5StomachLeft lobeUnknownYesRemoval of the toothpick and abscess drainageNo
[28]1988GonzalezAbdominal pain, fever, jaundice, nausea1 moFish boneUnknownStomachLeft lobeUnknownYesRemoval of the fish bone and abscess drainageNo
[29]1981RafizadethLow-grade fever10 dToothpick4.2DuodenumLeft lobeEstreptococcusYesRemoval of the toothpick and abscess drainageNo
[30]1966AronAstenia, fever, jaundice3 moFish bone2.2StomachRight lobeE. coli, ProteusYesRemoval of the toothpick, abscess drainage and piloroplastyNo
[31]1971BerkRight upper abdominal painSeveral weeksChicken bone4.0StomachLeft lobeUnknownYesRemoval of the chicken bone, abscess drainage and parcial gastrectomy
[32]1996AcostaNeedle-AppendixUnknown
[33]1971AbelNoneUnknownNeedle2.5StomachLeft lobeUnknownYesRemoval of the needle and segmentectomyNo
[34]1981TsuboiEpigastralgia, weight loss1 moFish bone4.7StomachLeft lobeUnknownYesRemoval of the fish bone and abscess drainageNo
[35]1984BlochFever, myalgia2 wktoothpick4.5Stomach or DuodenumLeft lobeEstreptococcusYesRemoval of the toothpick and abscess drainage
[36]1955GriffithsSeptic shockUnknownNeedle4.0StomachRight lobeUnknownAutopsyYes
1955GriffithsFever , vomiting1 moToothpick6.0DuodenumRight lobeUnknownAutopsyYes
[37]1990DuggerFever, right upper abdominal pain3 wkFish bone or Chicken bone3.8StomachRight lobeE. coli, ProteusAutopsy
[38]2005LeeEpigastralgia5 dBody piercing5.0StomachLeft lobeKlebsiella spp, Streptococcus milleriYesRemoval of the piercing, closure of the perforated hole and abscess drainageNo
2005LeeFever, epigastralgia, nausea, vomiting1 wkFish bone3.5StomachLeft lobeStreptococcus milleriYesRemoval of the fish bone, closure of the perforated hole and abscess drainageNo
2005LeeEpigastralgia10 d--StomachLeft lobeStreptococcus milleriYesClosure of the perforated holeNo
[39]2005GohFever5 dFish bone3.0DuodenumLeft lobeStreptococcus milleriYesRemoval of the fish bone and abscess drainageNo
[40]2006ChiangRight upper abdominal pain, fever3 dToohpick6.7DuodenumRight lobeStaphylococcus aureusNoAntibiotics (refused surgery)No

Our clinical report is similar to the world literature and enhances the difficulty of diagnosing such an entity. Our patient who did not recall the ingestion, had non specific symptoms and laboratory results as well as US and CT showed a hepatic abscess on the left lobe and its fistulous track. The diagnosis was obtained after exploratory laparotomy. Considering all issues we suppose that the chicken bone perforated through the pylorus.

Hepatic abscess treatment includes aspiration and antibiotic therapy[4]. Nevertheless if we suspect perforation of the gut caused by a foreign body or it is detected by radiography, US or CT, surgery is the option[13], although there are some descriptions of endoscopic[4,12,15] or percutaneous[4,14] removal. In our case surgery not only allowed to make a diagnosis but also treated it.

In conclusion, hepatic abscess diagnosis based on perforation of the gastrointestinal tract caused by a foreign body is difficult due to a variety of non specific symptoms and because patients are often unaware of the ingestion. In a hepatic abscess that does not respond to aspiration and antibiotic therapy we should look for an aetiology. Despite its rarity we should consider a foreign body and surgical therapy. Surgery still has a major role in the diagnosis and treatment of hepatic abscess induced by a foreign body although US and CT may establish it in some cases.

Footnotes

S- Editor Liu Y L- Editor Wang XL E- Editor Zhou T

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