25 Hepatic abscess secondary to migration of fish bone impaction from the duodenum: a challenging management

Abstract Introduction Foreign body ingestion is a common condition. Over 80% of cases are accidental and even unnoticed by the patient, 10–20% need endoscopic treatment for extraction, and only 1% of cases need surgical intervention. There is a wide range of possibilities and complications in the gastrointestinal tract related to foreign body impaction. A very uncommon complication is perforation of bowel with migration of the foreign body and underlying insidious infection. These situations usually require a surgical approach to resolve the problem. We present the case of a patient with a liver abscess secondary to fishbone impaction in the duodenum with migration into the liver. Case Report A 79-year-old male with a medical history of duodenal ulcer, hiatal hernia, and benign prostatic hyperplasia arrived to the Emergency Department (ED) with shortness of breath, fever and general malaise. On laboratory exams he presented leukocytosis and high C reactive protein (CRP). A simple Chest X-ray reported pleural effusion. Blood cultures informed of a S. intermedius. As his first diagnostic approach was pneumonia, he was admitted to the Pneumology Department. During admission, a thoraco-abdominal CT scan was performed. It informed of a liver abscess (2.5 × 2.3 cm) with a foreign body of linear morphology in the middle, probably a fishbone. This foreign body had one end located in the first duodenal portion and the other end at the edge of the hepatic abscess (segment IV), close to the falciform ligament. The patient was finally diagnosed with a liver abscess with pleural effusion in the infectious context. He received empirical antibiotic treatment and conservative management. After clinical improvement, the patient was discharged. However, he returned to the ED again due to a poor general condition. An abdominal CT scan was performed which reported enlargement of the liver abscess, with increased inflammation around it. Gastroenterologists performed an endoscopy to try and remove the fishbone, but it was unsuccessful due to scar tissue blocking access. Percutaneous drainage of the abscess was performed to achieve source control with the isolation in cultures of the same S. intermedius as in blood. The patient received targeted antibiotic treatment after source control and he was scheduled for elective surgery. The operative findings described a fibrous tract leading from the duodenum to the liver: it was opened, and the fishbone removed. The tract was resected, and the duodenal orifice was closed. The patient recovered uneventfully. Educational Highlights The range of clinical manifestations of foreign body impaction can be acute or insidious. In this case, a high level of suspicion was needed for diagnosis, as symptoms were atypical and initially ruled as pneumonia. It is important to remember that source control is the main objective when treating abdominal infections. If conservative management is not effective, optimization of the patient and medical treatment to reduce inflammation can be a wise strategy before surgery. The optimal treatment of abdominal foreign bodies is a challenging condition and treatment must be tailored to each patient and presentation.