Liver abscess secondary to fishbone ingestion: case report and review of the literature.

We report a rare silent migration of a fishbone into the liver and review the relevant literature. A 56-year-old man presented with a 2-day history of dull epigastric pain and raised inflammatory markers. Computerized tomography scan revealed a 4-cm abscess in the left lobe of the liver, with a linear radio-dense foreign body within the collection. At laparoscopy the hepatogastric fistula was disconnected. The fishbone was retrieved from the liver. Gastrostomy was closed with an omental patch. The patient had an uneventful recovery. Fifty-two cases of liver abscess secondary to enterohepatic fishbone migration were reported with over two-thirds presenting with a left-lobe abscess. There was marked variability in the management of liver abscess in the setting of fishbone migration-summarized in table. We believe that laparoscopic drainage of the abscess and extraction of the foreign body offer control of the source of sepsis and diminishes recurrence, whilst having a low-risk profile. Published by Oxford University Press and JSCR Publishing Ltd.

INTRODUCTION

Foreign body ingestion is a common occurrence, majority of these pass without complications [1]. An estimated 1% of ingested foreign bodies result in gastrointestinal perforation, these are often sharp objects, such as accidentally ingested fishbones [2]. The sites of perforation vary, with the rectosigmoid or ileocolic being the most common [3].

We report a rare case of fishbone migration resulting in liver abscess and review of the literature. This was originally described in 1898 by Lambert [4].

CASE PRESENTATION

A 56-year-old man presented with a 2-day history of epigastric pain, leucocytosis and raised C Reactive Protein (CRP). A computed tomography (CT) scan revealed evidence of a 4.2 × 2.5 cm abscess in the left lobe of the liver (Segment III), with a linear radio-dense foreign body seen within the collection (Fig. 1). There was fat stranding around the pylorus. The patient was treated with antibiotics in his local hospital and a trial of aspiration revealed purulent fluid. An oesphagoduodenoscopy (OGD) was normal with no evidence of foreign body or inflammation in the stomach.

Figure 1

CT scan showing left lobe liver abscess with fishbone.

The patient was transferred to our Hepatopancreaticobiliary (HPB) unit. On arrival, he was clinically well and asymptomatic. A repeat CT scan showed a persistent collection in the liver. On further enquiry, the patient revealed that a few weeks earlier as he had a transient episode of choking and discomfort whilst eating fish.

On laparoscopy, the left lateral segment of the liver was adherent to the gastric antrum (Fig. 2). Adhesions between the liver and stomach were divided with blunt and sharp dissection. The fishbone was pulled out of the liver intact and extracted through the port. The abscess was opened, drained and washed. A sealed fistulous tract was identified at the antrum; this was repaired with an omental patch. The patient had an uneventful recovery and was discharged the following day.

Figure 2

Fishbone extraction from the liver.

DISCUSSION

Fifty-two cases of liver abscess secondary to enterohepatic fishbone migration have been reported in the English literature (Table 1). Most common symptoms included: anorexia, epigastric pain and fever. The lack of history of ingestion of a fishbone often leads to a diagnostic dilemma. CT scan was diagnostic in 47 that had axial imaging, three fishbones were found intra-operatively and two on autopsy. Over two-thirds of reported cases presented with a left lobe abscess, this is attributable to the anatomical proximity of the stomach.

Table 1

Review of literature reported cases of enterohepatic fishbone migration

Author	Patient details	Symptoms	Duration (d)	Fishbone location	Fishbone size (mm)	Site of perforation	Management
Hernández-Villafranca, Spain, 2021 [26]	73 F	NA	14	Left lobe	30	Duodenum	Laparoscopic fishbone removal
Allam, UK, 2020 [9]	53 F	Pain, fever	7	Right lobe	NA	Pylorus	Antibiotics. Fishbone left in situ
Barkai, 2020, Israel [11]	66 F	Pain	NA	Right lobe	NA	NA	Laparoscopic fishbone removal
Burkholder, USA, 2019 [14]	64 F	NA	8	Left lobe	21	NA	Percutaneous abscess drainage. Fishbone left in situ
Bandeira-de-Mello, Brazil 2018 [10]	44 F	NA	14	Left lobe	25	Antrum	Laparoscopic fishbone removal
Bekki T, Japan, 2019 [13]	51 M	Fever	NA	Left lobe	24	Antrum	Laparoscopic fishbone removal
Beckers, Belgium, 2021 [12]	74 F	Pain, fever	3	Right lobe	35	NA	Laparoscopic fishbone removal
Goyal, USA, 2019 [25]	68 M	Pain, fever, WL	30	Left lobe	NA	Pylorus	Percutaneous abscess drainage. Fishbone left in situ
	56 M	Pain, fever	14	Right lobe	NA	Duodenum	Robotic fishbone removal
Li, China, 2019 [32]	58 M	Fever	9	Left lobe	40	NA	Laparoscopic left hepatectomy
Sim, Singapore, 2019 [42]	56 F	Fever, vomiting	2	Right lobe	NA	Stomach	Laparotomy and abscess drainage. Fishbone left in situ
Queiroz, Brazil, 2019 [40]	50 M	Pain, fever	10	Left lobe	NA	Antrum	Surgical removal
Yu, China, 2018 [49]	34 F	Pain, fever, vomiting	8	Left lobe	30	NA	Laparotomy and fishbone removal
Peixoto, Portugal, 2016 [38]	78 M	Fever, vomiting	2	Right lobe	35	NA	Laparotomy and fishbone removal
Venkatesan, Australia, 2019 [44]	88 F	Pain	60	Left lobe	NA	Antrum	Laparoscopic fishbone removal
Gómez Portilla, Spain, 2019 [24]	50 F	Pain, fever	28	Left lobe	25	NA	Left hepatectomy with bone removal
	69 F	NA	NA	Left lobe	NA	NA	Surgical removal
Chen, 2019, China [15]	37 M	Pain	60	Left lobe	17	NA	Liver resection
Mateus, Portugal, 2018 [34]	76 M	Pain	3	Left lobe	50	NA	Laparotomy and fishbone removal
	45 M	Weakness, chills	2	Right lobe	NA	NA	Percutaneous abscess drainage Fishbone left in situ
Fujiwara, Japan, 2017 [21]	69 M	Pain, fever	14	Right lobe	35	NA	Laparotomy with Fishbone removal
Dias, Brazil, 2018 [18]	35 M	Pain, fever	NA	Left lobe	25	NA	Laparotomy with fishbone removal
Lau, Singapore, 2017 [30]	85 F	Pain, fever	NA	Left lobe	40	Pylorus	Percutaneous fishbone removal
Tan, Singapore, 2016 [43]	56 M	Pain, fever	14	Left lobe	NA	Antrum	Laparoscopic Fishbone removal
	63 M	Fever	14	Left lobe	NA	Stomach	Laparoscopic Fishbone removal
Esseghaier, Tunisia, 2015 [20]	68 M	Pain, fever	7	Right lobe	20	Duodenum	Laparotomy with fishbone removal
Ede, South Africa, 2015 [19]	61 M	Pain, fever	21	Left lobe	60	NA	Laparotomy with fishbone removal
Panebianco, Italy, 2015 [37]	57 F	Pain, fever	14	Left lobe	40	Antrum	Laparoscopic Fishbone removal
Dinnoo, France, 2015	60 F	Pain, Sepsis	NA	Right lobe	NA	Duodenum	Laparoscopic fishbone removal
Xiao, China, 2015 [46]	47 F	Pain	365	Left lobe	25	NA	Laparoscopic fishbone removal
Venkatesh, Singapore, 2015 [45]	69 M	Pain, fever	5	Left lobe	14	Stomach	Left hepatectomy
Koşar, Turkey, 2014 [29]	73 F	Fever	NA	Left lobe	NA	NA	Laparoscopic fishbone removal
Dangoisse, Belgium, 2014 [17]	56 M	Fever, SOB	3	Left lobe	30	Stomach	Laparotomy with fishbone removal
Matrella, France, 2014 [35]	63 F	Pain, fever	10	Right lobe	40	NA	Laparotomy with fishbone removal
	83 F	Pain, fever	NA	Left lobe	NA	NA	Laparotomy with fishbone removal
Gaba, USA, 2013 [22]	33 F	Fever	14	Left lobe	30	NA	Percutaneous removal of fishbone
Masoodi, Saudi Arabia, 2012 [5]	45 M	Pain, fever	10	Right lobe	25	Duodenum	Laparotomy with fishbone removal
Jarry, France, 2011 [27]	68 F	Pain, fever	14	Right lobe	35	Duodenum	Laparotomy with fishbone removal
Liang, China, 2011 [33]	60 M	Pain, fever	30	Left lobe	27	Stomach	Surgical removal
Ng, Singapore, 2011 [36]	59 M	Fever	NA	Right lobe	NA	Pylorus	Antibiotics. Bone left in situ
Chen, China, 2011 [15]	59 F	Pain, fever	14	Left lobe	40	Duodenum	Liver resection
Yen, China, 2010 [48]	36 M	Pain, fever	14	Left lobe	NA	NA	Surgical removal
Santos, Portugal, 2007 [41]	62 F	Pain, fever	42	Left lobe	33	Antrum	Laparotomy and fishbone removal
Kadowaki, Japan, 2007 [28]	73 F	Pain, fever	7	Left lobe	28	NA	Laparotomy and fishbone removal
Clarençon, France, 2008 [16]	64 M	Pain, fever	NA	Right lobe	23	NA	Failed open surgical removal Percutaneous removal of fishbone
Perera, Sri Lanka, 2007 [39]	59 F	Pain	NA	Left lobe	45	NA	Laparotomy and fishbone removal
Lee, China, 2005 [31]	65 F	Pain, vomiting	7	Left lobe	35	Antrum	Laparotomy and fishbone removal
Goh, Singapore, 2005 [23]	32 M	Fever	5	Right lobe	30	Duodenum	Laparotomy and fishbone removal
Yang, China, 2005 [47]	40 M	Fever	7	Left lobe	50	NA	Percutaneous abscess drainage. Fishbone left in situ
Theodoropoulou, Greece, 2002 [7]	46 M	Pain, fever, jaundice	3	Left lobe	50	NA	Antibiotics. Fishbone left in situ
De la Vega, Spain, 2001 [6]	86 F	Pain, vomiting	NA	Right lobe	25	NA	Antibiotics. Fishbone left in situ
Horii, Japan, 1999 [2]	61 M	Fever	14	Left lobe	28	NA	Percutaneous abscess drainage and removal of fishbone.

There was marked variability in the management of liver abscess in the setting of fishbone migration. A variety of approaches including laparotomy, laparoscopy, CT guidance and liver resection were utilized to remove the fishbones. Percutaneous drainage usually results in the resolution of liver abscess, but recurrence is likely. Nine patients had the fishbone left in situ, one patient ultimately required a laparotomy for fishbone removal [5]. There were two mortalities in these patients with the fishbone left in situ (2/7, 29%), these were secondary to overwhelming sepsis, and the fishbones were discovered at autopsy [6, 7].

LEARNING POINTS/TAKE-HOME MESSAGES

Left lobe liver abscess should raise the suspicion of a foreign body. Antibiotic treatment and drainage are effective in the short term. The retained foreign body acts as a nidus for recurrent infection and requires removal to prevent recurrence and mortality.

Previous presentation: Poster presentation in UGI conference 2021.

CONFLICT OF INTEREST STATEMENT

None declared.

FUNDING

Kings College London (JISC affiliated).